WarringtonandHaltonHospitalsNHSFoundation …...LetterfromtheChiefInspectorofHospitals...

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Urgent and emergency services Good –––

Medical care (including older people’s care) Requires improvement –––

Surgery Good –––

Critical care Requires improvement –––

Maternity and gynaecology Requires improvement –––

Services for children and young people Good –––

End of life care Good –––

Outpatients and diagnostic imaging Requires improvement –––

Warrington and Halton Hospitals NHS FoundationTrust

WWarringtarringtonon HospitHospitalalQuality Report

Warrington HospitalLovely LaneWarringtonCheshireWA5 1QGTel: 01925 635911Website: www.whh.nhs.uk

Date of inspection visit: 7, 8, 9, 10 March 2017 and 23March 2017Date of publication: 27/11/2017

1 Warrington Hospital Quality Report 27/11/2017

Letter from the Chief Inspector of Hospitals

We carried out an announced inspection of Warrington Hospital between the 7 and 10 of March 2017. In addition, wecarried out an unannounced inspection between 3pm and 9pm on the 23 March 2017. This inspection was to follow upon the findings of our previous inspections in January and February 2015, when we rated the trust as requiresimprovement overall. We also looked at the governance and risk management support for all of the core services weinspected.

At this inspection we inspected the following services at Warrington Hospital:

• Urgent and Emergency Care

• Critical Care Services

• Services for Children and Young People

• Maternity and Gynaecology Services

• Medical Services [Including the care of older people]

• Surgery

• End of Life Services

• Outpatient and Diagnostic Services

As part of this inspection, CQC piloted an enhanced methodology relating to the assessment of mental health caredelivered in acute hospitals; the evidence gathered using the additional questions, tested as part of this pilot, has notcontributed to our aggregation of judgements for any rating within this inspection process. Whilst the evidence is notcontributing to the ratings, we have reported on our findings in the report.

We rated Warrington Hospital as requires improvement overall with Medicine [including older people’s care] CriticalCare, Outpatient and Diagnostic services and Maternity and Gynaecology Services as requires improvement. We ratedUrgent and Emergency , Surgery, End of Life Services and Services for Children and Young People as good.

There had been progress since our previous inspection with, improvements noted in urgent and emergency care,maternity, surgery, outpatient and diagnostic services and Critical care. However, Warrington Hospital continues torequire improvement in key areas.

Our key findings were as follows:

• Systems had been put in place to improve access and flow through the Accident and Emergency department andalthough targets were not been met there had been a continuous improvement in waiting times.

• The trust monitored the number of cancelled operations on the day of surgery. Performance data showed that thenumber of cancelled operations on the day of surgery had improved from 11.9% in February 2016 to 8.8% inJanuary 2017.

• The National Paediatric Diabetes Audit 2014/15 showed that Warrington hospital performed better than theEngland average for the number of individuals who had controlled diabetes.

• There had been some improvements since our last inspection in January 2015: working relationships betweenmedical staff and midwifery staff, overall culture was improving, WHO checklist and consent forms, laparoscopichysterectomies were undertaken and mandatory training for nurse and midwifery compliance rates had improved.

We saw some areas of outstanding practice including:

Summary of findings


• The trust had developed the Paediatric Acute Response team to deliver care in a Health and Wellbeing Centre incentral Warrington. This allowed children and young people to access procedures such as wound checks andadministration of intravenous antibiotics in a more convenient location. It also allowed nurse-led review of a rangeof conditions such as neonatal jaundice and respiratory conditions in a community setting that would havepreviously necessitated attendance at hospital.

• Within the urgent and emergency care division, the use of the Edmonton frailty tool in the treatment of olderpeople in the department and the wider health economy.

• The training of all the consultants within the accident and emergency department in the use of ultrasound fortimely diagnosis of urgent conditions.

• The trust had direct access to electronic information held by community services, including GPs. This meant thathospital staff could access up-to-date information about patients, for example, details of their current medicine.

• The environment on the Forget Me Not ward had been designed using the recommendations set out by The KingsFund to be dementia friendly. The ward was designed to appear less like a hospital ward and featured colour codedbay areas and a lounge and dining area designed to look like a home environment. There was access to anenclosed garden and a quiet room.

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

Importantly, the hospital must:

• The hospital must ensure that staff receive training on the Mental Capacity Act (2005) and that staff work inaccordance with The Act.

• The hospital must ensure that paper and electronic records are stored securely and are a complete and accuraterecord of patient care and treatment.

• The hospital must ensure that staff receive the appropriate level of safeguarding training.

• Critical care services must improve compliance with advanced life support training updates and ensure that thereis an appropriately trained member of staff available on every shift.

• The hospital must ensure that the formal escalation plan to support staff in managing occupancy levels in criticalcare is fully implemented.

• The hospital must ensure that there are appropriate numbers of staff available to match the dependency ofpatients on all occasions.

• The hospital must ensure that all risks are formally identified and mitigated in a timely way as part of the riskmanagement process.

• The hospital must take action to ensure that all safety and quality assurance checks are completed anddocumented for all radiology equipment, in accordance with Ionising Radiations Regulations.

• The hospital must ensure midwifery, nursing and medical support staffing levels and skill mix are sufficient in orderfor staff to carry out all the tasks required for them to work within their code of practice and meet the needs of thepatient.

• The hospital must ensure all necessary staff completes mandatory training, including Level 3 safeguarding training.

• The hospital must ensure that the assessment and mitigation of risk and the delivery of safe patient care is in themost appropriate place.

Summary of findings


• The hospital must review the impact of the triage system on access and flow and the appropriate assessment ofpatient safety.

• The hospital must review the safety of the induction bay environment to ensure patient safety is maintained at alltimes and that the premises are safe to use for the purpose intended.

• The hospital must ensure that all staff receives medical devices training and this is recorded appropriately.

• The hospital must ensure that that the risk register and action plans are comprehensive, robust and adequate toimprove patient safety, risk management and quality of care.

• The hospital must ensure staffing levels are maintained in accordance with national professional standards.

• The hospital must ensure that there is one nurse on duty on the children’s unit trained in Advanced Paediatric LifeSupport on each shift.

In addition the trust should:

• The hospital should ensure that the mandatory and safeguarding training rates are monitored for medical staff.

• The hospital should consider that the urgent and emergency care department make improvements to the roomused to see patients with mental health problems, particularly to the doors so that they open outwards.

• The hospital should make reasonable adjustments for appropriate patients including those with a learningdisability.

• The hospital should improve appraisal rates for nurses and medical staff.

• The hospital should consider that the Early Pregnancy Assessment Unit (EPAU) is opened seven days a week.

• The hospital should identify ways to improve multidisciplinary attendance at local and divisional meetings.

• The hospital should consider the safe storage of patient’s notes on the wards.

• The hospital should consider the dignity and privacy of patients within the clinical areas and maternity theatre.

• The hospital should review accommodation on wards where patients are at the end of their lives. To allow themto supported in rooms that afford privacy for the patient and families.

• The hospital should review access to specialist palliative care medical support out of hours.

• The hospital should continue to review compliance with DNACPR policy and clear application and documentationof mental capacity assessments.

• The hospital should ensure all patient case note records are maintained in a complete and chronological order,with accurate details of follow up for patients who did not attend appointments.

• The hospital should ensure patients receive sufficient, clear and appropriate information regarding their hospitalappointment. This should include adequate directions to clinic locations and relevant written information abouttreatment plans where this is indicated.

Professor Ted BakerChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Good ––– At the previous inspection in January 2015, werated this service as good. Following this inspectionwe have maintained the overall rating because:On arrival at the hospital, patients were triaged tothe most appropriate department to meet theirneeds. Appropriate risk assessments were in placeto protect patients and analgesia for pain reliefcould be administered to patients. Patients weremonitored using appropriate tools and anydeterioration in a patient’s condition would beescalated.There were processes in place to help to keeppeople safe, incident reporting was good andinfection control measures were in place. Medicineswere administered to patients in a timely way andthere were regular checks of equipment. The nurseshad reached the trust target for mandatory training.Treatment and pathways for patients weredeveloped using national and local guidance andwas delivered by competent staff working inmulti-disciplinary teams. There were reviewstructures in place so that treatment was up to dateand these were monitored by the staff.Staff were caring and supported patients and theirrelatives and carers. Privacy and dignity weremaintained at all times. Systems had been put inplace to improve access and flow through thedepartment and although targets were not beenmet there had been a continuous improvement inwaiting times.Governance structures were robust and there wasstrong leadership in the department. Staff wereempowered through development and learningopportunities and morale in the department wasgood.However:The department was not meeting Department ofHealth standard for emergency departments is that95% of patients should be admitted, transferred ordischarged within four hours of arrival in the urgentand emergency care centre.The department was not meeting the targets fortime to initial assessment (emergency ambulance

Summaryoffindings

Summary of findings


cases only) which should be less than 15 minutesand the time patients should wait from time ofarrival to receiving treatment is no more than onehour.There was insufficient medical cover at night in thedepartment though this had been addressed by theunannounced inspection.Doctors had not completed their mandatorytraining. Appraisals for nurses and doctors had notbeen completed.The mental health room in the department was notfit for purpose and needed to be improved.The department needed to work better withpatients with learning disabilities to understandtheir needs.Reasonable adjustments needed to be made forappropriate patients.

Medical care(includingolderpeople’scare)

Requires improvement ––– At the previous inspection in January 2015, werated this service Requires improvement. Followingthis inspection we have maintained the overallrating because:There were times when there were insufficientregistered nurses to care for patients. There werehigh numbers of medical staff vacancies and agencyuse was high.Patients did not always receive timely medicalintervention, for example in cases of sepsis.Medical handovers were unstructured and medicalnotes did not always contain sufficient informationabout patient care and treatment.Mandatory training rates for medical staff, includingsafeguarding training, were all below trust target.Appraisal rates were also below the trust target.Patients were at risk of being unlawfully deprived oftheir liberty or receiving care and treatment withoutconsent to because staff did not follow the trustMental Capacity Act procedure.Governance systems were not sufficientlyembedded within the acute care division. The riskregister was not effectively managed to show howrisks to patients or the service were being reduced.Complaints were not always responded to in atimely way.However:Care was provided in line with best practice bymulti-disciplinary teams who worked well together.

Summaryoffindings

Summary of findings


Patient outcomes were generally good and the trustmet the national target for treatment waiting times.Staff were kind, caring and compassionate andunderstood the emotional needs of their patients.The Forget Me Not ward was designed to meet theneeds of patients living with dementia and staffprovided individualised care for this patient group.Staff were positive about the leadership and cultureof the service.

Surgery Good ––– At the previous inspection in January 2015, werated this service as good. Following this inspectionwe have maintained the overall rating because:We found there was a good culture of incidentreporting in order to learn and share good practice.Serious incidents were investigated fully toestablish the root cause, and lessons learnt wereshared with staff to avoid reoccurrence.All clinical areas and bed spaces on the surgicalwards we visited appeared visibly clean andcleaning schedules were maintained.Staff could identify and respond appropriately tochanging risks to patients, including deterioratinghealth and wellbeing or medical emergencies.Mandatory training compliance for nursing staffacross the division had improved following the lastinspection.We saw that the service took part in a range of localand national audits and results were discussed atclinical audit meetings and actions for furtherimprovements identified.All patients and relatives we spoke with told us thatthat all members of staff treated them with dignityand respect.We observed many positive interactions betweenstaff and patients during our inspection. We sawthat staff were professional and friendly andcreated a relaxed friendly environment.Patients we spoke with were very positive about theway staff treated them.Patients and those close to them told us that theywere involved in planning and making decisionsabout their care and treatment.Bed meetings took place four times a day to ensureflow was maximised across the hospital.

Summaryoffindings

Summary of findings


The trust monitored the number of cancelledoperations on the day of surgery. Performance datashowed that the number of cancelled operations onthe day of surgery had improved from 11.9% inFebruary 2016 to 8.8% in January 2017.Between October 2015 and November 2016, theaverage length of stay for surgical elective patientswas better at the trust at 2.7 days, compared to 3.3days for the England average.There were a number of specialist nurses within thetrust to help support the care and treatment ofpatients.The trust’s referral to treatment time (RTT) for thepercentage of patients seen within 18 weeks was76.9%, which was better than the England averageof 71.5%.There was 24-hour medical cover on site to attendto patients who had deteriorating needs.Senior managers were clear on their strategy toprovide high quality services for patients, whichincluded working collaborative within theorganisation, and in partnership with other trusts todeliver high quality services.We saw that Local Invasive Standards for InvasiveProcedures (LocSSIP’s) had been developed inpartnership with the North West theatre network.The standards were in place to ensure high quality,safe care and treatment for all patients.However:We found not all theatre equipment was clean.However, we saw on the unannounced inspectionthat all theatre equipment appeared clean and newcleaning schedules introduced with oversightprovided by managers.We found some omissions in the completion of dailychecks such as resuscitation equipment, anestheticmachines and controlled drugs. However, we sawon the unannounced inspection that newanesthetic logbooks were in use, and daily checksrecorded and, controlled drugs and resuscitationequipment had been checked.We found in theatres that not all stock ready for usewas within its expiry date. For example, on theemergency airways trolley the suction catheter andflexible tracheal tube introducer commonly knownas a bougie had passed its expiry date.

Summaryoffindings

Summary of findings


Vacancy rates for nurse staffing was variable acrossthe wards. All staff we spoke with reported this as aconcern and often meant they needed to movewards to provide safe staffing levels.In recovery, we saw that national guidance was notbeing adhered to ensure there were enoughsuitably qualified recovery nurses on shift withadvanced life support training.Although ward staff had knowledge of capacityassessments and best interests meetings, we sawno evidence in three applicable records that thishad been applied for those patients who wereunable to consent to care and treatment.Theatre lists did not always run on time due tothere not always being available beds for patientspost operatively.Data provided by the trust showed that betweenSeptember 2016 to December 2016 there were 1180medical outliers on surgical wards. This number ofmedical outliers impacted on the number ofavailable beds for surgical patients on the surgicalwards.Although there were formal audits completed thatincluded infection control, we saw no evidence thatmanagers had a formal system or process ofoversight, that ensured the cleanliness ofequipment, and system checks were maintained.However, during the unannounced inspection wesaw that the service managers had reacted quicklyto our concerns, and new systems and processesimplemented with management oversight toensure compliance with standards and policy.September 2016 to December 2016, there were 1180medical outliers on surgical wards. This number ofmedical outliers impacted on the number ofavailable beds for surgical patients on the surgicalwards.

Critical care Requires improvement ––– At the previous inspection in January 2015, werated this service as Requires Improvement.Following this inspection we have maintained theoverall rating because:We were not assured that critical care services wereable to provide a member of staff who was up todate with advanced life support training on everyshift. Advanced life support training for adults and

Summaryoffindings

Summary of findings


children was not provided for any nursing staff.Additionally, only 55% of medical staff and 79% ofacute response team staff had completed trainingupdates.At the time of inspection, there was limitedevidence that sufficient controls were in place toprevent the service exceeding full capacity. This wasbecause critical care services were not currentlyusing a formal escalation policy.There were several occasions when the service hadbeen unable to provide appropriate numbers ofnursing staff to match the dependency of patients.Critical care had an informal vision and strategy toimprove the services provided. However, we foundthat this plan was not documented in eitherdepartmental documentation or in the divisionalbusiness plan. This meant that we were unsure howthe strategy was being monitored and measured.We found that appropriate actions had not alwaysbeen taken in a timely way to mitigate the level ofrisk for those which had scored highly. Additionally,there were a number of risks that had not beenformally identified.The critical care unit had struggled to meet thestandard set by the Department of Health inmanaging mixed sex accommodationappropriately. We saw examples of this during theinspection.Records indicated that between January 2016 andDecember 2016, there had been 75% delayeddischarges (greater than four hours following thedecision being made that a patient is fit fordischarge to a ward).However:The unit used a combination of best practice andnational guidance to determine the care that theydelivered. These included guidance from theNational Institute for Health and Care Excellence(NICE) and the Intensive Care Society (ICS).The most recently available and validated ICNARCdata (April 2016 to September 2016) showed thatthe patient outcomes and mortality were similar tobenchmarked units nationally.

Summaryoffindings

Summary of findings


Staff treated patients in a caring andcompassionate way; maintaining their privacy anddignity at all times. Both relatives and patients werepositive about their time in the unit and spokehighly of the way in which they had been cared for.Staff informed us they felt that there was an openand honest culture within the department. Weobserved all team members working well togetherduring the inspection.

Maternityandgynaecology

Requires improvement ––– At the previous inspection in January 2015, werated this service as Requires Improvement.Following this inspection we have maintained theoverall rating because:Although staffing levels had improved since the lastinspection, adequate staffing and skill mixremained an issue within the service.Shift leaders on the labour ward and other wardswithin the division, were often not supernumerarydue to staffing levels and workload.There was no dedicated Triage area or Triage teamin the maternity unit.The induction bay area was an inadequate andunsafe environment for patients and had anadverse effect on staffing levels on the maternityward.Due to medical staffing levels and access and flowissues, there were often delays in patients beingadmitted, reviewed and /or discharged fromhospital.Outlier patients posed access and flow issues on thegynecology ward.There were no established transitional care facilitiesavailable for babies on the maternity wards.There was no dedicated obstetric staff for the dailyelective caesarean section list. This led tocancellations and delays in treatment and care.The maternity services did not have a currentrobust data collection system, such as a maternitydashboard, to benchmark and review clinical andquality performance outcomes and implementclinical changes to improve patient care.The risk register did not provide assurance thataction plans were comprehensive, robust andadequate to improve patient safety, riskmanagement and quality of care, as many riskswere static in their ratings.

Summaryoffindings

Summary of findings


The service did not record staff competencies formedical devices training.Patient records were not securely stored in lockedtrolleys.We observed a patient experiencing a sensitiveprocedure in a six-bedded bay ina gynaecology ward. This was due to access andflow issues but also highlighted that the needs ofthe individual were not met.Staff informed us that senior trust leadership were“still slightly reactive” in their management style,even though this had improved recently. Seniormanagement told us that the organisation tendedto focus on displays of compliance and safety afterincidents and events had taken rather thananticipating and mitigating risks to improve thequality of care.Not all staff were clear on the future strategy formaternity services.However:There had been some improvements since our lastinspection in January 2015: working relationshipsbetween medical staff and midwifery staff, overallculture was improving, WHO checklist and consentforms, laparoscopic hysterectomies wereundertaken and mandatory training for nurse andmidwifery compliance rates had improved.The appointment of the new Head of Midwifery hada positive effect on staff and the future of theservice.The Alongside Midwifery Led Unit (AMU) was in itsearly stages of development but there was a realfocus on normal labour and birth.The service had recently relaunched the MaternityServices Liaison Committee (MSLC) with a newlyappointed chair.Staff were caring, kind and patient and werecommitted to providing good care to patients.

Services forchildren andyoungpeople

Good ––– Staff could demonstrate the process to reportincidents.The wards and clinical areas were visibly clean.Staff were aware of and adhered to currentinfection prevention and control guidelines such asthe ‘bare below the elbow’ policy.

