Mid Cheshire Hospitals NHS Foundation Trust

We inspected Mid Cheshire Hospitals NHS Foundation Trust as part of our new comprehensive inspection programme.

We carried out an announced inspection of Leighton Hospital between 8 and 10 October 2014. We also carried out an announced inspection of the Victoria Infirmary and Elmhurst Intermediate Care Centre on 9 October 2014.

In addition, an unannounced inspection was carried out between 5pm and 8.30pm on 24 October 2014 at Leighton Hospital The purpose of the unannounced inspection was to look at the management of medical admissions out of hours.

Overall, we rated this trust as ‘good’ and we noted some outstanding practice and innovation. However, improvements were needed to ensure that services were responsive to people’s needs.

Our key findings were as follows:

Access and patient flow

Bed occupancy for the trust was consistently above 90% and worse than the England average. It is generally accepted that the quality of patient care and how well hospitals perform start to be affected when occupancy rates rise above 85%.

The trust was under significant pressure from high numbers of emergency admissions, which meant that some patients were not seen in the Emergency Department within the national target of four hours. The pressures on the number of available beds, particularly in the medical care wards, meant that once assessed patients could wait for extended periods of time to be seen by a specialist doctor. In addition, the lack of available beds meant that patients were often placed in areas that were not best suited to their needs (outliers). Patients also spent long periods in the Primary Assessment Area (PAA). This area was not a suitable environment for patients to be cared in the medium term. However, there were occasions when patients had remained in this area for up to three days. During our unannounced inspection we found the trust had implemented the ‘Golden Patient’ initiative to ensure that patients did not spend more than 24 hours in this area and were moved to a setting more suited to their needs at the earliest opportunity.

Surgical patients were also affected because operations were cancelled if intensive or inpatient beds were not available.

We also found that patients were in hospital longer than they needed to be and that patient discharges were not always managed in a timely way.

Delays in discharge were made worse by delays in securing community-based care packages. Although the trust was well aware of its challenges and was working on a solution, the required improvements were not yet visible at the time of our inspection. As a result, the management of patient access and flow across the hospital was of immediate concern and remained a significant challenge for managers.

Cleanliness and infection prevention and control

Patients received their care in a clean and suitably maintained environment. There was a high standard of cleanliness throughout the trust. Staff were aware of current infection prevention and control guidelines and consistently applied them when delivering care to patients.

There was a good rate of compliance with hygiene audits across the trust.

From July 2013 to July 2014 the trust reported four cases of methicillin-resistant staphylococcus aureus (MRSA) in the last year. This was a small number of cases and the trust had performed better than the England average since April 2014. For the same period an average of 30 cases of C. difficile infections were reported. This was worse than the England average until April 2014, when the numbers fell and remained better than the England average. Incidents of reported methicillin-sensitive staphylococcus aureus (MSSA) infections were variable but were generally better than the England average.

Medical staffing

Medical treatment was delivered by highly professional and committed medical staff. However, there were a number of consultant vacancies and this meant there was not always enough medical staff to provide timely treatment and review of patients, particularly out of hours.

The trust was working hard to recruit and retain consultants. It had a number of initiatives in place including cross-working with neighbouring trusts and recruiting medical staff from overseas. These initiatives were helping to address medical shortfalls. Nevertheless, the shortage of medical staff meant that patients sometimes waited for extended periods of time to be seen by a consultant.

The pressures on the medical workforce had also led to delays in discharge letters to GPs. There were also concerns about the quality and content of the discharge letters as they were of variable quality and clarity. The lack of clarity had the potential to lead to confusion about who was responsible for the ongoing care of patients. The trust had recognised this as an issue and had begun to pay medical staff overtime to reduce the backlog. However, there were a number of wards and departments that were still struggling to send out this important information in a timely way.

There was also a shortage of trainee doctors. This was being taken forward by the Medical Director with the regional training schools with a view to the trust being allocated a full complement of trainee doctors. This would alleviate pressures on the existing team and free up more senior colleagues so they could see patients quickly.

Nursing staff

Care and treatment was delivered by committed and caring nursing staff who worked well together for the benefit of patients.

Nurse staffing levels were calculated using a recognised dependency tool. Although we found that staffing levels were appropriate at the time of our inspection, the trust was aware there was limited flexibility in nursing numbers to cope with increased demand or short notice sickness and absence. In response, the trust had worked hard to increase nursing capacity and had been successful in securing nursing staff from overseas. This initiative was seen very positively by the trust’s nursing team, who had made their new colleagues very welcome. This active approach to nurse recruitment was ongoing at the time of our inspection. However, nurse staffing on the critical care unit did not always meet best practice requirements.

In maternity services, we found that the midwife to birth ratio was better than the England average.

Mortality rates

The trust showed insight in understanding the mortality data and identifying any potential improvement areas for patient safety or the patient pathway. In addition, work had been undertaken with the coding team and the medical staff to improve the coding information. Changes in coding practice had been made and the trust was confident that its mortality data quality had improved and would continue to do so.

Mortality and morbidity meetings were held weekly and were attended by representatives from all teams within the relevant divisions. As part of these meetings attendees reviewed the notes for every patient who had died in the hospital within the previous week. Any learning identified was shared and applied.

