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Provider: Royal Liverpool and Broadgreen University Hospitals NHS Trust Requires improvement

On 17 July 2019, we published a report on how well Royal Liverpool and Broadgreen University Hospitals NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 July 2019

Our rating of the trust went down. We rated it as requires improvement because:

We rated the trust as requires improvement for responsive and well led. We rated caring as outstanding and safe and effective as good. We rated five of the trust’s services at this inspection. In rating the trust, we took into account the current ratings of the services not inspected this time.

We rated well-led at the trust level as requires improvement.

We rated community services as good for safe, effective, responsive and well led. We rated caring as outstanding.

Our decisions on overall ratings take into account, for example, the relative size of services and

we use our professional judgement to reach a fair and balanced rating.

  • Services had not always completed and updated risk assessments for patients. We found that risk assessments such as those for falls or pressure ulcers had not always been completed where required.
  • The trust had not ensured that there had been sufficient numbers of suitably qualified staff available in endoscopy to recover patients. Nursing staffing numbers were not always sufficient for the number of patients being cared for in urgent and emergency services.
  • The service had suitable premises and equipment but had not always looked after them well. This was because we found substances that were hazardous to health that had sometimes been left in unlocked areas, meaning that patients or members of the public could access them. In addition, oxygen cylinders had not always been stored safely, in line with best practice guidance and trust policy.
  • The trust had not always collected, analysed, managed and used information well to support all its activities. This was because information that was provided to CQC before, during and after the inspection had not always been accurate.
  • Staff did not always understand how and when to formally assess and record whether a patient had capacity to decide about their care. We found that capacity had not always been documented when it should have been.
  • The waiting list for the dental paediatric department was excessive. The referral to treatment (percentage within 18 weeks) compliance for October 2018 was 41.9%. This had worsened since October 2017 when the compliance was 54.7%.
  • Medication and controlled drugs were not always securely stored or prepared in line with trust policy, national guidance and legislation. Antibiotic medication were not always reviewed in line with trust policy and best practice guidelines.
  • Waiting times in the emergency department had all risen and were greater (longer or more) than the national average. Patients waited for extended periods of time on the corridor to be seen, in some cases more than ten hours. Although complaints had been managed appropriately and with compassion, response times needed improving
  • There was evidence that incidents were not always being reported and investigated in a timely way in line with trust policy and national guidance.

However:

  • The trust managed infection prevention and control well, the results of infection prevention and control audits were scrutinised and improvements to practice actively sought.
  • The service had effective arrangements in place to recognise and respond appropriately to patients
  • Staff understood how to protect patients from abuse and the service worked with other agencies to do so. Staff received training in safeguarding.
  • Managers across services promoted a positive culture that and valued staff, creating a sense of common purpose based on shared values.
  • Staff cared for patients with compassion and patient’s dignity was maintained on all occasions that we observed care being delivered.
  • There was consistent and effective multidisciplinary working across the service. Staff worked alongside; medical staff, external partner agencies, mental health professionals, commissioners and social workers to plan care for patients and provide a joint approach to patient care.
  • The trust had developed appropriate strategies which directly linked to the vision and values of the trust.

Our full Inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website –

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Inspection areas

Safe

Good

Updated 17 July 2019

Our rating of safe stayed the same. We rated it as good because:

  • There were systems and processes in place to keep people safe from abuse and safeguarding policies were in line with best practice guidance.
  • Staff could access patient information when they needed it to plan and deliver care, treatment and support
  • People received their medicines when required.
  • Staff kept detailed records of patients' care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

However

  • There were periods of understaffing or inappropriate skills mix which were not always addressed quickly enough. Due to sickness and vacancies in the trust there was a high number of bank and agency staff used.
  • Information on patient safety was not always timely. Risk assessments were not always being completed in some service areas.
  • Incidents were not always being recorded or investigated in a timely way and in line with national guidance and trust policy. People did not always receive a timely apology when something went wrong.
  • There were areas where medication was not securely stored in line with national guidance and trust policy.
  • There were areas that had equipment that were overdue for servicing in line with guidance

Effective

Good

Updated 17 July 2019

Our rating of effective stayed the same. We rated it as good because:

  • People’s care and treatment was planned and delivered based on national guidance and standards and there was participation in relevant local and national clinical audits to help improve standards of care.
  • Pain relief was effectively managed.
  • There was good multidisciplinary team working throughout services with treatment plans being discussed by a range of healthcare professionals.