Summaryoffindings

Summary of findings


Staff were aware of their safeguarding roles andresponsibilities and knew how to raise matters ofconcern appropriately.Paediatric consultants who took part in a“Consultant of the week” rota were present in thehospital during times of peak activity.Age dependant pain assessment tools were in use inthe children’s unit and analgesia and topicalanaesthetics were available to children whorequired them.The National Paediatric Diabetes Audit 2014/15showed that Warrington hospital performed betterthan the England average for the number ofindividuals who had controlled diabetes.Staff were observed treating patients and theirrelatives with kindness and respect both in personand on the telephone. Facilities were available forparents to stay with their children.Specialist nurses were in post in a range ofspecialities including Epilepsy and Diabetes andprovided support to young people transitioning toadult services.A Child and Adolescent Mental Health Services(CAMHS) worker was present in the paediatricemergency department between 5pm and 11pmseven days per week to ensure timely assessment ofchildren and young people.The Paediatric Acute Response Team (PART) workedwith a local community trust to reduce the need forchildren and their families to attend hospital.Data from the trust showed 90.5% of patientsreferred to paediatric services were seen within the18-week standard.There was no dedicated paediatric pharmacist forthe children’s unit which is not in line with acceptedbest practice. There was not always a nurse on dutyon the children’s unit with Advanced Paediatric LifeSupport (APLS).Staffing within the children’s unit did not followRoyal College of Nursing (RCN) standards (August2013) and neonatal nurse staffing did not meetstandards of staffing recommended by the BritishAssociation of Perinatal Medicine (BAPM).Adult areas were children were seen with theexception of ophthalmic clinic, lacked any childfriendly decoration or activities.

Summaryoffindings

Summary of findings


End of lifecare

Good ––– At the previous inspection in January 2015, werated this service as Good. Following this inspectionwe have maintained the overall rating because:Since our last inspection the hospital specialistspalliative care team (HSPCT) had reviewed thestrategy for end of life care and had undertaken aself-assessment structured around the six nationalambitions for palliative and end of life care.We reviewed the trust self-assessment and actionplan for ensuring the implementation of the“Ambitions for Palliative and End of Life Care” toimprove the provision of better care for patients atend of life. Actions included the development ofmore leaflets for relatives to improvecommunication and active engagement in regionalaudits to ensure the HSPCT is complying with bestlocal and national best practice.There were systems for reporting actual andnear-miss incidents across the hospital whichmeant the service was able to monitor any risks andlearn from incidents to improve the quality ofservice delivery.There were sufficient numbers of trained clinical,nursing and support staff with an appropriate skillmix to ensure that patients receiving end of life carewere well cared for in all the settings we visited.Medicines were prescribed, stored andadministered safely. Access to medicines for peopleneeding continuous pain relief was available toensure patient’s pain was managed.The HSPC team had received mandatory trainingsuch as safety and safeguarding in order tomaintain the safety of patients.To meet patients’ needs the HSPC team haddeveloped a training programme for specialistpalliative care across the trust with end of life linknurses for each ward to support, advise andeducate other ward staff in relation to end of lifecare.The HSPC team was adequately staffed, well trainedand received regular appraisals.A care management approach “amber care bundle”was in place when doctors were uncertain whethera patient may recover and were concerned thatthey may only have a few months left to live. This isan approach to care management used in hospitalswhen doctors are uncertain whether a patient may

Summaryoffindings

Summary of findings


recover and are concerned that they may only havea few months left to live. The trust had appointed adesignated member of staff who worked within thepalliative care team to facilitate implementationacross the trust.The trust participated in the “End of life care Audit:Dying in Hospital 2016”, which replaced the NCDAH.The audit results showed an improvement in end oflife care at the trust. Out of 17 clinical andorganisational indicators the trust had performedeither better than or in line with national average inthe majority of the indicators. The trust performedbetter than the England average for three of the fiveclinically related indicators. The trust scoredparticularly well for having documented evidencethat the needs of person(s) important to the patientwere asked about, scoring 3% compared to thescore of 56%.However:At our last inspection, we found there was no accessto specialist palliative care medical support out ofhours. At this inspection, we found this was still thecase with no access to out of hour’s specialistpalliative care medical support.Senior managers told us that they had improvedaccess to support and advice through the hospitalintranet and the lack of specialist palliative medicalsupport had been identified on the trust riskregister.The trust had commissioned an external audit ofthe use of the DNACPR policy as well as its owninternal audit. Results showed there were a numberof occasions, where documentation in relation toDNACPR forms has not been in line with TrustPolicy.Engaging in difficult conversations with patients,family or carers was not always fully recordedwithin the case notes. Patient’s wishes were notappropriately discussed and recorded, and as aresult, they are not treated appropriately Wereviewed the action plan which had been put inplace to ensure the staff training and monitoring ofthe DNACPR policy was strengthened.to ensure thatthe DNACPR’s are completed accurately with themedical rationale for not attempting resuscitationand discussions with patients and family beingrecorded appropriately.

Summaryoffindings

Summary of findings


The lack of a clear mental capacity assessmentmeant that the service could not be clear how muchthe patient understood the care they were receivingand it may not have access to reasonableadjustments such as access to specialist support.We found that patients at the end of their livescould not always be assured of a single room toensure privacy.

Outpatientsanddiagnosticimaging

Requires improvement ––– At the previous inspection in January 2015, werated this service as Requires Improvement.Following this inspection we have maintained theoverall rating because:The CT waiting area was not suitably designed tokeep people safe. The area was too small andlacked equipment that would be required in anemergency. The area lacked also privacy anddignity.We found three breaches of Health and SafetyExecutive guidance note PM77 ‘Equipment used inconnection with medical exposure’ Regulation 36where there was no record that the equipment hadbeen tested and signed back into use following faultrepairs in the CT department.Audit evidence showed poor compliance with theWHO (World Health Organisation) surgical safetychecklist in interventional radiology.We found six separate breaches of IonisingRadiation Regulations 99, regulation 32, whichrefers to routine quality assurance of equipmentused in diagnostic imaging.Appraisal rates and personal development reviewsacross the department did not meet the trust targetof 85%.The general outpatient area was difficult to locatewith poor signage from the main entrance to thedepartment.There was a lack of available rooms for counsellingpatients in the breast screening clinic.There had been significant changes in theleadership team which had the left the staff feelingdisconnected and ensure of the strategy and futurevision of the service.However:We saw evidence of safe practice within theOutpatient department.

Summaryoffindings

Summary of findings


There was evidence of hand hygiene complianceand monitoring with regular audits undertakenacross six outpatient locations.Clinical audits were performed in line with bestpractice and results frequently shared at a regionaland national level.We saw evidence that staff from several disciplineswork together to assess, plan and deliver care andtreatment to patients including clinicians and alliedhealth professionals.Cross-site culture was good and staff reported goodcollaborative working, staff were happy to movebetween hospital teams.

Summaryoffindings

Summary of findings


WWarringtarringtonon HospitHospitalalDetailed findings

Services we looked atUrgent and emergency services; Medical care (including older people’s care); Surgery; Critical care;Maternity and gynaecology; Services for children and young people; End of life care; Outpatients anddiagnostic imaging


Contents

PageDetailed findings from this inspectionBackground to Warrington Hospital 19

Our inspection team 20

How we carried out this inspection 20

Facts and data about Warrington Hospital 21

Our ratings for this hospital 21

Findings by main service 23

Action we have told the provider to take 232

Background to Warrington Hospital

Warrington Hospital is the main district general hospitalsite, located in Warrington, Cheshire, which hosts theaccident and emergency department.

Medical care is provided at Warrington Hospital from 12inpatient wards and an endoscopy unit. There were17,803 inpatient medical admissions between October2015 and September 2016. Over 90% of patients wereadmitted under general medicine or gastroenterology.Other medical specialities provided at the hospitalinclude cardiology, haematology, stroke medicine andrespiratory medicine.

Surgical services including: urology, ophthalmology,trauma and orthopaedics and general surgery (such ascolorectal surgery). Hospital episode statistics showedthat between October 2015 to September 2016, 29,590patients were admitted for surgery at the trust acrossWarrington and Halton sites. The data showed that18,069 (61%) of patients had day case procedures, 4240(14.3%) had elective surgery and 7281 (24.6) wereemergency surgical patients. The number of patientsadmitted for surgery had increased by 8726 from the2013/14 statistics.

Critical care services are divided into two main areas. Themain intensive care unit is an open area which has a totalof 14 bed spaces. The high dependency area has six beds,including two isolation rooms that produce positive or

negative pressure. The unit is part of the Cheshire andMersey Critical Care Network (CMCCN). Between April2015 and March 2016 there had been approximately 800admissions to the service from the local area.

Warrington Hospital offers pregnant patients and theirfamilies’ antenatal, delivery and postnatal care in theWarrington and Halton areas. The maternity facilities arebased at Warrington Hospital. The services provideantenatal and post-natal care (inpatient and outpatient),labour ward, ultrasound scanning, two obstetric theatresand an Alongside Midwifery Led Unit (AMU), which is in itsearly development stage.

Warrington Hospital provides a range of paediatric andneonatal services. Neonatal services are located on thefirst floor and paediatric services are located on theground floor of the main hospital building in Warrington.The neonatal unit has 18 cots and provides intensivecare, high dependency care and special care for newbornbabies. The children’s unit consists of 37 beds, whichinclude a 10 bedded cubicle area incorporating one highdependency bed, a seven bed paediatric day surgery areaa six bedded assessment area and a 14 bedded bay area.A dedicated paediatric outpatient clinic is located next tothe children’s unit and a paediatric accident andemergency area is situated next to the main accident andemergency department. A paediatric acute responseteam (PART) deliver care in conjunction with a localcommunity provider at a Health and Wellbeing centre inWarrington town centre.

Detailed findings


Hospital episode statistics data (HES) showed there were5435 children and young people seen between 1December 2015 and 30 November 2016. Of these 93.1%were emergency admissions, 5.4% were day caseadmissions and 1.5% were elective admissions.Gynaecology services are based at both the Warringtonand Halton sites. The gynaecology/surgical ward atWarrington had 14 inpatient beds and a separatededicated bay for clinic patients, however; this is used asan escalation bay when bed shortages in the hospital.The ward has provision for emergency attenders whorequire a medical review. The Early PregnancyAssessment and Gynaecological Rapid Access clinic issituated at the end of the area in a separate space. Theward also consists of outpatient procedure rooms forColposcopy and Hysteroscopy. Main GynaecologyOutpatients is a dedicated outpatient area with adedicated scanning room from January 2017.

End of life care services were part of the hospital acutecare division. Warrington Hospital’s specialist palliativecare team offered a service from Monday to Friday withcore hours of 9am to 5pm seven days a week. Patientswith palliative/end of life needs were accommodated onthe general wards in the hospital. The trust provided a

consultant led hospital specialist palliative care (HSPC)team. The HSPC team is a resource available to all clinicalareas within the hospital providing specialist palliativecare, advice and support for adult inpatients that areaffected by cancer and other life limiting illnesses. TheHSPC team provides an advisory and supportive servicewhilst the medical and nursing management of thepatient remains the responsibility of the ward teams.

A range of outpatient and diagnostic services areprovided at Warrington Hospital. A number of outpatientappointments are also offered at the Halton site.

Warrington Hospital offers a combination of consultantand nurse-led clinics for a full range of specialitiesincluding cardiology, respiratory medicine, breastsurgery, gynaecology, dermatology, pain management,trauma and orthopaedics, maxillo-facial surgery,audiology and therapy services.

Warrington Hospital offers a comprehensive range ofdiagnostic and interventional radiography services topatients including: general x-ray, computerisedtomography (CT) scans, magnetic resonance imaging(MRI), ultrasound and mammography.

Our inspection team

Our inspection team was led by:

Chair: Bill Cunliff, Consultant colorectal surgeon with 6years’ experience as a medical director

Head of Hospital Inspection (lead): Ann Ford, CareQuality Commission.

The team included two CQC Inspection Managers, 12 CQCinspectors and a variety of specialists including Juniordoctor, NHS Consultant, Emergency Department Doctorand Nurse, Consultant physician, Clinical NurseSpecialist: Infection Prevention & Control, Surgeon, LeadSpecialist Nurse, Midwife, Consultant Obstetrician,

Midwifery Nurse, Consultant Paediatrician and PaediatricNurse Consultant, a Head of Safeguarding, a SeniorGovernance and Risk Manager, Allied Health Professional,Senior Nurse Practitioner, Clinical Governance lead,Emergency Department nurse specialist and consultant,a Critical Care nurse, Specialist Occupational Therapistand an End of Life Specialist Consultant.

We had four Experts by Experience on the team and helda listening event on 21 February 2017 which wasattended by a number of local people who hadexperienced the services at the trust.

How we carried out this inspection

To get to the heart of patients’ experiences of care, wealways ask the following five questions of every serviceand provider:

• Is it safe?

• Is it effective?

Detailed findings


• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

The inspection team inspected the following coreservices at the Warrington Hospital:

• Emergency Department

• Critical Care

• Children and Young People

• End of Life

• Outpatients and Diagnostic Imaging Services

Prior to the announced inspection, we reviewed a rangeof information we held and asked other organisations toshare what they knew about the hospital. We interviewedstaff and talked with patients and staff from all the wardareas and outpatient services. We observed how peoplewere being cared for, talked with carers and/or familymembers, and reviewed patients’ records of personalcare and treatment.

We received feedback through focus groups. We wouldlike to thank all staff, patients, carers and otherstakeholders for sharing their balanced views andexperiences of the quality of care and treatment atWarrington and Halton NHS Foundation Trust.

Facts and data about Warrington Hospital

Warrington Hospital is one of three locations providingcare as part of Warrington and Halton Hospitals NHSFoundation Trust. In total, the trust has 591 beds.Between January 2016 and January 2017, there were500,000 individual patient appointments, procedures,stays, and 109,000 emergency department attendances.Warrington and Halton Hospital NHS Foundation Trustprovides services across the towns of Warrington,Runcorn (where Halton General Hospital is based),Widnes and the surrounding areas. It provides access tocare for over 500,000 patients. The trust employs 4,200

members of staff. The total revenue for the trust was£212.7 million while the full cost was £215.6 million. Thismeant the trust had a deficit of £2.9 million. The health ofpeople across Warrington and Halton varies, butoutcomes for people tend to be worse than the nationalaverage, particularly in the Halton area. Life expectancyfor men and women in both areas is worse than thenational average. There is also a higher number ofhospital stays due to self-harm and alcohol related harmin both areas, compared to the national average.

Our ratings for this hospital

Our ratings for this hospital are:

Detailed findings


Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices Good Good Good Requires

improvement Good Good

Medical care Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Surgery Good Good Good Good Good Good

Critical care Requiresimprovement Good Good Requires

improvement Good Requiresimprovement

Maternity andgynaecology

Requiresimprovement


improvementRequires

improvementRequires

improvement

Services for childrenand young people Good Good Good Good Good Good

End of life care Good Good Good Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement Not rated Good Good Requires

improvementRequires

improvement

Overall Requiresimprovement


improvementRequires

improvementRequires

improvement

Detailed findings


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Good –––

Information about the serviceThe urgent and emergency care department was part ofthe acute care directorate. Patients were triaged onarrival in the department to the most appropriate area;the areas were resuscitation, major injuries, minorinjuries, clinical decision unit, ambulatory care andpaediatrics.

In the period April 2016 to February 2017 the departmenthad seen 57,922 adult patients and 15,714 patients whowere children and young people. In the period April 2015to March 2016, the department saw 64,758 adult patientsand 17,728 children and young people. Approximately21% of attendances at the unit were children and youngpeople.

During the inspection we spoke with fifteen patients andtwo carers. We also spoke with the business unit clinicalleads and business lead, five consultants (including thetraining lead), a paediatric nurse consultant, a locumdoctor, two middle grade doctors, a trainee doctor and apaediatric doctor. We also met with the matron and thedeputy matron for the department and the paediatricmatron, two paediatric nurses, the clinical practicefacilitator, three senior nurses, three mental healthnurses, two staff nurses, a band four nurse and two healthcare assistants. We spoke with the lead nurses forambulatory care and the clinical decisions unit, a studentradiographer, the alcohol specialist nurse, two studentnurses, an agency nurse, a porter and two reception staffincluding the co-ordinator.

Before the inspection we looked at information suppliedby the trust and nationally available data. As part of theinspection, we reviewed policies and procedures,minutes of meetings and we spoke with staff and patientsand their carers. We also looked at patient records.

The trust was previously inspected in January 2015 andwere rated as good.

Urgentandemergencyservices

Urgent and emergency services


Summary of findingsWe rated this service as good because:

• On arrival at the hospital patients were triaged to themost appropriate department to meet their needs.Appropriate risk assessments were in place toprotect patients and analgesia for pain relief couldbe administered to patients. Patients weremonitored using appropriate tools and anydeterioration in a patient’s condition would beescalated.

• There were processes in place to help to keep peoplesafe, incident reporting was good and infectioncontrol measures were in place. Medicines wereadministered to patients in a timely way and therewere regular checks of equipment. The nurses hadreached the trust target for mandatory training.

• Treatment and pathways for patients weredeveloped using national and local guidance andwas delivered by competent staff working inmulti-disciplinary teams. There were reviewstructures in place so that treatment was up to dateand these were monitored by the staff.

• Staff were caring and supported patients and theirrelatives and carers. Privacy and dignity weremaintained at all times.

• Systems had been put in place to improve accessand flow through the department and althoughtargets were not been met there had been acontinuous improvement in waiting times.

• Governance structures were robust and there wasstrong leadership in the department. Staff wereempowered through development and learningopportunities and morale in the department wasgood.

However:

• The department were not meeting Department ofHealth standard for emergency departments is that95% of patients should be admitted, transferred ordischarged within four hours of arrival in the urgentand emergency care centre. The department werenot meeting the targets for time to initial assessment

(emergency ambulance cases only) which should beless than 15 minutes and the time patients shouldwait from time of arrival to receiving treatment is nomore than one hour.

• There was insufficient medical cover at night in thedepartment though this had been addressed by theunannounced inspection.

• The department needed to work better with patientswith learning disabilities to understand their needs.This includes making reasonable adjustments tomeet the needs of the individual.




Are urgent and emergency services safe?

Good –––

We rated safe as good because:

• Staff reported an open culture of incident reporting inthe department and there was a variety of ways thatsenior staff fed back to staff about incidents. Mortalitymeetings were used to identify trends and issues.

• There were audits and actions were put in place forinfection control purposes and the numbers of healthcare acquired infections were low. Patients said thatareas were visibly clean and tidy and there was pointof care testing for appropriate patients to identifythose who may need to be isolated to reduce thespread of infection.

• There were issues with the reconciliation of medicinesaccording to the trust policy.

However:

• There were insufficient middle grade doctors to coverthe night shift at the hospital. This had beenaddressed by the unannounced inspection and workwas on going to address this.

• Doctors were not always compliant with the trustmandatory training targets.

• Equipment, including resuscitation trolleys werechecked regularly and this was recorded. Medicineswere stored correctly and fridge temperatures wererecorded.

• There had been a reorganisation of nurse staffing, ascurrently the department did not have enough nurses.There was a programme of workforce development tohelp to address the gaps in nurse staffing and activerecruitment of graduate nurses.

• Risk was managed in the department and there wereprocesses in place to monitor adults and children whowere deteriorating clinically.

• There were issues with the reconciliation of medicinesaccording to the trust policy.

Incidents

• The trust had an electronic system for the recoding ofincidents. In the reporting period 1 January 2016 and

31 December 2016, the ED recorded 1,224 incidents.Most of the incidents were no harm or minor harm, 14were moderate harm. The three top categories fortypes of incidents were pressure ulcers, falls andmedicine incidents. There was feedback to the staffthrough the daily safety briefings, staff meetings andby e-mail.

• It was evident that there had been significant underreporting of incidents before April 2016. There was achange in the senior management of the urgent andemergency care department in April 2016 andfollowing this, the numbers of incidents reportedincreased. There was an open culture of reporting inthe department.