While we were carrying out our inspection the latest SHMI data became available. This indicated that the trust was moving nearer to expected levels at 104, continuing the positive downward trend. The trust stated its intention to remain proactive and vigilant in understanding and improving its mortality rates.

Incident reporting and investigation

The trust had a robust system for reporting incidents and near misses. Staff were confident and competent in reporting incidents and were supported by their managers to do so. The trust reported 4 never events during 2013/14. (Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.)

All never events had been subject to Root Cause Analysis (RCA) investigations and included a concise timeline and evidence of using recognised root cause analysis tools. There was good evidence of shared learning following RCAs and robust monitoring of recommended actions.

Safeguarding

Safeguarding policies and procedures were available on the trust’s intranet for both vulnerable adults and children. Safeguarding was supported by staff training and we found evidence of appropriate adult safeguarding referrals in line with trust policy and expected practice. However, there were some examples where the policy for safeguarding children was not followed appropriately. This included not seeking advice from the named doctor and not completing a body map when bruising was identified. In terms of safeguarding children, we also found that investigation findings were not shared widely and that opportunities for learning had been lost as a result.

Nutrition and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs were supported by dieticians and the speech and language therapy team. Overall patients were complimentary about the quality of food that was served.

There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. There was a coloured tray system in place so that patients who needed assistance with eating and drinking could be easily identified and offered appropriate and discreet support.

Medicines management

Medicines were provided, stored and administered in a safe and timely way.

Anticipatory end of life care medication was appropriately prescribed for patients at the end of life. This was good practice as it enabled community nurses to give symptomatic relief without delay from the time the patient arrived home and helped avoid unnecessary readmissions to hospital.

We saw several areas of outstanding practice including:

• In medical care, the trust had introduced an electronic handover tool (e-handover) for which they had received a Health Service Journal Award. Medical staff at the trust had developed documentation for the care of patients on an alcohol detox pathway.
• The new critical care unit had been designed in accordance with the latest best practice guidance with the aim of reducing delirium and the problems associated with sensory deprivation. For example the rooms on one side of the unit benefitted from full length windows incorporating an electronic blind so that natural light was visible. In addition the unit made use of sky ceiling photo panels above patient beds, which displayed realistic images of blue skies, white clouds and blossom trees.
• The end of life care service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medication.
• The hospital had a rapid discharge pathway to enable patients to be discharged from the acute hospital to home in the last hours /days of their lives. An audit in March 2014 showed that the preferred place of care (PPC) was achieved for 84% of patients seen by the specialist palliative care team (SPCT) and PPC wishes were met for 96% of the patients seen by the team.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times including and out of hours.

• Ensure that medical staffing is appropriate at all times including medical trainees, long-term locums, middle-grade doctors and consultants.

• Improve patient flow throughout the hospital to reduce the number of patient bed moves and patients’ length of stay – particularly in the medical division.

• Take action to clear the backlog of discharge letters and implement an effective system for managing discharge letters so that GPs receive accurate and robust information about their patients in a timely way

• Ensure that escalation areas are appropriate environments for the care of patients and provide them with ready access to bathing and toilet facilities.

In addition the trust should:

• Consider improving arrangements for clinical supervision to ensure they are appropriate and support staff to effectively carry out their responsibilities, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.
• Ensure that where patients are deemed not to have capacity to consent, staff are establishing and acting in accordance with the best interests of the patient and that this is appropriately documented.

In emergency & urgent care services:

• Ensure that all staff completed their mandatory training in a timely manner.
• Consider updating the sudden death checklist for paediatrics to include a “do not leave child alone with parents” step.
• Ensure they have a list of appropriate staff that have been trained with the required scene safety and awareness training.

In medical care services:

• Ensure timely access to treatment for upper gastrointestinal bleeds and stroke thrombolysis, including out of hours.
• Ensure action is taken to improve outcomes for patients with diabetes or who have had a stroke.

In surgery services:

• Ensure that appropriate action is taken to reduce the number of elective surgical patients that are readmitted to hospital following discharge.
• Continue to monitor and fully implement the proposed actions in order to reduce the number of cancelled operations and improve theatre utilisation.

In maternity & gynaecology services:

• Review and improve the provision of consultant anaesthetic sessions for elective caesarean sections to provide a more responsive service for women.

In services for children & young people:

• Consider reviewing safeguarding children training to ensure that the format, content and duration is in line with best practice guidance, in particular the provision of inter-agency training and that the time allowed for level 3 training is appropriate to support the learning needs of staff
• Ensure that safeguarding concerns are reported via the incident reporting systems to make sure that incidents are fully investigated and provide assurance that all relevant staff are aware of lessons learned.

In outpatients and diagnostic imaging services:

• The trust should take action to ensure that waiting times for outpatient clinics are improved and that clinics do not over run leading to cancellation of appointments.

At Elmhurst Intermediate Care Centre:

• Ensure that soiled linens are stored in a secure and appropriate manner.
• Ensure there are clear plans in place to address and manage identified risks. In particular the trust should ensure that outstanding portable appliance testing is completed.
• Ensure there are robust processes in place for staff to receive “lessons learned” feedback from incidents.
• Consider providing all staff with appropriate dementia care training.

Professor Sir Mike Richards

Chief Inspector of Hospitals