However

  • Staff did not always adhere to the Mental Capacity Act 2005 principals and guidance was not always effective. There were times when a capacity assessment had not been undertaken before deprivation of liberty safeguards applications had been made.
  • In some services outcomes for patients who used services were sometimes below expectations when compared with similar services.
  • Not all staff had the right skills and experience to fulfil their roles.

Caring

Outstanding

Updated 17 July 2019

Our rating of caring improved. We rated it as outstanding because:

  • Feedback from people who used the services and those close to them were positive about the way staff treated people.
  • People were treated with respect and kindness during all interactions we observed. People felt supported and said staff cared for them.
  • Staff supported people and those close to them to manage their emotional responses to care and treatment. Personal, cultural, social and religious needs were understood.
  • People said staff spent time with them and provided information in a way they could understand. Staff responded compassionately when people needed help and support.
  • People’s privacy and confidentiality was respected the majority of times.

Responsive

Requires improvement

Updated 17 July 2019

Our rating of responsive stayed the same. We rated it as requires improvement because:

  • Complaints were not always being responded to in a timely way.
  • People did not always receive treatment in a timely way. This was because the urgent and emergency service had continually failed to meet the target to transfer, admit or discharge patients.
  • There were long waits for paediatric dental patients to be seen within dental services.
  • People could not always access services when they needed it. Waiting times to access gastroenterology and dermatology services were worse than the national average.
  • Access and flow continued to be a challenge for the trust and there were a number of patient moves out of hours, a high number of delayed discharges and patients being cared for on a ward or that did not meet their speciality. There were also times when patients were held in recovery areas for a long period of time due to lack of beds on the wards.

However

  • Services had responded to individual needs. For example, areas designed to help people living with dementia and support for people living with a learning disability.
  • There was a translation service in place and there was access to a psychiatric liaison service when required.

Well-led

Requires improvement

Updated 17 July 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • People did not always receive a timely apology when something went wrong in line with national guidance and regulation.
  • Information that was used to monitor performance or make a decision could not be relied on to be accurate or reliable. For example, staffing information.
  • Initial reviews of serious incidents had not always taken place in a timely manner and there was evidence that incidents were not always being reported in a timely way which was not being monitored or reported through governance structures.
  • The process for escalating and de-escalating risk within the organisation was not always clear with different understanding of the system expressed by different levels of staff.

  • Although the trust recognised their plans to deliver financial sustainability were linked to the full business case for the merger with another trust this was not completed when we undertook the inspection.
  • Managers had not always been aware of areas of poor performance. For example, senior managers had not been aware that mental capacity assessments had not been completed correctly, particularly when applications for Deprivation of Liberty safeguards had been made.

However

  • The trust had an experienced leadership team with the skills, abilities, and commitment to provide high-quality services. They recognised the training needs of managers and worked to provide development opportunities for the future of the organisation.
  • The trust was committed to improving services by promoting training, research and innovation. They were part of the Global Digital Exemplar programme and had also been involved in a number of clinical research studies.

  • Managers across services promoted a positive culture that promoted and valued staff, creating a sense of common purpose based on shared values.

Checks on specific services

Community health services for adults

Good

Updated 17 July 2019

This service had not previously been inspected. We rated it as good because:

  • There were appropriate systems in place to keep people safe. Relevant risk assessments were completed for each patient who accessed community services. Thorough records were kept detailing the care and treatment provided to each patient and these records were accessible when needed.

  • Staff took a holistic approach to planning patient care. Where appropriate, staff took the opportunity to promote positive lifestyle changes such as to improve diet and exercise. As well as this, staff considered the emotional needs of patients and those close to them.

  • We observed staff treating patients and their relatives with respect and compassion. Feedback from patients was consistently positive and those we spoke to told us of how accessing the services had directly improved their quality of life.

  • Staff across the service had worked to build and maintain close links with local charities, support groups and patient groups so that they could provide more holistic care to patients and their relatives.

  • There was consistent and effective multidisciplinary working across the service. Staff worked alongside; medical staff, external partner agencies, mental health professionals, commissioners and social workers to plan care for patients and provide a joint approach to patient care.

  • There was effective leadership across the service. Senior leaders acted as a driver for continuous learning and improvement.

  • Staff working within the service worked alongside external stakeholders such as charities and patient groups to deliver services which met the needs of patients.

    However;

  • Staff working remotely told us that they were unable to access the same information within the electronic records system used by acute services within the Trust and external providers. When we raised this with senior managers they informed us that staff did have access to these systems.

  • Service leads were working to improve data collection so that they could better evidence the effectiveness of the service in terms of patient outcomes.