• In accordance with the serious incident framework,the trust had reported three serious incidents(SI’s) inthe urgent and emergency care department whichmet the criteria set by NHS England. The trust hadconducted investigations into these serious incidents.One of the three incidents was a slip trip or fall asecond was abuse/alleged abuse of child patient bythird party. The third of the serious incidents wasdetected at the mortality review group and was afailure to act on test results; the incident was reportedon the 27 January 2016. The investigation report was alevel two serious incident investigation and an actionplan has been put in place following the incident. Theduty of candour was not applied within theappropriate timescales as the incident was detectedat the mortality review group.

• There were criteria for the reviews of deaths and thiswas done by consultants who reviewed patientrecords. The outcomes of reviews were fed into themortality and morbidity group and any concerns werethen taken to the mortality review group. Thesemeetings were used to identify any themes, issues orproblematic areas in the trust.

• A 72-hour report following an incident had highlightedtraining needs around domestic violence, andmulti-agency referrals for children, training had beenput in place following the review.

• We observed that duty of candour was being appliedin the department; this was demonstrated through




incident investigations. We spoke with staff about dutyof candour and that staff understood the duty ofcandour, they apologised to patients who had beenwaiting for treatment and explanations were given.

Safety thermometer.

• The Patient Safety Thermometer is used to record theprevalence of patient harms and to provide immediateinformation and analysis for frontline teams tomonitor their performance in delivering harm freecare. Measurement at the frontline is intended to focusattention on patient harms and their elimination.

• Data from the Patient Safety Thermometer showedthat the trust reported no new pressure ulcers, threefalls with harm and no new catheter urinary tractinfections between February 2016 and February 2017.

• All three falls happened between July and August2016.

Cleanliness, infection control and hygiene

• There was a housekeeper who worked in the urgentand emergency care department. Other housekeepingand domestic staff came into the department earlyand we observed that all areas in the urgent andemergency care department were visibly clean andtidy. Areas were well maintained and in a good state ofrepair. There was a task team who were responsiblefor monitoring and changing curtains in the urgentand emergency care department. All the curtains wechecked were clean and in date.

• Personal protective equipment (PPE) was plentiful andhand gel was available in all areas of the departmentand on going compliance to infection control auditshad improved since April 2016. We saw that staff usedPPE as appropriate.

• There was a trust specialist nurse for infection controland a link nurse in the department. Infection controlwas an agenda item on the senior management teammeetings.

• The department undertook health care acquiredinfection monitoring for MRSA, methicillin-sensitivestaphylococcus aureus (MSSA), clostridium difficile(c.diff), catheter associated urinary tract infections andwound infections. In October 2016 there had been onereported MSSA infection in the clinical decisions unit

of the department for the period October 2016 toDecember 2016. In the previous three months therehad been no health care acquired infections in theurgent and emergency care department.

• Hand washing audits took place every three months,most areas in the department had between 90%and100% compliance with hand washing though inthree areas of the department there was a complianceof 87.5%, 89.6% and in one area 62.6%. Actions wereput in place to improve the hand washing auditcompliance. During the inspection we saw that staffwashed their hands. The department had introduceda hand hygiene light box in September 2016, the boxhelped to detect flaws in hand washing techniques.

• The audit of sharps bins which was completed everythree months and showed 95% compliance with theaudit standards. Actions were put in place ifcompliance fell below 95%.

• There was a trust staff uniform policy and staff uniformaudits were 100% compliant in October 2016. In theprevious three months there had been an issue withthe uniforms of two agency staff which were raisedwith the agency.

• There were commode audits completed which were100% compliant in October 2016.

• There was point of care testing for patients whopresented with diarrhoea; the kit was requested fromthe microbiology department on authority from theinfection control lead. This could identify whether thecause of the diarrhoea was due to infection andevaluate the need for barrier nursing and otherprecautions. The test took approximately one hour.

• In a patient survey members of the public were asked“how clean was the accident and emergencydepartment” the replies were about the same as theEngland average. Patients we spoke with said that thedepartment was very clean and that they had seenhousekeeping and domestic staff cleaning thedepartment.

• Coloured tape was used to show that equipment wasclean and ready for use.

• In June 2016, 88% of the staff were trained in puttingon and removing personal protective equipment forpreparedness for any infectious disease outbreaks.




Environment and equipment

• The urgent and emergency care departmentcomprised of a triage area or hub which had fivetrollies and six seats, a resuscitation area which hadfive cubicles with a specific cubicle for children. Therewas a clinical decisions unit with four beds for malepatients and four for female patients; an ambulatorycare unit with 16 spaces for chairs and trollies and anarea for minor injuries. There was a separatepaediatric unit with six cubicles.

• There were resuscitation trolleys in the five bays in theresuscitation area and one in all the areas of thedepartment. All trolleys had security tags with a tagnumber. Oxygen and suction were available in all theresuscitation bays and were wall mounted.

• In one of the bays in the majors area of urgent andemergency care unit we checked the resuscitationtrolley, all medicines were in date and equipment hadbeen portable appliance tested.

• There was a dedicated anaesthetics trolley for useonly by the anaesthetics team in the bay, we saw thatthe equipment had been portable appliance tested.

• In the clinical decisions unit of the urgent andemergency care unit, the trolleys were well stockedwith appropriate equipment and medicines, all themedicines and equipment were in date but themonitoring and recording of the trolley had not alwaysbeen recorded and so we were unaware if the dailychecklists had been completed. We raised this withthe nurse in charge during the inspection.

• There was an equipment audit to check thatequipment in the different areas of the departmentwas present in the department, that servicing was indate and that it worked correctly. Actions were put inplace following the audit. We saw that weighing scaleshad been calibrated, this was done annually.

• In the ambulatory care department we checked theequipment; all had portable appliance testing in date.Trolleys were well stocked and checklists had beencompleted with very few gaps.

• There were paediatric resuscitation trolleys in thepaediatric in the resuscitation area of the departmentand one in the paediatric emergency department. Thepaediatric resuscitation trolley in the resuscitation

area was sealed and tagged and had appropriatemedicines and equipment including equipment forintraosseous (injecting directly into the marrow of abone) access for paediatric patients. We consideredthat the trolley in the paediatric department wasoverstocked and this was raised with the departmentduring the inspection who said that they wouldaddress this.

Medicines

• The trust reviewed incidents regarding medicinesevery week for the quality of reporting and incidentsinvolving medicines were reviewed monthly by thetrust for any trends and there was feedback todepartments with the learning from incidents.

• There were patient group directives (PGD’s) availablefor specific nurses to give patients appropriate painrelief. PGD’s allow healthcare professionals to supplyand administer specified medicines to pre-definedgroups of patients, without a prescription. This helpspatients to access medicines in a safe and timelymanner and PGD’s were audited by the department.There was a competency framework for those nursescovered by the PGD. The department was alsoconsidering a PGD for some antibiotic therapies andthere was a need to consider the development ofPGD’s for paediatric patients.

• There were six advanced nurse practitioners and aspart of this role they were nurse prescribers who couldprescribe medicines from a set formulary. We spokewith a non-medical prescriber (NMP) who told us theyreceived good support from the consultant in thedepartment and received individual feedback inresponse to audit. Additionally, the trust NMP leadco-ordinated twice-yearly meetings for sharinglearning and updates.

• In the CDU we saw examples where people’smedicines had not been reconciled (checked andconfirmed) within the trust’s target of 24-hoursaccording to trust policy. The clinical decisions unit isa 24-hour observation ward but three of the fourpatients had been in the unit for longer than this.None of these three patients’ medicines had beenreconciled within 24-hours.

• There were link nurses for intravenous medicines.




• Medicines were stored securely in the department andwere checked daily and stocks were replenished.Fridge temperatures were monitored and recorded.We saw that records that showed that appropriatechecks had been made and recorded. We saw thatdrug charts had been completed appropriately.

Records

• Patient records were electronic though there weresome paper records in the department.

• A consultant had completed an audit of recordkeeping of doctors’ records, this was done in October2016 and they looked at 33 records. Areas that scoredhighly were records of acceptable quality 96%,pathways followed 91% and a clear management planfor patients 96%. Areas that needed to be addressedwere recording of medicines 73%, correct coding 76%and GP discharge letters 76%. There was individualfeedback to each doctor with a quality improvementplan.

• An emergency nurse practitioner had completed anaudit of 99 nursing records. They used the 12standards of record keeping from the Royal College ofPhysicians. The average score overall was 96%, thelowest scoring area was recording of medicines 85%with all other standards scoring over 94% and someareas scoring 100%. There was feedback to the nursesas a whole and individual feedback.

• We reviewed six patient records during the visit; five ofthe records had appropriate risk assessmentscompleted except one that did not have a pressurearea assessment. Allergies were recorded and we sawthat early warning scores and pain assessments withappropriate analgesia provided had been completed.Confusion assessments had been completed onappropriate patients.

• One of the senior nursing staff in the department didan informal audit of a random sample of records whenon shift and fed back to the staff.

Safeguarding

• There was a trust safeguarding policy and femalegenital mutilation was part of this trust policy.

• The nursing staff in the department were compliantwith the trust safeguarding training target of 85% for

vulnerable adults’, level one and two and for childrenand young people levels one, two and three. However,the medical staff had not met the trust target forsafeguarding for vulnerable adults and children andonly 68% of the medical staff had completed levelthree safeguarding training for children and youngpeople.

• There were specialist nurses for adult and paediatricsafeguarding in the trust and link nurses in thedepartment.

• There was a coloured file in the paediatric emergencydepartment which contained all relevant informationabout safeguarding. This was accessible to staff.

• There was a separate page on the electronic recordssystem for children. If registered as a child the systemwould generate a none accidental injury screeningtool within the documentation. This was for childrenunder 16 years of age and would appear in the nursingand doctor’s records. If there was a safe-guardingconcern about a child there was an alert in theelectronic record.

• If staff has suspicions about any child they couldcontact social services, staff said that they were veryresponsive and would respond in a timely wayincluding out of hours.

• If there were concerns about a child, staff wouldcomplete the notification forms and contact socialservices and the health visitor liaison.

• A hidden child pathway had been developed with thetrust safeguarding lead. An example of this was aparent who might remove a child before or duringtreatment.

• During the inspection we spoke with a nurse who hadraised a safeguarding concern for the child of a patientwho was admitted to the department. They wereconcerned about the effect of the patients’ health onthe child, the nurse tried to contact the duty socialworker but could not get a response and so theycontacted the child’s school so that the safeguardinglead at the school could let the child know aboutarrangements for their care while their parent was inhospital.




• A nurse we spoke with described a recent incident andhow staff became suspicious about a child’s injuries.They then described the procedures that werefollowed to safeguard the child.

Mandatory training

• At the time of the inspection, we saw the trainingmatrix that showed that at least 85% of all nursingstaff were compliant in their mandatory training. Thisincluded fire safety, infection control, moving andhandling, health and safety equality and diversity,mental capacity act and medicines management.However the medical staff had not achievedcompliance with mandatory training with the lowestcompliance 36% for equality and diversity and mentalcapacity act and the highest for medicinesmanagement of 57%.

• Training lists were circulated every month to identifythose staff that were close to the expiry of theirmandatory training or who were non-compliant withtheir mandatory training. Incremental payments tosalaries were withheld for those staff that were notcompliant in their mandatory training.

• All staff including porters received training in mentalhealth awareness as part of the induction process.

Assessing and responding to patient risk

• There was a nominated nurse and medical lead foreach shift who managed staff in the departmentaccording to patient risk.

• The department used a recognised triage system tomanage patient flow and assess patient risk; patientswere then signposted to the most appropriatedepartment in the department for treatment. Thishelped to facilitate the release of patients from theambulance service into the department.

• The triage (known as the hub) was run by emergencynurse practitioners (ENP’s) who would undertake arapid review of patients which included a fallsassessment, a mental health assessment and a painassessment and provide pain relief for patients onarrival in the department as appropriate. The nursescould order pathology testing and some diagnosticimaging for patients and patients were then streamed

to the most appropriate part of the department fortheir treatment needs, these departments wereresuscitation, majors, minors, ambulatory care or theclinical decisions unit (CDU).

• Walk in patients who arrived in the department whowere complaining of chest pain were asked to sit infront of the triage cubicles so that the triage nursecould see them and the reception staff made thetriage nurses aware of their condition.

• On admission, patients at high risk were placed oncare pathways so that they received the appropriatelevel of care. The department used an early warningscore tool (EWS) that recorded and scored the patientsvital signs and staff were then able to identify patientswho were deteriorating clinically. The vital signs wererecorded in the patient record and there were clearinstructions for the escalation of these deterioratingpatients. This was compliant with guidance from theNational Institute for Health and Social CareExcellence (NICE). The escalation policy for thesepatients was detailed and explicit with evidence ofrapid assessment and treat processes.

• All band 6 and 7 nursing staff received advanced lifesupport (ALS) training and all nurses were trained inpaediatric intermediate life support.

• All shifts in the department were covered by a doctoror nurse with ALS training. It was proposed that allband 6 and 7 nurses would be trained in both ALS andadvanced paediatric life support (APLS). This wouldgive a larger pool of nurses who could support themedical staff. This was evidenced in the training needsanalysis and was a requirement of the faculty ofEmergency Medicine and Nursing Skill Competencefor Caring for Children in the Emergency Department.(RCN) Skills for Health.

• There was a daily safety briefing of nurses and medicalstaff by the nominated nursing and medical lead forthe shift. This coincided with the medical handover;these were at 9am, 3pm and 10pm. We observed asafety briefing and saw that it was well managed witha register taken.

• There was a standard operating procedure for corridornursing and only patients with a EWS score of four orless were nursed on the corridor. Patients withdementia were not nursed on the corridor. There was




a ratio of one nurse to four patients on the corridor.During the inspection, the department became verybusy and there were trollies in the corridor becausethe department was full. There was intentionalrounding by the nursing staff and we saw that patientsreceived appropriate care and treatment while waitingon the corridor.

• There was an interdepartmental handover form forpatients who were moving to different areas of thedepartment for treatment, the form noted situation,background, assessment and recommendation(SBAR). We saw that these forms had been completedappropriately.

• Patients who required thrombolysis following a strokeand patients who required percutaneous coronaryintervention (PCI) were transferred to nearby specialisthospitals for treatment; this was part of theappropriate care pathway.

• There was a mental health team based in the hospitalduring the day and the department were doing a pilotof a mental health triage tool to identify the level ofrisk to patients with a mental health condition.Patients with mental health problems were gradedinto low, medium and high risk and those who were athigh risk of harm were nursed in the clinical decisionsunit of the department with one to one observation orin one of the high visibility cubicles in the majorssection of the department so that staff could observepatients at all times.

• There were posters around the department flaggingthe sepsis pathway and we saw that sepsis wasincluded in the safety briefing that we attended.

• There was a potential risk to staff and patients as thealarms in the department showed an incorrectlocation on the panel when activated, this wasaddressed during the inspection.

• Children and young people were not triaged by apaediatric-trained nurse though this was part of thefuture plans for the paediatric service and there hadbeen an audit of initial assessments of children in thedepartment. Following the inspection all children andyoung people were triaged by a paediatric nurse. A

training programme to develop on going assessmentskills to utilise the triage tool had been undertakenand a core group of eight paediatric emergency nurseswere trained.

• There was a dedicated paediatric resuscitation bayand this would be attended by a paediatric nurse ifnecessary. Less urgent paediatric patients were takendirectly to the paediatric area by ambulance crews.

• The services used paediatric early warning scores(PEWS) to monitor and observe patients; these weredone according to pathways. Staff told us that thesepathways were very clear.

• There was a paediatric escalation tool and a feverchart for children under five years of age. Thepaediatric acuity escalation tool was for patients to bechecked every two hours; Staff gave good feedbackabout the use of the tool.

• One of the cubicles in the paediatric department hada resuscitaire and new-born resuscitation equipmentfor treatment and management of very young babies.Oxygen and suction outlets were available in each ofthe bays in the paediatric department.

• There was an emergency button in the paediatricdepartment, staff told us that when it was pressedeveryone came running.

Nursing staffing

• The department was using the safer staffing model,this tool determines the number and skills of the staffneeded to effectively manage and care for patients.The nursing establishment for the department was for44 full time nurses and at the time of the inspection,there were just under 39 full time equivalent nurses inpost. In December 2016 the vacancy rate for nursestaffing was 21.9%. Nurse staffing was on the riskregister.

• There were currently ten nurses on the early shift, 11nurses on the late shift and nine staff on the night shift.The matron had submitted a safer staffing proposalfor 11 nurses on the early shift, 13 nurses on the lateshift and 11 staff on the night shift which included atwilight shift that finished at 2pm. The increase instaffing would cover the busy periods from November




to March and allow staff to take annual leave andundertake training from April to November. We weretold that the trust was looking favourably at theproposal.

• In January 2017, 26.1% of qualified nursing shifts wereunfilled and in February 2017 23.5% of nursing shiftswere unfilled.

• As a result of the gaps in nurse staffing the matron,who had been appointed to the department in May2016, had made significant changes to the nursingstructure in the department. Many of the nurses hadbeen upgraded or were on secondment to higherbanded roles. Training and competency assessmentshad been put in place to support this. Nursing staffwere more autonomous and this was supported bythe medical staff. The matron said that the trust hadbeen very supportive of this workforce developmentand it had supported retention of staff in thedepartment as some staff who had consideredapplying for other jobs had decided to stay because ofnew opportunities.

• There were less band five staff in the department butthe matron had recruited a number of student nurseswho were graduating in summer 2017, we spoke withtwo student nurses who said that they had been givenjobs in the department and were looking forward tostarting work as they had enjoyed their placements.An agency nurse told us that they were going to applyfor a permanent position in the department as theysaid it was a good place to work. The matron said thatthe department would be fully staffed with nurses bySeptember 2017.

• The department was using band 4 nurse associatesand health care assistants to support the work of thedepartment.

• The matron told us that they tried to keep agencycosts to a minimum by not using bank and agencycosts at weekend. Staff did extra shifts and receivedovertime payments and bank and agency staff weregenerally known to the department.The sickness ratesat the end of March 2017 for nursing staff within theemergency care department was 8.5%.Following

further recruitment, improved return to work interviewrates the implementation of the new absencemanagement policy this sickness rate was 2.5% at theend of June 2017.

• Nursing staff rotated around the different departmentsof the urgent and emergency care departmentincluding into the medical assessment unit. Thishelped staff to understand how the different areas ofthe department worked.

• Following the recent change in the management ofthe paediatric urgent and emergency care departmentfrom the paediatric department a paediatric nurseconsultant, from a neighbouring trust, had beenworking to review the staffing and training needs inthe department. A transformation plan had beendeveloped and was being implemented.

• The paediatric nurse consultant was undertakingclinical work for 50% of their time.

• An additional four paediatric nurses had beenrecruited in February 2017 and the department wasover established by three nurses, this was to increasethe numbers of nurses on each shift in thedepartment.

• There was a small core of band 6 and band 5 nurseswho worked in the department and other staff rotatedfrom the paediatric department. Staff we spoke withsaid this was unsatisfactory as there was no continuityin the department.

• There was always a registered children’s nurse on dutyin the paediatric emergency department and apaediatric nurse would attend the resus area of thedepartment to support care of a sick child if necessary.

Medical staffing

• There werenine consultant posts, though not all werefull time and two associate specialists who took partin the consultant rota and were considered equal inthe department. There were no consultant vacanciesat the time of the inspection. This was the same as theEngland average.

• There was always a consultant presence in thedepartment between 8am and 11pm though when thedepartment was very busy consultants would coverthe period 7am to 8am and 11pm to 1am. Shift times




were staggered to meet anticipated demand. Therewas a consultant on call rota from 11pm to 7am atweekend consultants worked 7am to 3pm or 3pm to11pm and there was an on call rota for the period11pm to 7am.

• There should have been 25 junior doctors but therewere vacancies in the junior staffing rota which werethree senior house officers, one registrar and sixmiddle grade doctors. This was a vacancy rate of22.6% which meant that the service was ten doctorsshort. The sickness rate for medical staff was 1.1%.

• Junior doctors worked a variety of shifts, seven oreight hours in the day and up to nine hours at night,shift times were staggered to try to anticipate thegreatest demand on the department.

• The shortage of junior doctors is a national issue andwe were told by senior medical staff that the shortfallof staff was not a financial issue but was a recruitingissue and they would appoint if there was theavailability of applicants.

• Medical daytime cover was two consultants, twomiddle grade doctors, two registrars and two seniorhouse officers. At night there was one registrar andtwo senior house officers which meant that the servicewas short of one doctor at night. In the periodfollowing the CQC visit the department were able toincrease their ‘as and when’ bank medical staff whohad previously worked within the Trust. There was ashared clinical fellow post within the critical carespeciality that further reinforced clinical cover. TheAugust rotation of junior doctors had increased theestablishment from 4.0 whole time equivalent (wte) to4.6 wte staff.

• The department spoke with other local hospitals toidentify their levels of cover overnight and found thatone senior doctor was standard practice for a nightshift and there were overlapping shift patterns whichmeant that another senior doctor was present until2am.As a result the department were trialling anadditional roistered shift of 19:00-03:00 within theurgent and emergency care department rota toenhance senior medical cover at night. There was aconsultant roistered until 11pm who will often stayuntil 1am as clinical need demands.

• Recognising the competitive market nationally forspeciality doctors, the clinical business unit hadredefined the approach to recruitment through thefollowing job advert and job description. This is in thehope of attracting speciality doctors to substantiveposts within the trust.

• The trust used locums to cover the gaps in medicalstaffing; locums were usually known to the trust andrequired no induction. If there was any agency staffing,there was an induction pack which was given to thestaff which we reviewed as part of the inspection. Oneof the consultants would provide an induction to theelectronic patient record system at the start of theshift. Bank and locum usage rate was 16.7% in thedepartment. At December 2016 medical staffingreported a turnover rate of 49.2%.

• We observed a medical handover, these happenedthree times every day at 9am, 3pm and 10pm. Thehandover was consultant led and attended byconsultants, junior doctors and nurses includingsenior nurses. A register was taken of those attendingand the meeting began with a safety briefing and thenproceeded to the handover. All the patients in thedepartment were discussed using the board in thedepartment was a guide and specific doctors wereallocated specific tasks and roles were clear.

• In the period April 2015 to March 2016 the paediatricservice in the urgent and emergency care departmentsaw 17,728 children aged between 0 and16 years. Theguidelines from the Royal College of Paediatrics andChild Health state that a consultant with sub-specialitytraining in paediatric emergency medicine should beemployed if the department was seeing more than16,000 patients per year.

• There had been a paediatric consultant for emergencymedicine who had left in December 2016 and aconsultant from the urgent and emergency caredepartment was covering the role until a paediatricconsultant could be appointed, the consultantcovering the role was also the associate medicaldirector for quality and was able to support staff inmeasures of quality and best practice.

• There was a review of the repatriation of paediatricaccident and emergency service to urgent andemergency care on going at the time of the inspection.




The service had only been part of the urgent andemergency care department for a month. The visionfor the paediatric service was to try to attract apaediatrician with an interest in emergency medicine,the trust were considering a rotation with the nearbyspecialist children’s trust.

• Following the inspection the trust had recruited to alead paediatric and urgent care consultant who hadaccreditation in paediatric emergency medicine. Thiswas in July 2017.

• The trust commissioned a review of paediatric urgentcare services from March to May 2017. The review wastasked to look at urgent care provision for childrenacross the urgent and emergency care department,the paediatric assessment unit and the communitypaediatric acute response team.

• The review had identified short, medium andlong-term actions required to deliver a paediatricurgent care service. The review has coincided with thesuccessful recruitment to a lead acute consultant inpaediatric emergency medicine. The substantive postwill lead the delivery and development of paediatricemergency care and will be supported by a middlegrade tier of medical staff who are keen to developskills and competencies within paediatric emergencymedicine.

• The nursing skill mix within the team was reviewed toidentify a team leader with management andleadership responsibilities for the paediatricemergency care service. A lead nurse was recruitedand a band six experienced urgent and emergencycare nurse will help lead and develop the service ofthe future.

Major incident awareness and training

• The major incident plan had been updated in 2017.New action cards had been produced and there hadbeen training including practical scenarios. We sawthe updated action cards around the department.There were a number of link nurses for majorincidents.

• There were simulations of major incidents every sixmonths and also table top multi-agency exercises thatinvolved the North West ambulance service. There wasa lock down plan that required staff to manually close

all points of access. This had a standard operatingprocedure and has been tested. The department wasworking with estates to implement an electronic lockdown which could be centrally managed.

• Major risks had been identified in the plan as therewere a number of heavy chemical industries and anuclear facility in the area. The trust had alsoidentified the threat from terrorism.

• We saw the decontamination tent which was used incase of chemical spillage and contamination. Therehad been two incidents of chemical contaminationone of which involved up to fifteen individuals. Thematron said that they had learnt from both incidentsand appropriate changes had been made to thepolicy.

• During the inspection there was a flood ofcontaminated water through the ceiling into the minorinjury department of the urgent and emergency careunit. The minor injuries area had to be closed and atemporary area was set up in another part of thedepartment Patients awaiting treatment wererelocated to this area. Staff in the department dealtwith the incident calmly and additional housekeepingstaff were brought in to clean the area, which wasreopened several hours later.

• We observed security staff in the department andthere were panic alarms in all areas of thedepartment.

• We saw on the children’s ward that there was anemergency evacuation procedure.

Are urgent and emergency serviceseffective?(for example, treatment is effective)

Good –––

We rated effective as good because:

• The department used guidance from the NationalInstitute of Health and Care Excellence and otherorganisations for their clinical care pathways.Compliance with guidance was audited and recorded.




• National and local audits were completed and actionsfrom audits changed practice in the department.

• The recognition and treatment of sepsis had beenredeveloped with the introduction of the sepsispathway. Patients received timely diagnosis andtreatment.

• Patient’s pain was assessed on arrival in thedepartment and appropriate pain relief wasadministered to patients.

• Staff were competent and there was a focus ontraining and development for all staff.

• There was good multi-disciplinary working with arange of agencies and organisations.

However:

• Appraisal rates were 50% for medical staff and 74% fornurses.

Evidence-based care and treatment

• The department used guidance from the NationalInstitute of Health and Care Excellence (NICE) andother organisations including the British ThoracicSociety, the regional trauma network and localspecialist hospitals. NICE guidance was assigned toappropriate consultants for implementation andcompliance was audited and recorded.

• There were a range of clinical care pathways thatadhered to NICE guidance and guidance from theRoyal College of Emergency Medicine (RCEM) andpoints relevant to this guidance in the pathways werehighlighted in the documentation. These pathwaysincluded cardiac chest pain, fractured neck of femur,sepsis and stroke. One of the consultants wasresponsible for pathways and these were updated atregular intervals.

• New guidance was assigned to relevant individualsand implementation was monitored. We saw anexample of where NICE guidelines had been updatedwith new guidance and how this had been circulatedto staff through the safety briefings and the clinicalgovernance newsletter which was circulated to all staffin the department every month. There were alsoemails of governance updates and teaching sessionswere used to inform staff of changes to guidance.

• The trust completed the trauma unit dashboard andthis showed that the trust scored 88.9% of patientshad rapid access to specialist major trauma carewithin 12 hours of the referral request. This comparedto a national mean value of 71.4%.The trust scoredhighly in every area except one which was theproportion of patients receiving a computerisedtomography (CT) scan within an hour of arrival in thedepartment.

• The paediatric department had identified theappropriate guidance from NICE and were developingpathways for a number of paediatric conditionsincluding sepsis, asthma and bronchiolitis.

Pain relief

• Pain scores were assessed on arrival at thedepartment by the triage nurse and recorded on theelectronic record system; appropriate analgesia wasadministered as necessary. This was audited by thedepartment.

• One of the questions for patients using the self-checkin was their requirement for pain relief and patientswho required analgesia were followed up by the triagenurses.

• There were specialist nurses for pain management inthe trust who supported the staff in the department.

• In answer to the question “do you think the hospitalstaff did everything they could to help control yourpain and “how many minutes after you requested painrelief medication did it take before you got it” the trustscored about the same as the England average.

• Patients we spoke with, with the exception of onepatient said that their pain had been discussed andappropriate medicines had been given.

• In the paediatric department we saw an observationalpain chart that was used for children and youngpeople and pain scoring tools with appropriateanalgesia.

Nutrition and hydration

• There were a number of vending machines availablein the urgent and emergency care department; we sawthat these were refilled on a regular basis. There werefood and drink outlets in the main hospital.




• During the busy period in the department we saw thatpatients on trolleys were provided with food anddrinks.

• A patient’s relative told us that that the patient wasrefusing food as they were nauseous but that the staffwere doing their best to find palatable foods for them.

• Patients in the clinical decisions unit had themalnutrition universal screening tool (MUST)completed, this identifies individuals who aremalnourished. We also saw that hydration charts hadbeen completed for patients on the unit.

• Various drinks including water and fruit squash wereavailable for children in the paediatric department.

Patient outcomes

• There was an audit programme that included auditsfrom the Royal College of Emergency medicine(RCEM), the Commissioning for Quality and Innovation(CQUINs) scheme and internal audits for thedepartment.

• Following sub-optimal findings from the RCEM sepsisaudit in 2013/14, the sepsis pathway had beenredeveloped with the consultant sepsis lead, amicrobiologist, a pharmacist and the infection controlnurse. There was a sepsis screening tool and everypatient attending the majors area of the departmenthad venous blood collected for a venous blood gasanalysis, there was a near point testing machine forblood gases and blood sugar levels in the department.

• Following learning from an incident and as part of thequality improvement work the pathology departmenthad changed their policies to always phone resultsthrough to the urgent and emergency caredepartment to speed up appropriate treatment forpatients with sepsis.

• There was an antibiotic formulary which wasaccessible via the trust extranet which advised onchoice of antibiotic therapy. Microbiology werecontacted for more complex cases and for patientswith drug allergies.

• Implementation of the revised sepsis pathway and thescreening tool had led to an increase of 81% ofpatients being screened from 28% a year ago and79.9% receiving antibiotics within an hour of

admission as compared to 29% a year ago. Since theinspection there has been an increase in the numberof patients screened for sepsis within one hour ofarrival in the urgent and emergency care department,this was 98% for the period April 1 April 2017 20 June2017, The percentage of patients being givenantibiotics within one hour of arrival in the urgent andemergency care department was 98% the same timeperiod.

• There was a sepsis nurse of the day who carried ableep who would undertake screening and initiate thesepsis six pathway. There was a sepsis trolley thatcontained everything required for the diagnosis andtreatment of sepsis.

• Twelve staff from the urgent and emergency caredepartment had received three hours protectedteaching time for training in sepsis management; thiswas to be rolled out to the paediatric nurses in thedepartment. Nurses had been trained to take bloodfor blood cultures for the diagnosis and treatment ofsepsis. The taking of blood for blood cultures wasaudited by the department.

• Since the inspection there has been a dedicatedcubicle in the urgent and emergency care departmentfor patients with possible sepsis, this has supportedthe early intervention and screening for sepsis. Thereare additional trollies for sepsis with one in majorsand one in the paediatric area. This means thateverything needed to treat a patient with sepsis isavailable and easy to find. There has also been ongoing education, particularly involving new membersof the urgent and emergency care team, to highlightthe importance of screening for sepsis.

• Audits from RCEM in 2014/15 included “ assessing forcognitive impairment in older people” the audit hadmixed results with one measure scoring in the top 25%and one in the bottom 25% with two other measuressomewhere in between. Actions had been put in placefollowing the audit.

• There was a RCEM audit of mental health in theemergency department in 2014-2015 which had alsoshown mixed results. One of the measures was that




patients did not have a documented mental healthrisk assessment, this had been addressed by thedepartment and appropriate patients undertook a riskassessment at triage.

• In the 2013-2014 RCEM audit for consultant sign-offthe trust was in the middle 50% for three out of fourmeasures and in the lower 25% for one of themeasures. Actions had been put in place to addressthis.

• There was a nurse-led pathway for patients withfractured neck of femur. At triage these patients hadblood taken for pathology, they also had diagnosticimaging and were given appropriate pain relief. Thedepartment was working towards a target ofdiagnostic imaging for patients in less than an hourand they had achieved this. Once a diagnosis wasconfirmed the patients would be sent directly to theorthopaedic ward. The department was workingtowards a target of diagnostic imaging for patientswith suspected pneumonia in less than an hour.

• The consultants were introducing the Edmonton frailtyscore into the department to improve outcomes forolder patients and the department had a “confusion”assessment tool which was a mini-mental healthassessment to help to identify patients with delirium.

• A pathway had been developed for non-invasiveventilation (NIV) and the nurse skills had beenidentified to support this pathway. NIV is used tosupport patients in acute and chronic respiratoryfailure. A standard operating procedure was in placefor the pathway. One of the consultants haddeveloped a thoracic injury pathway which was nowbeing used in the department.

• The department unplanned re-attendance rate withinseven days from November 2015 and October 2016was worse than the national standard of 5% andgenerally similar to the England average. Thepercentage of attendances requiring an admission tohospital was 20.1% for 2015 to 2016 compared to theEngland average of 21.6%. For the period 2014 to 2015the trust percentage was 21.7% compared to theEngland average of 22.2%.

• The department had a radiology alert log and one ofthe consultants would work through this every day. Itwas a list of abnormal reports produced by the

diagnostic imaging department and the consultantsworked through the list checking that each one hadbeen recognised and acted on. All were listed anddocument with a clear outcome described. We sawevidence that the consultant had emailed a GP toclarify the diagnostic image reporting.

• The nurse consultant was working to developpathways for children across the paediatricemergency department, the paediatric departmentand primary care.

• Paediatric referral to specialities was generally to anearby children’s hospital.

• In the RCEM audit of initial management of the fittingchild (2014 to 2015) the department was in the lower25% of hospitals for two of the five measures, in thetop 25% for one of the measures and between for twoof the measures. In the audit of asthma in children(2013 to 2014) the department was in the top 25% forfour of the ten measures, and in the bottom 25% forone of the measures. The other five measures fell inthe middle 50%. Actions had been put in place toaddress issues arising from the audit.

Competent staff

• There was a consultant trauma lead for thedepartment who maintained their high skill level skillsby carrying out sessions at a nearby major traumacentre.

• One of the consultants had taken a lead on the newultrasound machine and was trained to level one fromthe British Medical Ultrasound Society; they weretraining other doctors in the department to use theultrasound machine. They were also working with theDeanery to train doctors from other hospitals in howto use ultrasound in an urgent and emergency caresetting.

• We spoke with one of the junior doctors in thedepartment. They spoke positively of their training,experience and support in the department from theconsultants. There was protected time for weeklyteaching which was rotated with the Deanery. Theyhad been involved in a College of Emergency medicine(CEM) audit, a hospital audit and were involved in thedevelopment of guidelines for the treatment ofanaphylaxis.




• There was a nurse clinical practice facilitator (PEF)who had been in post for three years as a clinical nurseeducator, the role had evolved as staff were becomingmore autonomous and were developing their skills.

• Five staff from the emergency department, twoconsultants and three nurses, have led a workinggroup to produce a new course for nurse trauma andcritical care. They have been working with the RoyalCollege of Surgeons and the local trauma network.The course will be approved by the Cheshire andMerseyside trauma network and will be offerednationally in 2018. Warrington emergency departmentnurses are the first in the United Kingdom who willattend the course, together with staff from a nearbymajor trauma centre. The course will cover all themajor trauma competencies.

• There had been a range of training for urgent andemergency care staff including advanced nursepractitioner training, emergency nurse practitionertraining, post –graduate qualifications, leadership andsome continuing development modules from localuniversities. Five nursing staff were booked on thetrauma nursing core course for 2017/18.

• There were trauma and paediatric simulations ofmedical emergencies that were run every week todevelop readiness to manage emergencies for doctorsand nurses. These were well attended and there wasfeedback to all staff involved. The feedback from staffabout the simulations was very positive.

• There had been training for nurses in the requesting ofdiagnostic imaging for x-rays of the chest and hips,pelvis and lower limb and the shoulder. A pathwayand standard operating procedures had been put inplace and staff had received appropriate training onthe ionising medical exposure regulations. Triagenurses could request x-rays for patients during thetriage process so that patients had these resultsbefore they saw a doctor.

• Drop in sessions for informal mental health traininghad been organised by the PEF, these were supportedby the mental health team. Training had been bookedfor a member of staff to attend suicide preventiontraining.

• The trust submitted data to CQC that indicatedmedical staff appraisal rates were at 50%. However as

part of the factual accuracy process a statement wassubmitted to indicates the rate reported to the trustboard for the year preceding the inspection was 94%.No additional evidence was submitted to support thisstatement. The appraisal rate for nursing staff was74%.

• Revalidation had been discussed at the safety briefand senior staff, the practice education facilitator anda link nurse were available to support staff. There waspreceptor scheme in place for newly promoted staffand those on secondment.

• If nursing staff had made any clinical errors or therewere concerns about their practice, there would be anopen discussion with the nurse and any additionaltraining needs would be identified and an action plandeveloped. This was known as a “record of contract”and became part of the staff member’s humanresource record.

• The paediatric nurse consultant and the clinicalpractice facilitator (CPF) were using the guidelines fortraining from the Faculty of Emergency Medicine andNursing Skill Competence for Caring for Children in theEmergency Department. They had undertaken atraining needs analysis of the nursing staff and hadidentified the essential skills and competenciesneeded in the paediatric department and werestarting to work towards them.

• The vision for the paediatric department was todevelop the nursing staff so they could become moreautonomous practitioners with advanced nursepractitioners and emergency nurse practitioners inpaediatric emergency care nursing.

Multidisciplinary working

• There was cohesive working between the urgent andemergency care doctors and the physicians inmedicine. The department were working towardsbetter joint working with critical care.

• Doctors and nurses worked well together in thedepartment and we saw physiotherapists treatingpatients.

• The department had strong links to the police serviceand there was a police liaison attached to the hospital,there were also good links to social services.




• The trust worked closely with neighbouring trustsincluding the major trauma unit, specialist trusts andother district general hospitals in the area. They alsoworked with the North West Ambulance Service.

• The paediatric department had good relations withthe nearby specialist children’s trust and with the childand adolescent mental health services from a nearbymental health trust. Children and young people couldalso be referred to drug and alcohol services.

• The paediatric nurse consultant had developed linksto primary care as part of their role.

• There was an alcohol liaison nurse who worked for thetrust. They were mental health trained and haddeveloped pathways in the trust for the treatment ofpatients following alcohol and substance misuse.Their role was to help to identify those patients whowere at risk from alcohol and substance misuse, togive advice to the patients and to staff, to plantreatment for patients and to provide aftercare forpatients. They had a liaison role and had links tomental health services, social care, housing, thevoluntary sector and the police.

Seven-day services

• The urgent and emergency care services wereavailable 24-hours, seven days per week though notall the departments were open for this time period.Ambulatory care opened between 10am and 9pm andminor injuries opened 8am till 10pm and till midnightat weekends.

• Diagnostic imaging and reporting was available 24hours a day, seven days a week.

Access to information

• Staff needed a smart card to access electronic systemsin the department and temporary staff were allocatedwith a card. Due to the number of temporary staffleaving the department with the cards, they wereasked to leave something in exchange so that theycould reclaim it at the end of the shift.

• NICE guidance and clinical pathways were availablethrough the trust electronic system.

• Staff in the mental health team said that there weregood electronic systems and so appropriate staffcould view appropriate information about patients indifferent organisations. The psychiatric liaison serviceused the same systems.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Mental capacity act training was part of adultsafeguarding training. The trust lead for mentalcapacity facilitated the nurse assessment training onthe assessment of capacity.

• There was a standard operating procedure for mentalcapacity and deprivation of liberty safeguards.

• Patient records showed that appropriate consent hadbeen taken and recorded.

• We saw that capacity assessments were discussedduring the medical handover.

• If a patient without capacity left the hospital beforereceiving treatment this was discussed with the policeand a pro-forma was completed to decide if the policeneeded to follow up on these patients

Are urgent and emergency servicescaring?

Good –––

We rated caring as good because:

• The department were consistently better than theEngland average in the friends and family test and thishad improved every month since April 2016.

• Patients we spoke with were full of praise for the carethat they received and for the staff in the department.Staff were polite and courteous even when thedepartment was very busy and privacy and dignitywere maintained at all times.

• Relatives and carers were supported by the staff andinformation about their relatives was delivered in acalm and consistent manner.

• Staff were being trained in delivering compassionatecare and communication in difficult circumstances.




Compassionate care

• The urgent and emergency care department friendsand family test (the percentage of people who wouldrecommend the department) was better than theEngland average between March 2016 and November2016. The trust were performing worse than theEngland average from December 2015 until February2016 and in January 2016 scored 76%, this rose to 92%in April 2016.

• We spoke with 15 patients and their relatives. All thefeedback about their care was positive and commentsincluded “the staff are brilliant here” and “this is notour local hospital but it is the one we choose to cometo.”

• Care was holistic and we saw that a patient had beenreferred for a benefits check. Staff introducedthemselves by name and told patients what their rolewas in their treatment. Patients said that they weretreated like a person and not a number.

• We observed that staff were courteous and kind topatients even when they were very busy.

• Privacy and dignity were always maintained in thedepartment and we saw that curtains were alwaysused when appropriate. During the medical handover,curtains were closed around the patients anddiscussions about them were discreet andconfidential. When the corridor in the urgent andemergency care department became busy we sawthat screens were used at both ends of the corridor toprotect privacy and dignity.

• We saw a patient in the emergency department whohad to go to another hospital for tests and only had anhour before he needed to leave. He spoke with thereceptionist and was triaged immediately even thoughhe had offered to return later that day.

• During the inspection a patient, with limited mobility,who was leaving the department stopped to thank theconsultant for their help. The patient had received anappointment for a magnetic resonance imaging scanbut as they were attending the urgent and emergencydepartment on an unrelated issue the consultant hadspoken with the diagnostic imaging staff and thepatients scan had been brought forward. This hadsaved the patient an additional journey.

• We saw some feedback from a parent whose child hadattended the paediatric urgent and emergency caredepartment who said that the care that they hadreceived in the department was fantastic.

Understanding and involvement of patients andthose close to them

• Relatives were involved in the decisions made aboutpatient’s treatment and staff communicated in calmand measured way. Staff showed empathy to patientsand their relatives.

• A patient’s relative told us that the doctor hadexplained everything about their relative’s conditionso that they would know what to expect. Anotherpatient told us that the staff had telephoned theirrelative to update them about her condition duringtheir time in the department.

• We observed that the department received a phonecall from a patient’s relative to ask on his progress asthe patient’s mobile phone wasn’t working. The staffasked the patient if they wished to speak with therelative and brought him to the phone on the nurses’station. Staff vacated the area to give the patientprivacy when speaking with their relative.

• The matron told us of an incident following thesudden death of a patient where relatives hadwatched the resuscitation efforts of the staff. Followingthe death of the patient, staff had been visibly upsetby the experience and the relatives returned thefollowing day to thank staff who had been involved inthe treatment of their relative.

Emotional support

• There were clinical nurse specialists in the trust whowere available to support patients in areas includingalcohol and substance misuse, dementia, palliativecare and transplant/organ donation.

• The alcohol specialist nurse was able to refer patientsto increased access to psychological therapies (IAPT).These services were for patients who suffered frommild to moderate mental health conditions such asanxiety and depression and included a range ofdifferent therapies.

• The band 5 nursing competency framework included anumber of modules including compassion,




communicating delicate information and confidencein their role. Stage five of these competencies was thatstaff would be able to support and guide others incompassion with individuals, undertake and deal withdelicate situations to a high standard and acteffectively as the patient’s advocate. Thesecompetencies were reviewed regularly and shouldhave been achieved after 12 months in post.Achievement of these competencies would enablestaff to effectively communicate, support andadvocate for patients.

• A nurse had provided support for a patient withadditional needs following a traumatic event, arelative had written to the trust to thank the nurse andthe department. The nurse had won employee of themonth for the department and the trust.

• We observed relatives of a young patient who haddied suddenly the day before, the nurse who hadcared for him spent time with the relatives and dealtwith the patient’s belongings.

Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)

Requires improvement –––

We rated responsive as requires improvement because:

• The department were not meeting a number of targetsset by the Department of Health.

• Processes were not in place to support patients whoneeded reasonable adjustments for their care andtreatment.

• There was little support for people with a learningdisability including easy read material and leaflets andinformation in pictorial form.

However:

• Although the department were not meeting targetsthey had consistently performed better than theEngland average in the delivery of some of the targetswith consistent improvement.

• There were processes in place when the departmentbecame extremely busy and there was a shortage ofbeds in the hospital.

• Services had been put in place to improve the flow ofpatients through the department; this included theambulatory care unit.

• Patients and their relatives were invited into thedepartment to attend staff meetings followingcomplaints, staff and patients had found the processuseful.

Service planning and delivery to meet the needs oflocal people

• The department was divided into triage (hub) majorinjuries (majors), minor injuries (minors), the clinicaldecisions unit (CDU), paediatrics and ambulatory care.There was a resuscitation area with five bays, one ofwhich was a dedicated paediatric bay and there wereseven cubicles in the majors department. The CDUhad four beds for male patients and four for femalepatients.

• All patients including those who arrived by ambulancewere triaged in the hub though some patients whowalked into the department used a self-check-in triagesystem. These patients would respond to a number ofquestions and would be directed to the mostappropriate place to receive treatment; this wasusually the minor injuries unit. We observed patientsusing the self-triage system and staff would help themif necessary.

• The minor injuries department was staffed byemergency nurse practitioners and by foundationlevel two doctors as part of their training. It was openfrom 8am until 10pm Wednesday to Friday and untilmidnight from Saturday until Tuesday.

• Ambulatory care was open from 10am till 9pm; theunit would take its last patient about 7.00pm. Anypatient remaining on the unit after 10pm was returnedto the main department, so that staff could go home.The unit had 16 spaces for chairs or trollies. Patientswith an early warning score of less than six wereadmitted to this unit and GP’s could admit patientsdirectly to the unit. There was close working betweenthe medical staff from urgent and emergency care andphysicians from the medicine department with




dedicated ward rounds by the physicians’ morningand afternoon to manage flow through thedepartment. Fewer than 10% of patients wereadmitted to the hospital from this unit which sawabout 40 patients per day.

• Respiratory nurses in the community could referpatients directly to the ambulatory care unit and therewere also direct referrals for patients with a deepvenous thrombosis and transient ischaemic attacks.Some of the consultants ran clinics the department.

• During the inspection the unit was used to keeppatients overnight due to high numbers of patients inthe emergency and urgent care department. This wasnot ideal though all the patients had a hospital bedbut no locker or bed side table. The unit could notserve hot food and drinks to patients as they had notrolleys so the matron had turned the staff room into adining room so that patients could have a hot meal. Allthe patients had a stay which was less than 24 hoursand all were being discharged or waiting for a bed ordiagnostic testing. We spoke with patients on the unitduring the inspection that had stayed overnight; theytold us that they all had a bed in the hospital or adischarge time. All said that their care had been goodand they didn’t have any complaints.

• Staff told us that it had been used to keep patientsovernight three times since Christmas 2016 and whenthis happened it did not function as an ambulatorycare unit. Consultants told us that this severelyimpacted on the flow through the urgent andemergency care department.

• The CDU had admittance criteria and generallyaccepted patients with head injuries, drug overdosesand patients waiting for the rapid response team.During the inspection we saw that three of the bedswere occupied with medical outliers and a patientwho was waiting for a care package from socialservices.

• The urgent and emergency care department had itsown x-ray facility with a separate waiting area forchildren with 24 hour, seven day a week access toplain imaging and computerised tomography (CT)

scanning with reporting of plain films between 8amand 5pm. For out of hours reporting the trust was partof the regional radiology hub that provided cover forthe reporting of CT scanning.

• Trauma scans were reported by a consultant withinone hour of the CT occurring and all other films werereported by the radiology registrar on-call. All imagesperformed overnight/out of hours were reviewed thefollowing day by a radiology consultant for assurancepurposes. Any discrepancies were highlighted andreviewed in the radiology discrepancy meetingminutes of this were maintained.

• Some of the consultants were trained in ultrasound,this meant that scans could be undertaken andpatients could access appropriate and safe treatmentin a timely manner.

• The department had a fast track to the orthopaedicward for patients with a fractured neck of femur.

• There was a relative’s room which contained a couch,a telephone and facilities to make a hot drink. Thiswas connected by an internal door to a viewing room;this room was basic with dimmable lighting. Thematron told us that is was going to be refurbished.

• There were plans to put a rapid response team (RRT)into the department to try to prevent admissions ofolder people. This would involve puttingphysiotherapists and occupational therapists into thehub so that patients who were triaged and could bedealt with by the RRT could be discharged home withappropriate support.

• There was an enhanced care home team with medical,nursing and pharmacy support from primary careservices to try to reduce admissions and to prioritisepatients with complex issues, those who had recentlybeen discharged and patients with advanced careplans for end of life conditions. A consultant told usthat they were not yet sure on the impact ofattendance or a reduction of admissions to thedepartment.

• There were six cubicles in the paediatric departmentone of which was designated for adolescents




• The paediatric emergency care department hadrestricted access and patients had to use a bell to gainentry. Staff on the desk could see everyone whoentered and left the department.

• The department was quite small but was visibly clean,bright and airy with themed murals on the walls andcurtains. The waiting area in the department wasbeing painted at the time of the inspection. There wasa small range of toys available for very young childrenand there was a television.

• There was a good range of advice leaflets available inthe paediatric department.

• The vision for the department was to have a paediatricassessment unit co-located with the paediatric urgentand emergency care department and an area in thedepartment had been identified as the most suitablearea for relocation.

Meeting people’s individual needs

• There was a mental health team based within theambulatory care unit from 8am to 8pm, 365 days peryear. There was 7.5 whole time equivalent nursing stafffor the service and one full time consultant who wasemployed by the nearby mental health trust. Thenurses were all mental health trained. The staffworking in the team felt that the service would beimproved if provided a 24 hour service.

• The mental health liaison services were able to accessacute physician and ED medical teams.

• Staff from the urgent and emergency departmentcould make referrals to the team by email during theday and at night referrals were faxed securely to thenearby mental health trust.

• There was a mental health room in the urgent andemergency care department. The room was soundproof and without windows. There was a concern thatthe room was not fitted with anti-barricade fixturesand the door opened inwards.

• Patients with mental health problems could be seenby the mental health team for face to face assessmentor following telephone triage would return home withfollow up from the home treatment team from thenearby mental health trust.

• There was a CRISIS team provided by the nearbymental health trust who were on site but they wererarely able to see patients from the urgent andemergency care department.

• The trust were working with commissioners acrossprimary care, and mental health services, as part of anational CQUIN, to look at improving outcomes forpatients with mental health needs. CQUIN iscommissioning for quality improvements and is ascheme is intended to deliver clinical qualityimprovements

• Although there was a trust policy for those with alearning disability support for those with a learningdisability was poor as there was no easy read material orpictures of procedures for patients.

• As part of the inspection we undertook a pathwaytracking exercise, this was a scenario where thepatient was a high-functioning female patient with ahistory of self-harm; she had two children who neededto be collected from school. The issues raised duringthe exercise were that the environment was very busyand no adjustments were made for the patient. Theinjuries sustained through self-harming were treatedbut the patient was passed on to multiple staffthrough the process instead of one member of staffstaying with the patient through the department. Thepatient was passed onto the psychiatric liaison whowas responsible for the patients discharge planningand after care. The psychiatric liaison did not feel ableto manage the case and wanted the psychiatrist to seethe patient, this involved a potential wait. During thevisit the patient visited five clinical areas and was seenor cared for by ten individual members of staff.

• Translators were available as necessary but the blackminority ethnic population in the area was very low.

• There was mandatory dementia training for the staff inthe department this was by e-learning and includedthe use of tools. Toilet doors in the department werepainted bright orange and so were very visible topatients with cognitive impairment. Patients withcognitive impairment were assigned to one nurse whotried to follow them through the department forcontinuity.

• One of the consultants told us that some of thepatients from a local head injuries unit attended the




department, they had health passports that containeduseful information about their health preferences andalso information about their “do not resuscitate”decisions. Some patients “do not resuscitate”documentation was scanned into the electronicrecords system.

• The department were doing an audit of attendancesin the department from care homes to decide if theattendance was unavoidable and if the patient wouldhave been treated more appropriately by anotherhealthcare professional or team. This audit was inprogress at the time of the inspection

• The department were using the Edmonton frailty toolto identify frailty in older people attending thedepartment; this would identify measures that couldbe put in place to support patients to help them tomaintain their independence. Recruitment of a nurseconsultant post to support this work was in progress inthe trust.

• There were a number of frequent attenders to thedepartment, action plans were in place for all frequentattenders, many of whom had refused an interventionfrom the mental health team.

• There was appropriate seating in the emergencydepartment for bariatric patients.

• The department saw approximately 1500 patients perweek (this was excluding minor injuries patients).

• The Department of Health’s standard for emergencydepartments is that 95% of patients should beadmitted, transferred or discharged within four hoursof arrival in the urgent and emergency care centre. Thedepartment had breached the standard betweenDecember 2015 and November 2016. However theyhad shown a consistent improvement and from April2016 had performed better than the England average.In December 2016 and January 2017 the departmenthad performed the same as the England average.Following the inspection the department hadimproved their escalation plans for adults and forchildren and young people.

• The declared figures included the urgent care centreat Halton and the Widnes walk-in centre, whichperformed consistently well. The figure for the period

April 2016 to June 2016 was 88.2% ( declared figure92%) for July 2016 to September 2016 was 90.1% (declared figure 93.4%) and for October 2016 toDecember 2016 was 84.2% ( declared figure 89.6%).

• The department were not meeting the targets for timeto initial assessment (emergency ambulance casesonly) which should be less than 15 minutes. Thefigures were worse than the England average. BetweenJune 2016 and February 2017 there was an upwardtrend in the monthly percentage of ambulancejourneys with turnaround times over 30 minutes.

• Following the CQC visit, the department has seen aconsiderable improvement in ambulance handovercompliance and the average overall turnaround time.The trust has been recognised by the North WestAmbulance Service (NWAS) as a top performing trustwithin the north west region and has started on a90-day improvement project with NWAS to improvinghandover compliance. The urgent and emergencycare department has been asked to present at thenext project group meeting for the region as anexample of good practice.

• The Royal College of Emergency Medicinerecommends that the time patients should wait fromtime of arrival to receiving treatment is no more thanone hour. The trust did not meet the standard for 11months over the 12 month period between January2016 and December 2016. Performance over the timeperiod showed a consistent trend of being higher thanthe England average. In August 2016 the trustsperformance was better the standard.

• The department had consistently achieved theaverage time to decision to treat in less than 60minutes from April 2016 to December 2016 with nowaiting time of greater than 56 minutes.

• Between December 2015 and November 2016 thedepartment monthly percentage of patients waitingbetween four and 12 hours from the decision to admituntil being admitted was worse than the Englandaverage until May 2016. From May 2016 the trustperformance had improved and is mainly better thanthe England average. Over the last 12 months nopatients waited more than 12 hours from the decisionto admit until being admitted.




• The total time that admitted patients were spendingin the department was worse than the Englandaverage from November 2015 to March 2016, howeverthe performance had improved and since April 2016the total time in the urgent and emergency caredepartment was better than the England average.

• The number of patients who left without being seenwas consistently worse than the England averagethough the trust have improved their performanceduring the time period(November 2015 and October2016).

• Between January 2016 and December 2016 there wasan increase in the monthly percentage of ambulancejourneys with turnaround times of 30 minutes. In theperiod 3 January 2016 to 1 January 2017, the trustreported 900 black breaches. This is when a patientwaits over one hour before they are handed over tothe staff of the urgent and emergency caredepartment. There was an improvement with thehighest number of breaches recorded in February,March and April 2016. Numbers fell until December2016 when there was a high number of breachesthough not as high as at the beginning of the year.

• The status of patients and the length of time that theyhad been waiting was available to staff in thedepartment. This was electronic and different colourswere used so that staff knew at a glance how longpatients had been waiting.

• There were daily bed meetings at 9.30am, 3pm, 5pmand 8pm, there were more meetings dependent onthe escalation level for the hospital and the escalationlevel was updated after every meeting.

• We attended a bed meeting during the inspectionwhen the trust was at red escalation level. Themeeting was attended by senior nurses, consultantsand staff from diagnostic imaging. The meeting waswell practiced and focused on an immediate plan toestablish the flow of patients through the hospital asthere were a number of patients who required a bed.Due to the pressure on the hospital there was aconference call at 11am with commissioners, socialcare and community services to look at howcommunity services could respond to the pressureson the hospital and support discharges.

• The ambulatory care unit opened from 10am until9pm and provided a flexible and adaptive area forambulatory patients, who could be more effectivelymanaged and the majority discharged within fourhours. Ambulatory care had improved both thepatient experience and benefited the performance ofthe main emergency department.

• There had been a GP based in the department andalthough this service had worked well, it had beenwithdrawn by the clinical commissioning group. Theservice had seen about 30 patients every day. Therewere access to emergency appointments at a nearbyGP surgery but staff said that patients could be quiteabusive if they were asked to take up theseappointments. There was an audit of numbers ofpatients who refused to go to primary care services.

• The lead nurse for the shift could move staff aroundthe department to meet varying demands on differentparts of the department.

• Staff told us that they could meet the demands of theirown patients but ambulances were diverted to thedepartment from other hospitals. In the two monthsbefore the inspection there had been four divertedambulances from the same trust all for sixty minutes.One of the diverts was at night. Doctors said theystruggled to manage sometimes when patients werediverted from other hospitals and that it was difficultto repatriate some of the diverted patients especially ifthey required intermediate care services or social careintervention.

• The department had its own porter service so thatpatients could be moved quickly around thedepartment and to other departments as necessary.

• The paediatric service saw 17,728 patients agedbetween 0 and 6 years in the period April 2015 toMarch 2016, this was a decrease from April 2014 toMarch 2015 when the service saw 18,108 patients. Thiswas about 21% of patients who attended thedepartment. This was about 50 patients per daythough they could see up to 70. Attendances ofchildren were usually highest between midday and8pm with decreasing numbers up to midnight.

• Staff told us that sometimes they had to wait for awhile before the doctor came to the department to




see non-urgent cases and numbers could haveaccumulated during this time. They said that this wascontributing to the four hour breaches in thedepartment.

• There was an on going audit of paediatric attendanceand parental awareness of services as an alternative tothe urgent and emergency care centre. Numbers of 0to 16 year old patients had fallen slightly in the period2015 to 2016 compared to the previous two years.

Learning from complaints and concerns

• Between January and December 2016 there were 52complaints about the urgent and emergency caredepartment. The trust took an average of 150 days toinvestigate and close complaints; this is in line withtheir policy which states that complaints should beclosed within six months.

• The matron told us that patients and relatives wereinvited into the department to attend staff meetingsfollowing an incident or complaint. Both the staff andthose complaining had found the process very useful.People could be asked to return to future meetings tolearn what changes had been made following theirconcerns.

• Plans were drawn up following complaints to addressissues raised in complaints; we were given an exampleabout how a patient with a disability was working withthe urgent and emergency care department and otherdepartments in the trust to help to address theircommunication problems on future visits.

Are urgent and emergency serviceswell-led?

Good –––

We rated well-led as good because:

• Robust governance structures were in place in thedepartment and there was reporting of governancewas done at departmental, directorate and boardlevel. The department was aware of their risks whichwere managed appropriately.

• Leadership was strong from senior managers and theywere keen to develop leaders throughout thedepartment.

• Staff said that they felt empowered and that thedepartment had invested in them. Morale was gooddespite the heavy workload.

• The culture in the department was open and therewas a positive approach to improvement and meetingtargets. Senior managers were visible in thedepartment.

• Although there had been significant change in thedepartment staff said that this was for the better andthat it was clinically led.

Leadership of service

• The urgent and emergency care department hadundergone a change in leadership early in 2016 withthe clinical business unit (CBU) model brought in. Thetrust had used assessment centres and othermanagement tools to identify leaders in the potentialapplicants for the clinical and nurse leads for the CBU.The CBU had a clinical lead who was a consultantanaesthetist, a lead nurse and a manager. Both of theclinical staff had come from outside of thedepartment. Since the implementation of the CBU,performance in the department had shown markedand on going improvements in safety andperformance. This was due to the leadership in thedepartment which was robust and the senior staff ledby example.

• The CBU had implemented improved integratedworking with other departments across the hospitalparticularly medicine, staff said that the departmentwas more fluid and responsive and that pathways andpartnerships were much improved. The departmentwere not afraid to try new ways of working and if theydidn’t work they would try something else. There wasa “can do” culture.

• Senior staff said that they felt that the trust was betterthan it had been a year ago; they said that this waspartly due to the appointment of the medical director.




• Staff said that there had been big changes in thedepartment but that this was change for the better. Itwas described as a massive shakeup. They said theactive involvement of clinicians at every level was whythe changes had been successful.

• The department had appointed a new matron in May2016 who had implemented significant change acrossthe department with development of the workforce tomeet the needs of the department. They had lookedat new ways of working and staff had been givenopportunities to develop through promotion andsecondment opportunities.

• The department was developing strong leaders in thenursing and medical staffing. This started with thecompetency framework for the band 5 nurses. Staffdescribed a vacuum in nursing leadership before themanagement changes.

• Every Friday from 1pm till 3pm the senior nurses in thedepartment had an open door policy where staff coulddrop in and discuss any issues. This was publicisedwidely across the department.

• Senior staff covered when the department was busy sothat staff could take breaks particularly for those onlong shifts.

• The staff who worked in the paediatric departmentsaid that they did not feel like they belonged to thepaediatric service of the urgent and emergency caredepartment. A nurse consultant had been brought into review the service and staff thought that this wouldbe beneficial. The matron from the urgent andemergency care department had started to visit thedepartment every day to speak with the staff.

Vision and strategy for this service

• There was a vision for the department which was thestrategic work programme, this included five currentstrategies of work and the progress of these strategieswhich were mainly about the development of theworkforce, including the medical workforce andimproving performance. Appropriate strategiesinvolved partners from outside the organisation.

• Staff we spoke with were aware of the vision for thedepartment particularly in improving the performanceof the department.

• The paediatric urgent and emergency caredepartment had only become part of the maindepartment in the month before the inspection. Atransformation plan with an accompanying trainingneeds analysis had been developed and a nurseconsultant had been brought in from a neighbouringtrust to drive and support the necessary changes inthe department.

Governance, risk management and qualitymeasurement

• There were departmental governance meetings everysix weeks which were attended by the consultant leadfor governance. There was a standard agendatemplate for the meetings and agenda items includeda review of guidance from the National Institute ofHealth and Care Excellence (NICE), a review ofcomplaints, incident investigations, action plans forserious untoward incidents and investigation reports.Mortality was also discussed. The meetings were wellattended with consultant and nurse representation.

• There were acute care directorate governancemeetings that were attended by the clinical businessunit (CBU) managers and these linked into the patientsafety and clinical effectiveness sub-committee of thetrust board. These meetings were for the acute caredirectorate and had a standard agenda templatewhich included review of new NICE guidance,complaints, investigations and information from subcommittees of the board including infection control.The risk register was reviewed monthly as part of thedirectorate meetings and appropriate risks wereescalated to the corporate risk register. Each risk had amitigation plan.

• Information from the governance meetings went tothe quality committee, this included riskmanagement, the quarterly governance report, thequality dashboard and a review of any safeguardingissues.

• There were staff meetings for senior nursing staff andband 5 staff, these were every month and there wasfeedback about complaints, incidents and outcomesof investigations.

• Clinical governance was seen as an integral part of thedepartment as a tool to deliver safe and effective care.Staff we spoke with said that they realised how clinical




governance could support them in their roles. Thelead consultant for governance had developed aclinical governance newsletter which was distributedto staff every month.

• There was a peoples measures action plan to try toaddress the issues of staffing, sickness, agency spendand training and appraisal compliance. Incrementalpayments could be withheld if staff did not completetheir mandatory training.

• There was a paediatric urgent care action plan thatsupported the move of the department into the urgentand emergency care department. The plan showedthat governance, the management of the nursing staffand medical leadership were issues. Actions had beenput in place to start to address these issues.

Culture within the service

• There was a culture of improvement and developmentin the department and staff morale was high despitethe busy workload. Staff now felt empowered as theyhad been given new roles, they felt that thedepartment had invested in them with training anddevelopment opportunities.

• The culture in the department had changed followingthe management reorganisation and staff we spokewith said that the culture was more open, staff wereencouraged to report incidents and that there wasfeedback and learning from incidents. This wasthrough safety briefings, staff meetings andgovernance meetings.

• Staff we spoke with said that the culture in thehospital had changed as previously the urgent andemergency care department seemed to be blamed foreverything but now there was an acknowledgmentthat problems were across the whole of the hospitaland not just in the urgent and emergency caredepartment. Staff said that they had beendisempowered and unappreciated.

• We saw from the minutes of meetings that staff werethanked for their efforts at every meeting

• We spoke with a junior doctor in paediatric urgent andemergency care who said that there was a lot of seniorsupport and there was always somebody to ask for

help. They had completed their student training atWarrington and then taken a junior doctor post; theysaid that they had seen things improve in thedepartment since they were a student.

• We spoke with three nurses who had noticedimprovements in the atmosphere and culture of theservice since the implementation of the clinicalbusiness unit structure. They agreed that the servicewas more cohesive and there was a team ethos thathad not been there before. They said that quality andpatient care had improved because everyone wasworking together. This included staff from the NorthWest Ambulance service.

• A nursing member of staff told us how the service hadrecently improved and how when they requestedfunding for improvements to the department thesehad been granted.

Public engagement

• The urgent and emergency care departments atWarrington and Halton were working with players andstaff from two local rugby league clubs. Thedepartment was promoting awareness of the differenturgent care services and when to use these servicesappropriately. Filming was due to take place forYouTube videos which would be promoted via thesocial media platforms at one of the rugby clubs.

• The department worked with local schools to promotethe work of the department.

• We saw from minutes of staff meetings that there werecharity events in the department and collections forfood banks.

• The department worked with a police liaison officerfrom the local police service.

Staff engagement

• The ambulatory care department had won anoutstanding contribution award at the staff awardsceremony and one of the nurses had won employee ofthe month for the department and the trust.

• The department was very busy and the seniormanagement team had introduced stress risk




assessments that were completed on line. If the scoreswere high there was input from the occupationalhealth department. The risk assessments weremandatory and carried out every year.

• There was a routine debrief following significantincidents and staff gave us examples of these.occupational health and the chief nurse had beeninvolved to provide information and to support staff.Mandatory counselling sessions had been provided tostaff involved.

• There was a closed Facebook page for the urgent andemergency care department, this was used as acommunication hub and was well used. Managersknew how many staff had read messages and staff wespoke with thought it was a great idea and that itworked well.

• Following the flood in the department there was around of applause at the morning safety meeting forall the domestic and housekeeping staff who hadbeen involved in the clear up, staff were also thankedindividually for their efforts.

Innovation, improvement and sustainability

• The department had improved on a number ofperformance indictors since the change in themanagement structure at the beginning of 2016.

• The workforce development of the nursing staff washelping in the retention of staff and improving morale.

• The introduction of the ambulatory care stream hadhelped to improve flow through the department andthe hospital.




Safe Requires improvement –––

Effective Requires improvement –––



Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceMedical care is provided at Warrington Hospital from 12inpatient wards and an endoscopy unit. There were17,803 inpatient medical admissions between October2015 and September 2016. Over 90% of patients wereadmitted under general medicine or gastroenterology.Other medical specialities provided at the hospitalinclude cardiology, haematology, stroke medicine andrespiratory medicine.

At our last inspection in January 2015, we told the trust itmust take action to improve medical services in anumber of areas. This included ensuring medical staffingcover is appropriate at all times, ensuring nursing staffinglevels and skill mix are appropriate, improving mandatorytraining and appraisal rates and improving patient flow toensure patients are cared for on a ward most appropriateto their needs and reduce the number of patient bedmoves.

We visited the hospital as part of our announcedinspection between 7 and 10 March 2017. We inspectedthe acute medical unit, endoscopy, the discharge lounge,cardiac catheterisation laboratory, coronary care unit, A7(respiratory medicine), A8 (neurology), B14 (stroke unit)and the Forget Me Not ward. The Forget Me Not ward is aspecialist unit caring for patients with a diagnosis orsuspected diagnosis of dementia or delirium. We alsocarried out an unannounced inspection on 23 March 2017when we carried out further inspection on the acutemedical unit and the Forget Me Not ward and also visitedward A3 (older persons assessment and liaison ward).

As part of our inspection, we observed care andtreatment and looked at 21 sets of patient records. Wespoke with 41 staff, including nurses, doctors,consultants, support workers, managers and allied healthprofessionals. We also spoke with 15 patients or theirrelatives who were using the services at the time of ourinspection. We looked at information provided by thetrust and other relevant information we requested. Wereceived comments from people who contacted us to tellus about their experience at the trust and reviewedperformance information.

Medicalcare

Medical care (including older people’s care)


Summary of findingsWe rated this service as requires improvement because:

• There were times when there were insufficientregistered nurses to care for patients. There werehigh numbers of medical staff vacancies and agencyuse was high. Patients did not always receive timelymedical intervention, for example in cases of sepsis.

• The trust had introduced a formal medical handoverat the end of 2016. However, we found that themedical handovers were unstructured and medicalnotes did not always contain sufficient informationabout patient care and treatment.

• Mandatory training rates for medical staff, includingsafeguarding training, were all below trust target.Appraisal rates were also below target.

• Patients were at risk of being unlawfully deprived oftheir liberty or receiving care and treatment withoutconsent because staff did not follow the trust MentalCapacity Act procedure.

• Governance systems were not sufficiently embeddedwithin the acute care division. The risk register wasnot effectively managed to show how risks topatients or the service were being reduced.Complaints were not always responded to in a timelyway.

However:

• Care was provided in line with best practice bymulti-disciplinary teams who worked well together.Patient outcomes were generally good and the trustmet the national target for treatment waiting times.

• Staff were kind, caring and compassionate andunderstood the emotional needs of their patients.

• The Forget Me Not ward was designed to meet theneeds of patients living with dementia and staffprovided individualised care for this patient group.

• Staff were positive about the leadership and cultureof the service.

Are medical care services safe?


We have rated safe as requires improvement because:

• Medical records did not always contain sufficientinformation or detail about medical reviews. It was notalways clear what grade of doctor had reviewed thepatient and there was a lack of information about howa clinical decision had been reached. Junior doctorswere not always present during consultant reviews.

• Records were not always stored securely on medicalwards. On three wards, records for scanning werestored loose in document folders or within notestrolleys. In another area, large numbers of medicalrecords were left unsecured in an office and recordswere left unattended on a desk.

• The medical handover was poorly structured with noformal handover document and no designated lead atthe handover. This meant there was a risk thatimportant information in relation to safe care andtreatment may not be communicated betweendoctors effectively.

• There were times when there were insufficientregistered nurses to care for patients. During ourinspection we saw that staff were expected to care forup to 11 patients during the day. There is evidencethat the risk of harm to patients increases if a nurse iscaring for more than eight patients during the day.

• There were high vacancy rates for medical staff insome specialities resulting in a high usage of locummedical cover. The overall locum usage rate was40.1%.

• Improvements were required in the implementation ofthe sepsis six care bundle. Only 75% of patients hadbeen screened for sepsis in line with trust guidanceand nearly half of patients did not receive intravenousantibiotics in a timely way.

• Mandatory training rates for medical staff did not meetthe trust target in any of the seven mandatorymodules. Safeguarding training rates for medical staff

Medicalcare



were all below target. Only 56% of doctors hadcompleted safeguarding adults level two and only54% had completed safeguarding children level two.Basic life support training was below the trust target.

• Staff told us that they did not always report near missincidents or receive feedback about incidents theyhad reported. This is despite the trust having a systemin place to summarise the incidents for each area, withrelevant 72-hour reviews, and cascade these to allwards for further learning and sharing with the staff ineach area.

• We reviewed information provided by the trust andsaw that Duty of Candour was not always followedcorrectly following patient safety incidents that hadcaused moderate harm or above.

However:

• There was good medicine management and we foundall medicines were stored correctly. On the acutemedical unit, pharmacy technicians wereadministering medications following appropriatetraining as an innovative way of reducing medicationerrors.

• Wards were clean and tidy and staff followed infectionprevention and control best practice. There had beenno cases of methicillin resistant staphylococcusaureus (MRSA) bacteraemia in medical services in2016.

• Electronic patient boards provided staff with a highlevel overview at a glance of any particular patientrisks or needs. The boards used symbols to highlightrisks such as mobility needs, requirement for a venousthromboembolism assessment, infection controlissues or acute kidney injury.

Incidents

• Staff reported incidents using an electronic reportingsystem. Staff were able to demonstrate how theyreported incidents and said they felt confident usingthe system.

• Staff were able to explain what types of incidents theywould report, however some staff told us they did notalways report near misses or incidents that caused noharm to patients. This meant there may be missedopportunities to learn from these types of incidents.

• Between September 2016 and March 2017, there were5,053 incidents reported within the acute care servicesdivision at the trust. Over 98% of these incidents wereclassified as no or low harm.

• Staff told us they did not always receive feedbackabout incidents they had reported unless there wasspecific learning or outcome. Most staff were able toprovide examples of learning from other specificincidents. For example, a fall in the x-ray departmenthad led to the development of a purple wristband toidentify patients with a cognitive impairment.

• The trust reported 36 serious incidents (SIs) in medicalcare between March 2016 and February 2017 whichmet the reporting criteria set by NHS England. Themost common type of serious incident reported was“slips, trips and falls” meeting the SI criteria whichtotalled 20 incidents.

• A root cause analysis tool was used to investigateserious incidents. We reviewed three root causeanalysis reports and saw that action plans weredeveloped where required to reduce the risk of theincident happening again. However, we asked thetrust to provide us with updates to show if actions onthe plans had been completed and the trust did notprovide us with this information.

• As part of the process the service completed 72 hourreviews to ensure any immediate actions could betaken and learning from the initial investigation couldbe shared.

• Learning from incidents across the service and thewider hospital was shared at ward safety briefings,team meetings and via team briefs. All staff told usthey received information in this way.

• Between January 2016 and December 2016, the trustreported no incidents which were classified as neverevents for medical care. Never events are seriouspatient safety incidents that should not happen ifhealthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

• Mortality and morbidity was discussed at monthlymortality and morbidity meetings. Serious cases were

Medicalcare



shared at the divisional clinical governance meeting.At the time of our inspection there was a back log of 42deaths to be reviewed which meant there was a riskthat learning from deaths did not happen in a timelyway. This was a reduction in the total numberoutstanding and the service was aiming to have noneoutstanding by April 2017.

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson. There was a trust wide policy and duty ofcandour process in place. Some staff understood thatthe duty of candour required services to be open andhonest, but others had not heard of the duty ofcandour. Senior staff understood the principles of theduty of candour.

• We saw that the duty of candour was not always fullyimplemented following relevant incidents. Wereviewed information provided by the trust and sawthat processes were not always followed. For example,there was not always evidence of an apology,discussions with the patient or their family or thatrelevant support had been given.

Safety thermometer

• The NHS safety thermometer is a nationalimprovement tool for measuring, monitoring andanalysing avoidable harm to patients and ‘harm free’care. Performance against the four possible harms;falls, pressure ulcers, catheter acquired urinary tractinfections (CAUTI) and blood clots (venousthromboembolism or VTE), should be monitored on amonthly basis.

• Medical services at the hospital used the NHS safetythermometer to monitor harm and harm free care andresults for the current month were displayed oninformation boards at the entrances to ward areas.

• Data from the safety thermometer showed thatmedical services reported 24 new pressure ulcers, 17falls with harm and 26 new catheter acquired urinarytract infections between February 2016 and February2017.

• There was a trust wide action plan to reduce thenumbers of hospital acquired avoidable pressureulcers led by the tissue viability team. The plan was ontrack to achieve an agreed reduction in grade twopressure ulcers however the plan for reducing gradethree and grade four pressure ulcers was not on trackto meet the target. A further action plan focusing onfive key themes had been developed in January 2017when it had become clear that these targets would notbe met.


• All areas we visited were visibly clean. Cleaningschedules were in place and used by ward domesticstaff. We saw that these were completed on a dailyand weekly basis. On one ward we saw that a usedurinal bottle had been left on a record trolley in thecorridor. This was immediately disposed of by theward manager.

• Equipment was cleaned following patient use andlabelled with an ‘I am clean’ label. In the equipmentstore room on the acute medical unit (AMU), we sawthat less frequently used equipment was covered witha plastic covering to prevent the build-up of dust.

• Decontamination procedures were followed in linewith best practice in endoscopy.

• We saw that staff had ‘bare arms below the elbows’and washed or cleansed their hands before and afterpatient contact.

• There was access to personal protective equipmentsuch as aprons and gloves and we saw staff using thisequipment appropriately to reduce the risk of thespread of infection.

• Patients told us that the environment was clean andtidy and that they saw staff washing their hands beforeand after their care.

• All wards had antibacterial gel dispensers at theentrances and by people’s bedside areas. Appropriatesignage regarding hand washing for staff and visitorswas on display.

• Sharps containers were dated and signed whenassembled and temporary closures were in placewhen sharps containers were not in use.

Medicalcare



• Patients with a known infection were nursed in siderooms and signs were placed on the entrance to theserooms to notify staff and visitors of the need to followextra precautions. Information about infection wasshared with staff during ward safety huddles to ensurestaff were aware of any additional infection preventionand control precautions. Domestic staff told us theywere also told about key infection control information.

• There had been no cases of methicillin resistantstaphylococcus aureus (MRSA) bacteraemia and 19cases of hospital acquired clostridium difficileinfection in medical services during 2016.

• Infection prevention and control training had beencompleted by 90% of nursing staff which was abovethe trust target of 85%. Medical staffing training rateswere below the trust target with only 71% of staff whohad completed this training.

• Matrons completed monthly infection prevention andcontrol (IPC) reports that included hand hygieneaudits, uniform audits and environmental audits. Themost recent hand hygiene audits reported inDecember 2016 showed that wards AMU, A2, A4, A7,B14, C21 and the CCU and cardiac catheterisation labachieved 100% compliance. Compliance on ward A8was 87.5%.

• Matron IPC reports were discussed at a monthlyinfection prevention and control subcommittee. Wereviewed the minutes of this subcommittee and sawthat any issues identified in these reports werediscussed in this meeting along with the actions beingtaken to improve compliance where necessary.

• Patient-led assessment of the care environment(PLACE) is a measure of the care environment inhospitals which provide NHS care. The assessmentssee local people visit the hospital and look at differentaspects of the care environment. The PLACE score for2016 showed the hospital scored 98% for cleanliness,which was the same as the England average.


• All areas we visited were tidy and well-organised. On anumber of wards, there was no door to access theclinic area where medicines and supplies such assharps, dressings and other sterile items were stored.This meant that patients or the public could access

these areas if left unattended. We were told there hadbeen no incidents of patients or the public accessingthese areas and this was confirmed when we reviewedincident reports.

• Medical wards used an electronic patient board thatwas linked to the EPR system. On all wards weinspected this board was located in a public area andwe noted that on two wards, patient names werevisible. This meant that patient identifiableinformation was available to other patients or visitors.In other areas, patient names were only visible when amember of staff used their EPR login card.

• All equipment we checked had up to date electricalsafety testing and had been serviced and calibrated asrequired.

• Resuscitation trolleys were available in all areas wevisited and were tagged with tamper proof seals. Trustpolicy set out that a full check of the trolley should becompleted monthly, or following use of the trolley anda daily more limited check should be completedwhenever the ward or area was open to patients. Thiswas to ensure that there was emergency equipmentavailable and in date when required.

• We saw that one resuscitation trolley on AMU had notbeen checked on 6 days since 1 January 2017. We alsosaw that the trolley in endoscopy had not beenchecked on 5 days between 1 February and 7 March2017. We checked a further six trolleys and saw thatthese had all been checked, including daily checks ofautomated external defibrillators, in line with trustpolicy.

• Staff told us they had access to sufficient andappropriate equipment to enable them to care forpatients safely.

• There were adequate arrangements in place for thehandling, storage and disposal of clinical waste,including sharps.

• Each ward had designated toilets and showers formale and female patients.

Medicines

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• Medicines were stored securely and appropriately inmost areas we visited, although one medicationcupboard containing intravenous medications wasunlocked on ward A3. We checked a sample ofmedicines and found that these were all within date.

• Controlled drugs were stored in line with Home Officeregulations. Controlled drugs records books werecompleted correctly including all relevant informationand signatures.

• Medicines requiring cool storage at temperaturesbelow eight degrees centigrade were appropriatelystored in fridges. Daily temperature checklists werecompleted on the wards we visited. This included thetemperate range. Guidance was available for staff touse if temperatures fell outside the recommendedrange.

• At the time of our inspection, 90% of nursing staff and85% of medical staff had up to date medicinesmanagement training. The trust target for completionwas 85%.

• Between September 2016 and March 2017, 398incidents related to medicines were reported withinacute care services. Seventy-one per cent of theseincidents were graded as no harm. There had beenonly one incident where harm to the patient had beengraded as moderate or above.

• On the acute medical unit, pharmacy technicians hadbeen trained to administer the majority of oralmedications to patients. They were also trained to actas an authorised second check and witness in theadministration of controlled drugs. This system hadbeen developed as a result of a high number ofmedication errors on this ward and was an innovativeway of improving safety in relation to medicines.Nursing staff described this as a positive change toworking practices.

• There were no dedicated pharmacists for medicalservices although pharmacists visited wards toreconcile medicines and check prescription chartsincluding antimicrobial prescriptions, to identify andminimise the chance of prescribing errors. Pharmacysupport was available using a bleep system.

• Medications were prescribed using a paper drugkardex which was stored with the nursingdocumentation.

• We reviewed eight prescription charts and found thatcharts contained details of patient allergy status,regular medications, one off and as requiredmedicines. Medications had been reconciled by apharmacist on each chart. Medication was signed ashaving been given or a number was documented toexplain the reason for omission of a medicine ifapplicable.

• Staff wore disposal red tabards to identify that theywere undertaking a medication round which provideda visual prompt to staff to remind them not to disturbthem during the round. This was to minimise any riskof medication error due to other distractions.

Records

• Records were a combination of electronic and papernotes. All medical entries were entered on theelectronic patient record (EPR), although prescriptioncharts were hand written.

• We saw that most medical entries did not alwayscontain sufficient information or detail about medicalreviews. It was not always clear what grade of doctorhad reviewed the patient or who was present on theward round. Notes did not always provide sufficientclinical detail to evidence that test results had beenreviewed, considered or information about how aclinical decision had been reached.

• When paper records were completed and no longer inuse, ward clerks scanned these paper records into theEPR system to form one medical record. However, wesaw that records waiting to be scanned were notalways stored securely on medical wards. On wards A3and A8 and records for scanning were stored loose indocument folders or within notes trolleys. This meantthere was a risk that these paper records could be lostor incorrectly filed. On other wards, completed paperrecords were stored securely in a medical recordfolder prior to being scanned into the EPR system.

• We noted that there was a large volume of papermedical records being stored in an unlocked andunattended office on AMU. We also saw that medicalrecords for discharged patients had been left on the

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unattended ward clerk desk. This meant that medicalrecords containing confidential patient informationcould be accessed by unauthorised staff or the public.We highlighted this to the nurse in charge whoremoved the records on the ward clerk desk and toldus she would immediately log a job for a key to besourced for the office to ensure that the records werestored securely when unattended.

• The monthly records audit showed that 99% ofrecords reviewed contained all relevant informationsuch as patient name, date of birth and hospitalnumber.

• In endoscopy, a paper based care pathway was in use.We saw that records were stored securely and werecomplete, legible and signed. The pre-operativeassessment included a comprehensive assessment ofpatient needs.

• The trust was in the process of training all nursing staffto use the electronic patient note system to completenursing risk assessments and care plans electronically.

Safeguarding

• There was a designated lead for safeguarding adultsand children within the trust. Staff in medical serviceswere aware of their responsibilities in relation to adultand children’s safeguarding. They were able to tell uswhere to gain advice and how to make a safeguardingreferral. The safeguarding team were available foradvice during normal working hours. A safeguardinghub was available on the trust intranet with additionalinformation to support staff.

• Staff in medical services were expected to completetraining on safeguarding adults and children whichincluded training on female genital mutilation (FGM).Clinical staff were expected to complete level twotraining in both of these subjects. The trust set a targetof 85% for completion of safeguarding training.

• Safeguarding adults level one training had beencompleted by 92% of nursing staff in medical services.Safeguarding adults level two had been completed by83% of nursing staff which was just below the trusttarget of 85%.

• Safeguarding children level one had been completedby 97% of nursing staff. Level two training was belowtarget at 82%. Level three training had beencompleted by all relevant staff.

• Safeguarding training rates for medical staff were allbelow target. Only 56% of doctors had completedsafeguarding adults level two and only 54% hadcompleted safeguarding children level two.

• The nursing risk assessment booklet promptednursing staff to ask if patients were known to socialservices and make consideration of whether therewere any issues relating to domestic violence.

Mandatory training

• Mandatory training was a mix of face to face ande-learning sessions. The trust set a target of 85% forcompletion of mandatory training. Mandatory trainingcourses included moving and handling, health andsafety and fire safety.

• Training rates for medical staff did not meet the 85%target in any mandatory training module. Rates fortraining in these mandatory modules were 77% orbelow, with health and safety training completion at54%.

• Nursing staff training figures met the 85% target in allbut one of the seven mandatory modules with trainingrates in these modules at 90% or above. The modulethat did not meet target was health and safety levelthree where two out of six relevant staff hadcompleted this.


• An early warning score (EWS) system was in use in allareas. The EWS system was used to monitor patients’vital signs, identify patients at risk of deterioration andprompt staff to take appropriate action in response toany deterioration. In all the records we reviewed, wesaw that scores had been calculated correctly andactions taken in line with trust guidance when apatient deteriorated.

• A medical emergency team was available andcontacted via an emergency number when a patient's

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EWS was over seven. There was also access to anacute care team 24 hours a day which was made up ofcritical care outreach nurses, assistant or nursepractitioners.

• The hospital audited the use of the early warningscore system on a quarterly basis. We saw that wardsC21 and A3 did not meet the 75% target set on thedeterioration recognition audit completed in July2016. Actions were taken and on the most recent auditin February 2017, both wards achieved the requiredcompliance rate.

• An ibleep system was in use to page staff whenrequired to review patients. Doctors and nurses told usthis worked well.

• In the acute care division, only 59.1% of all staff hadcompleted basic life support training betweenFebruary 2016 and January 2017. This was below thetrust target of 85%. Forty-one percent of nursing staffwithin the division had completed immediate lifesupport training and less than 1% of staff (eightnurses) had completed advanced life support training.

• The trust provided details that indicated 21 (12.5%)nursing staff had completed the acute illnessmanagement course. Additional information wasprovided as part of the factual accuracy check thatgives more details as follows, at end January 2017there were 114 (24.36%) staff with AIM certificationwithin Acute Care Division. these numbers arecalculated from Jan 2014 as the AIM coursecertification lasts for 3 years.

• In quarter three, only 75% of patients were screenedfor sepsis where the trust sepsis screening protocolshould have been completed. Only 51.4% of patientswith severe sepsis, red flag sepsis or septic shockreceived IV antibiotics within 90 minutes ofidentification. This had improved from the quarter twoaudit which showed 48% had been screened and 50%had received antibiotics within 90 minutes. Wereviewed one set of records where sepsis had beendiagnosed and saw that there had been no screeningfor sepsis despite the patients presenting conditionand that sepsis six had not been implemented for 48hours.

• In addition to clinical observations rounds, a comfortround was carried out regularly by care workers. This

included ensuring patients were comfortable, that thenurse call bell and drinks were available, positionalchanges if necessary and asking patients if there wasanything else they needed. We saw that these roundswere recorded in the patient notes when completed.

• A paper based nursing risk assessment booklet was inuse on each of the wards we visited. Assessments inthe booklet included risk of falls, use of bed rails,mobility and pressure ulcers. We reviewed eight riskassessment booklets and found that risk assessmentshad been completed and appropriate care plans hadbeen put in place where indicated. Clinicalobservations charts, fluid balance charts and fooddiaries were also paper based and these had also allbeen completed correctly.

• A monthly audit was completed to monitorcompliance with key risk assessments. We reviewedthe audit completed in January 2017 and saw that100% of patients had a completed bed railassessment, mobility assessment and Waterlow(pressure ulcer) assessment.

• Wards used bay tagging if there were a number ofpatients at high risk of falls or with cognitiveimpairment. Bay tagging is a method of ensuring onemember of staff is always present in a specified clinicalarea to reduce the risk of patient harm. One to onesupport was provided when patients required anenhanced level of support and observation.

• Electronic patient boards provided staff with a highlevel overview at a glance of any particular patientrisks or needs. The boards used symbols to highlightrisks such as mobility needs, requirement for a VTEassessment, infection control issues or acute kidneyinjury.

• On AMU, staff told us they placed low risk patients inthe GP assessment area. However, when we visited theward on 8 March we saw that all patients in this areahad been assessed as high risk of falls.

• The cardiac catheterisation lab used an adaptedversion of the World Health Organisation (WHO)surgical safety checklist. The surgical safety checklistwas introduced by WHO as a tool to improve the safetyof surgery by reducing deaths and complications. Wesaw that this had been completed correctly in therecords we reviewed.

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• On CCU, we saw that nursing staff monitoredtelemetry systems at all times. Patients on AMU or A2who needed continuous monitoring via telemetrywere fitted with the monitoring device and monitoredremotely by the trained staff on CCU. Staff on CCUcommunicated with AMU via an intercom system toalert them to any action they needed to take.

• The service used an “SBAR” (situation, background,assessment, recommendation) document whenpatients were moving between wards to effectivelycommunicate key information regarding the patients’clinical presentation and plan of care and areas of risk.

• In the endoscopy unit, baseline observations ofpatients were taken before the procedure and atregular intervals during the procedure to monitor forany deterioration. A safety huddle was held beforeeach patient list to discuss the upcoming list and anypotential safety issues or particular needs of thepatients. This was formally documented for an audittrail.

• Access to an emergency gastrointestinal (GI) bleedconsultant was available 24 hours a day. This meantthat in the event of a GI bleed, patients could betreated quickly at the hospital.

Nursing staffing

• The Safer Care Nursing Tool had been used tocalculate nursing staffing on medical wards. This hadbeen reviewed most recently in April 2016. Theintroduction of this tool had resulted in an increase inthe nursing establishment on some wards. The ChiefNurse had also met with some ward managers toreview nurse staffing levels in November 2016. Staffinglevels were reviewed by matrons on a daily basis andstaff were reassigned to support other wards orbrought in via the nurse bank or agency whennecessary.

• There was a nursing staffing escalation procedure inplace which included details of actions to be taken bystaff at all levels to ensure safe staffing levels. The trustcollected data to compare the planned nursingcoverage to the actual nursing coverage for each wardon a daily basis. Wards we visited displayed plannedand actual staffing levels for each shift that day.

• Senior staff told us that although unfilled shifts wereadvertised through the nurse bank or agency, shiftswere not always filled. The overall fill rate forregistered nurses during the day was 87.8% betweenSeptember 2016 and February 2017. The fill rate forcare staff during this time period was 92%. Nurses toldus that they regularly worked late to catch up onpaperwork when shifts had been unfilled.

• When we visited ward A8 we saw that the plannednurse cover was five registered nurses but the actualwas three registered nurses. This meant that the nurseto patient ratio was one to 11 and the nurseco-ordinating the shift was also expected to care for agroup of patients.

• Although there is no national maximum nurse topatient ratio, there is evidence that the risk of harm topatient increases if a nurse is caring for more thaneight patients during the day. One additional bankhealthcare support worker had been allocated to theward to support the shift.

• We also noted that the nurse co-ordinating was alsoexpected to complete IT training on the ward whilststill being expected to care for patients andco-ordinate the shift. The average fill rate for registerednurses on A8 in January and February 2017 during theday was 88.1%.

• During our unannounced inspection, we visited wardA3. We saw that the planned registered nurse on theshift was four and the actual was three nurses. Thismeant that the nurse to patient ratio on this shift wasone to 11. The average fill rate for registered nurses onA3 in January and February 2017 during the day was87.8%.

• The average fill rate for registered nurses on A2 inJanuary and February 2017 during the day was 80.4%.The fill rate on the coronary care unit (CCU) was 76.8%.This meant that nearly a quarter of shifts on CCU didnot have the required number of nursing staff on duty.The CCU is a ward that frequently cares for patientswith a higher level of nursing monitoring andintervention (level two care). Nursing staff on this wardwere also expected to monitor telemetry remotely forpatients undergoing continuous monitoring on AMU.

• We asked the trust how they monitored nurse staffingon AMU when the assessment area was being used as

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an escalation area to care for up to nine additionalpatients. The trust did not provide us with thisinformation and we were therefore unable to establishwhether the shift fill rates provided included theadditional staff required to safely care for thesepatients. Senior staff told us that the ward was usuallystaffed with six registered nurses to 39 beds, with oneof these nurses coordinating the shift. the trustclarified that to co-ordinator is responsible for lookingafter and monitoring these patients.

• Wards were generally staffed adequately on nightshifts. The overall fill rate for registered nurses at nighton the medical wards was over 98% betweenSeptember 2016 and February 2017.

• The trust reported an average vacancy rate forqualified nurses of 15.4% in medical services inDecember 2016. There had been high levels of bankand agency nursing staff to improve staffing levels onmedical wards. Between April 2015 and March 2016,the trust reported an average bank and agency usagerate of 16.4% in medical services. Bank and agencyusage was highest on ward A8 at 32.5%.

• Bank or agency nurses completed a local induction ontheir first shift on a ward. This was an electronic formthat was completed and automatically submitted tothe human resources department and includedessential information such as location of emergencyequipment, systems for documentation and processesto follow in the event of an emergency. Staff told usthat they had regular bank and agency staff workingon the wards.

• A recruitment and retention group had been set up bythe Chief Nurse and there was an associated strategyin place with two matrons leading on nurserecruitment.

• The trust was piloting the new associate nurse trainingprogramme and some of these students were placedon medical wards. There were seven nurse associatesin training in medical services. These students wereundertaking a two year programme of study. Thenursing associate role is a regulated role bridging thegap between a support worker and registered nurseand will support registered nurses in the delivery ofcare.

• Nursing handovers took place at each change of shift.We observed two handovers and saw that the verbalhandover was thorough and covered patients’ needsand plans for care and treatment. Healthcare supportworkers held a separate handover to shareinformation specifically related to patients’ careneeds.

• In addition to the nursing handover, a ward safety briefwas held highlighting any specific patient safetyconcerns such as risk of falls, safeguarding concerns orthat Deprivation of Liberty Safeguards were in placealong with specific feedback from incidents ofcomplaints. These were formally recorded and keymessages were distributed to staff working on thewards.

Medical staffing

• In October 2016, the percentage of consultant staffworking at the trust was lower than the Englandaverage. In medical services, 27% of medical staff wereconsultants in comparison to the average of 37%. Theproportion of junior doctors was 36% at Warringtoncompared to the average of 20%. This meant that thetrust employed a higher number of junior doctors thanother trusts.

• There was consultant presence on AMU and for acuteadmissions between 8am and 9.30pm Monday toFriday and 9am until 9.30pm on Saturday and Sunday.Access to a consultant was available on call outside ofthese hours.

• Consultant ward rounds on AMU were not consistentin how they were run. Some junior doctors told us theywere not always at the patient bedside duringconsultant review and therefore did not necessarilyhave a full oversight of the patients care andtreatment.

• Medical staffing overnight was provided by oneregistrar and three other junior doctors. The teamwere supported by the acute care team which wasmade up of critical care outreach nurses, assistant ornurse practitioners should a patient deteriorate.

• Medical cover for ward A4 (a discharge andassessment ward) was provided by a GP andsupported by a junior doctor (F2). On the Forget MeNot ward, patients were reviewed by a consultant

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three times per week. This ward is a specialist unitcaring for patients with a diagnosis or suspecteddiagnosis of dementia or delirium who did not have asignificant physical illness but who still required acutehospital care and therefore only required this level ofconsultant input.

• There were high vacancy rates for medical staff insome specialities. In December 2016, the trustreported an average vacancy rate of 21.1% in care ofthe elderly and 16.8% in specialist medicine.

• Between April 2015 and March 2016, bank and locumusage rate was 40.7% in medical care. The specialitieswith the highest usage were acute medicine andendocrinology (35.7%), specialist medicine (27.4%)and care of the elderly (11.8%). Senior staff told us thatwhere possible, regular locum consultants who werefamiliar with trust systems and processes were used.

• During the winter pressure months, an additionallocum consultant and junior doctor was provided tocare for patients on the winter pressure ward.

• There was medical handover between doctors eachmorning and evening at the change of shifts. Weobserved a medical handover and saw that there wasno formal handover document and that the handoverwas unstructured with no clear way of sharinginformation. It was unclear who was leading thehandover. This meant there was a risk that importantinformation in relation to safe care and treatment maynot be communicated between doctors effectively.

• There was a trust wide recruitment action plan inplace that had been developed jointly with HealthEducation North West and the General MedicalCouncil. The acute care division was looking at waysto make medical positions at the trust more attractiveto applicants. For example, a chief of service was inpost and there were plans to recruit a chief registrar toprovide better clinical leadership, roles were beingredefined and rosters were being reorganised. Themedical director had raised these concerns to the trustboard at the February meeting and work was on goingto address this shortfall.


• There was a trust wide business continuity and majorincident policy in place. All new starters were expected

to complete an emergency preparedness trainingsession. Senior staff and on-call managers undertookadditional training to prepare them as ‘silvercommanders’ in the event of a major incident.

• There had been no major incident table top exercise inmedical services since the establishment of theclinical business unit and senior staff said that it hadbeen about four years since the last table top exercise.

• The trust developed a winter pressures plan each yearto manage the anticipated increase in demand forhospital beds during this period.

Are medical care services effective?


At our last inspection we rated effective as good. We haverated effective as requires improvement because:

• Staff did not follow the trust Mental Capacity andDeprivation of Liberty Safeguards OperationalProcedure. Large numbers of patients were subject toDeprivation of Liberty Safeguards without anappropriate assessment of their capacity to consent.In other cases, best interests decisions were beingmade without an appropriate capacity assessment.

• Following assessments, patients identified asrequiring a further assessment by a dietician were notalways referred.

• Appraisal rates were below the trust target. Doctors intraining could not always access the trainingopportunities they required.

However;

• Patient outcomes were good. The hospitaldemonstrated good performance on the heart failureaudit, myocardial ischaemia national audit project(MINAP) and improving performance on the sentinelstroke national audit programme (SSNAP).

• Care and treatment was generally delivered in linewith evidence based guidance and local pathwaysreflected national guidelines. The service auditedcompliance with NICE guidance and participated in allrelevant national audits.

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• The endoscopy unit had achieved Joint AdvisoryGroup on Gstro Intestinal Endoscopy (JAG)accreditation. JAG accrediation indicates that theservices provides endoscopy in line with the GlobalRating Scale Standards and is a mark of best practice.

• There was access to a range of healthcareprofessionals to support the delivery of care. Staff toldus that multidisciplinary working was good and therewere good working relationships between disciplinesand with the local authority.


• Care and treatment was delivered in line with nationalguidance from National Institute for Health and CareExcellence (NICE), the Royal College of Physicians(RCP) and Royal College of Nurses (RCN). There werelocal pathways in place to support decision making inline with best practice guidance although somedoctors found it difficult to locate local pathways, forexample for acute kidney injury, on the trust intranet.

• In endoscopy, procedures were carried out in line withprofessional guidance produced by NICE and theBritish Society of Gastroenterologists.

• Patients received an assessment of their risk of avenous thromboembolism (blood clot) on admissionand were given treatment in line with NICE qualitystatement (QS) 66. Staff provided care in line with‘Recognition of and response to acute illness in adultsin hospital’ (NICE clinical guideline 50).

• Medical services participated in all relevant nationalaudits they were eligible to complete. There were alsotrust wide, divisional and clinical business unit auditprogrammes that reviewed compliance with localguidelines and evidence-based care. Following audits,action plans were developed to address any areas ofshortfall or where further improvements could bemade.

• A recent audit of the care of patients with acute kidneyinjury stage three showed poor compliance with NICEguidance in relation to prescription of fluids. An actionplan had been developed to improve medical staffeducation in the prescription of fluids. We asked the

trust if the actions in this plan had been implementedand if there was a follow up audit planned to reviewcompliance but the trust did not provide us with thisinformation.

Pain relief

• Pain scores were recorded as part of the clinicalobservations rounds and patients were also askedabout pain levels during comfort rounds. We saw thatpatients’ pain levels were recorded on early warningscore documentation in line with the core standardsfor pain management services in the UK (Faculty ofPain Medicine 2015).

• Patients told us they were offered pain relief and it wasprovided in a timely way.

• There was access to a range of medications for painrelief, including patient controlled analgesia andstrong pain relieving drugs. When pain was poorlycontrolled or difficult to manage, patients werereferred to the specialist pain team for advice andsupport.

• Patients were offered sedation and pain relief whenundergoing endoscopy. A “comfort score” was used toassess pain following any procedure in endoscopy.


• A coloured tray system was in use to highlight patientswho needed assistance with eating and drinking.Patients were offered assistance when needed.

• Water jugs and cups were available at patients’bedsides.

• An audit completed by the trust in January 2017showed that 92% of patients had received anutritional assessment using the MalnutritionUniversal Screening Tool (MUST). Of these patients97% had a personalised care plan in place however,only 40% of relevant patients had been referred to adietician for assessment. We reviewed one recordwhere the MUST score was high and in this case areferral had been made appropriately.

• Patients were provided with drinks and snacksfollowing procedures in the endoscopy unit. Therewas access to food and drink in the discharge lounge.

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• Patients told us that the quality of food was good andthat meals were hot when they arrived. On the ForgetMe Not ward, a range of finger foods were available asan alternative to a main meal. The availability of fingerfood for patients living with dementia who maywander on a ward is good practice.

• On the stroke unit, nursing staff had been trained toundertake swallowing assessments to ensure patientscould safely eat and drink without needing to wait foran assessment by a speech and language therapist.

Patient outcomes

• The myocardial ischaemia national audit project(MINAP) is a national clinical audit of the managementof heart attacks. The hospital took part in the 2013/14MINAP audit and scored better than the Englandaverage for all of the three key indicators. MINAP auditresults for 2013/14 showed the number of patientsdiagnosed with a non-ST segment elevationmyocardial infarction (NSTEMI-a type of heart attackthat does not benefit from immediate percutaneouscoronary intervention) seen by a cardiologist prior todischarge was better than the national average at97.8%. Sixty-four per cent of patients with an NSTEMIwere admitted to a cardiology ward. This was betterthan the England average of 55.6%. The hospitalscored better than the England average for thenumber of NSTEMI patients who had or were referredfor angiography (91.3%).

• The hospital took part in the quarterly Sentinel StrokeNational Audit programme. On a scale of A to E, whereA is best, the trust achieved grade C overall in the mostrecent audit between April 2016 and June 2016. Thiswas an improvement on the grade D achievedbetween January and March 2016. The hospital scoreda grade E for speech and language therapy. Werequested the trust action plan to review any plannedor proposed action to further improve performance onthis audit, however the action plan supplied related tothe 2014 organisational audit and did not containdetails of current actions.

• Warrington Hospital’s results in the 2015 Heart FailureAudit were better than the England and Wales average

for all of the four of the standards relating toin-hospital care. The results for the seven standardsrelating to discharge were also better than theEngland and Wales average.

• In the 2015 National Diabetes Inpatient Audit thehospital scored better than the England average in 14metrics and worse than the England average in threemetrics.

• The proportion of patients with NSCLC receivingsurgery was 36.3%. This was significantly better thanthe national level and an improvement from theresults of the audit carried out in 2014. The proportionof patients with Small Cell Lung Cancer (SCLC)receiving chemotherapy was 64%. This was similar tothe national level.

• There was a lower (better) than expected risk ofreadmission for non-elective admissions at thehospital. However, there was a higher (worse) thanexpected risk for elective admissions. Of the top threespecialties for elective admissions, respiratorymedicine had a relative risk of readmission of morethan double the expected level. This meant thatpatients electively admitted for respiratory care weremore than twice as likely to be readmitted to hospital.

• At the time of our inspection, the trust had two activemortality outliers. There had been a higher thanexpected death rate for patients with regional enteritisand ulcerative colitis. The trust had investigated eachdeath, including an external review of one case, andfound these to have been unavoidable deaths but hadidentified and shared learning from these cases.

• The trust was also an outlier for in hospital mortalityrates for urinary tract infections. At the time of ourinspection, the trust was reviewing these mortalityrates to gain a better understanding of the potentialreason for this outlier. Following the insp3ection thattrust have reported the finding along with an actionplan to the CQC.

• The endoscopy unit had achieved Joint AdvisoryGroup on Gastro Intestinal Endoscopy (JAG)accreditation. JAG accreditation indicates that theservice provides endoscopy in line with the Global

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Rating Scale Standards and is a mark of best practice.We saw that there were plans in place to meet therequirements of JAG (an additional interview room)within two months of our inspection.

• The service was able to demonstrate reduced levels ofagitation and behavioural symptoms in patientsadmitted to the Forget Me Not unit. This demonstratedthat the environment and management methods werebeneficial to patients living with dementia.

Competent staff

• Between April 2016 and December 2016, on average74% of staff within Medical Care at the trust hadreceived an appraisal. This included 78% of nursingstaff, 71% of medical staff and 100% of allied healthprofessionals. Only 25% of additional professional andscientific staff had received an appraisal during thistime period.

• Staff were able to access training internally andexternally. Nursing staff had allocated mentors andallied health professionals had a named clinicalsupervisor.

• New staff were given a period of time where theyworked supernumerary that was appropriate to theirrole. For example, in endoscopy staff worked for twoweeks and on AMU staff worked for six weeks to givethem time to familiarise themselves with the runningof the department and systems in the hospital andaddress any immediate training needs.

• The trust had begun the implementation of the carecertificate for non-qualified care assistants in January2016. The care certificate is knowledge andcompetency based and sets out the learningoutcomes and standards of behaviours that areexpected of staff giving support to clinical roles suchas healthcare assistants.

• There was a designated training lead in the endoscopydepartment with an established system of inductionand training. This included access to allocated lists asa trainee, twice yearly appraisals and agreedcompetency sign off.

• There were systems in place to check thecompetencies of staff working in the cardiac

catheterisation lab. Nursing staff in the urgent andemergency care CBU rotated through AMU,ambulatory care and A2 to develop competencies andgain experience in other areas.

• A practice educational facilitator had recently beenappointed to work with AMU. As part of thedevelopment of this position, a clinical skills lab wasplanned to train staff on AMU in specific clinical skillsto enable them to accept patients with more complexneeds.

• The service was working with Health EducationEngland to improve the education and supervision ofdoctors in training. There was a risk that the lack ofpost graduate education available within the servicewould lead to the removal of training posts at thetrust. At the time of our inspection an action plan wasin progress however we found that some juniordoctors still felt they were unable to access sufficienteducational opportunities. Some junior doctors toldus they were not always able to attend teaching oroutpatient clinic observation due to the demands oftheir workload. This was more common in somespecialities than others. Others told us they were ableto access teaching.

• The acute care division had recognised an unmetneed in providing education supervision to doctorsworking within care of the elderly and had thereforeoutsourced this supervision to ensure thisrequirement was met.

• Therapy teams held regular in service training sessionsand staff on the Forget Me Not ward had attendedadditional training in the principles of dementia care.

• Staff had been supported to develop extended skills insome areas. Advanced nurse practitioners hadundertaken training to become nurse prescribers andthere were nurse endoscopists working in endoscopy.


• There was access to a range of healthcareprofessionals to support the delivery of care. Referralswere made to physiotherapy, occupational therapy,speech and language therapy and dietetics if required.

• Staff told us that multidisciplinary working was goodand there were good working relationships betweendisciplines and with the local authority. Daily board

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rounds were held on most medical wards at the startof the working day to allow multi-disciplinary team(MDT) members to exchange information aboutpatient care and treatment and discharge plans.

• We saw allied health professionals working withpatients in the ward areas we visited and saw evidenceof multi-disciplinary input in patient records.Occupational therapists and physiotherapists oftenworked closely with patients to deliver effectiveoutcomes for patients.

• We observed a bed management meeting and sawthat these were attended by a range of professionalsto ensure all disciplines were represented andinvolved in discussions about patient flow at thehospital.

• There was access to a psychiatry liaison service forpatients with mental health, drug or alcohol issues.The trust had recently employed a psychiatrist tosupport the delivery of psychiatric care to patientsduring their admission.

Seven-day services

• There was access to X-ray and CT scanning 24 hours aday, seven days a week. The magnetic resonanceimaging scanner (MRI) operated Monday to Sunday8am to 8pm.

• Consultant cover was provided seven days a week toreview all new admissions and patients who requireda consultant review.

• There was access to input from specialist medicalteams at weekends and out of hours such ascardiology.

• Inpatient and day case endoscopy appointments wereavailable Monday to Friday 8am until 6pm. Emergencyendoscopy was available 24 hours a day to managegastrointestinal bleeding.

• Occupational therapy (OT) and physiotherapy (PT) wasprovided Monday to Friday on the stroke unit. Therewas also a service on Saturdays and Sundays from8.30am till 12.30pm to assess any new admissions tothe unit. Speech and language therapy was providedsix days a week.

• There was access to a rapid response team of OTs andPTs seven days a week between 8.30am and 8pm forpatients on AMU and A2. This team could makearrangements for a rapid discharge from these areasincluding reinstating care packages.


• The endoscopy department had a full set of policiesbased on NICE guidance that was easily accessible onthe trust intranet.

• Reports were produced in real time in the cardiaccatheterisation lab and sent to the patients GP on theday of the procedure.

• Letters were sent to GPs on discharge to inform themof the reasons for admission and care and treatmentprovided during the patients’ hospital stay. Referralswere also made to other community health staff suchas district nurses and AHPs to ensure continuation ofthe patient’s care.

• Staff had access to the information they needed todeliver effective care and treatment to patients in atimely manner including test results, risk assessments,and medical and nursing records.

• There were computers available on the wards wevisited, which staff accessed for patient and trustinformation. Policies, protocols and procedures werekept on the trust’s intranet, which meant staff hadaccess to them when required.

• On the majority of wards there were files containingminutes of meetings, ward protocols and audits,which were available to staff.


• The trust reported that between January 2014 andDecember 2016 Mental Capacity Act (MCA) traininghad been completed by 77% of staff within MedicalCare. This was below the trust target of 85%.

• There was a trust wide Mental Capacity andDeprivation of Liberty Safeguard OperationalProcedure in place which set out the legalrequirements of the Mental Capacity Act (2005) andcontained information and procedures for staff tofollow when there was reason to doubt a patient’scapacity to consent.

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• We found that there was a widespread failure to act inaccordance with this procedure and the MentalCapacity Act (2005) in each of the areas we visitedduring our announced inspection. We found that staffhad not completed capacity assessments based onthe two stage test as set out in the Mental Capacity ActCode of Practice. On the Forget Me Not ward, we foundthat 15 patients had Deprivation of Liberty Safeguards(DoLS) in place but only two of these patients had aformal documented capacity assessment completed.On the stroke unit, there were six patients with DoLS inplace and none of these had a capacity assessment.This meant that patients were at risk of beingunlawfully deprived of their liberty. The trust MCA andDoLS policy had not been followed in a further threerecords we reviewed. We also saw that best interestsmeetings had been held to agree the place ofdischarge for two patients and that there was norecord of an assessment to determine the patients’capacity to make this decision for themselves beforethese meetings had taken place. We raised theseissues with the trust safeguarding lead during theannounced inspection. When we returned on ourunannounced inspection, we saw that capacityassessments had been completed correctly for each ofthe patients who had DoLS in place on the Forget MeNot ward. The ward manager also told us that staffwere attending additional training from the localclinical commissioning group and there were plans toarrange further training specifically aimed at band 5nurses.

• Staff on the Forget Me Not ward had a good level ofunderstanding about what constitutes a deprivation ofliberty and when to apply for a DoLS; however we sawthat on other wards staff did not always have this levelof understanding.

• Staff on the Forget Me Not ward had a goodunderstanding of the role of Lasting Power of Attorney.The ward manager told us they always requestedcopies of the LPA to ensure the LPA was for health andwelfare decisions.

• The service had identified a need to review theprescription of sedation to cognitively impaired orconfused patients who had fallen following asafeguarding review. The dementia lead nurse hadundertaken a review of incidents in February 2017 to

identify if sedation had been used as a form ofrestraint. The audit had found that sedation had beenprescribed appropriately where it had been used andhad not been used as a form of restraint. The audit didhowever contain recommendations about the use ofDoLS and documentation surrounding the MCA (2005).This review is an example of good practice.

• Consent was taken from patients attending endoscopyon the day of the procedure. Patients told us they weregiven sufficient information about the procedure andtime to ask questions. When we reviewed consentrecords during our inspection we saw that one patienthad not signed the consent form although theprocedure had been undertaken. We discussed thiswith the patient and staff at the time of the inspectionand found that the consent process had beencompleted but the patient had not been asked to signthe consent form. This was immediately addressed bystaff in endoscopy. We reviewed consent forms for twopatients on the cardiac catheterisation lab and sawthat these had been completed correctly.

Are medical care services caring?

Good –––

At our last inspection in January 2015 we rated caring asGood. We have maintained this rating because:

• Staff were kind, caring and compassionate. Staffrespected and maintained patients’ privacy anddignity. Friends and family test response rates werehigh and results were generally positive. The coronarycare unit and day case catheterisation laboratory bothhad average recommendation scores of 99% andabove.

• Staff gave explained care and treatment in a way thatpatients could understand and provided opportunitiesfor them to ask questions. Relatives were involved indecisions about care and treatment.

• On the Forget Me Not unit, relatives were encouragedto visit for extended periods of time and were made tofeel welcome by staff and volunteers.

• A range of specialist nurses were available in medicalservices. These nurses provided additional

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information and emotional support. Staff madereferrals for additional emotional support and signposted patients or their relatives to other sources ofsupport such as charitable organisations.

Compassionate care

• Patients told us staff were kind and caring and theyintroduced themselves when they first met. Staffcalled patients by their names. We saw that staff tookall possible steps to maintain patients’ privacy anddignity and patients confirmed this.

• We saw staff communicating with patients and theirfamily members in a respectful, compassionate andconsiderate way.

• Staff respected patients’ preferences and choices. Onthe Forget Me Not ward, staff treated each patient asan individual. They spent time with patients and theirrelatives to find out about their individual needs, likesand preferences and tailored activities around thepatient.

• In endoscopy, staff had identified that patient’s privacyand dignity may not always be maintained if otherclinical staff entered the procedure room during aprocedure. They took action to ensure this did nothappen.

• The Friends and Family Test response rate for medicalcare at the hospital was 32% which was better thanthe England average of 25% between December 2015and November 2016. Recommendation scores weregenerally over 80% during this time period althoughfor Ward A3 the recommendation rate was 69% inAugust 2016 and B18 scored only 50% in October 2016.The Coronary Care Unit and Day case Catheter Labboth had average recommendation scores of 99% andabove.

• All patients we spoke with told us they wouldrecommend the hospital to their family and friends.

• The endoscopy unit used a departmental patientsurvey to gain feedback about patient experience. Onthe most recent review of the survey, all patients hadreported they had been given enough privacy anddignity before, during and after their procedure.

Understanding and involvement of patients andthose close to them

• Patients told us they were given enough informationabout their care and treatment. They were givenopportunities to ask additional questions of nursingstaff and consultants.

• Patients felt their relatives had been involved inplanning their care, treatment and discharge.Relatives had been kept up to date with plans fordischarge.

• On the Forget Me Not unit, relatives told us they hadbeen given information about their loved one and hadbeen given opportunities to input into their care whenrelevant. Relatives were encouraged to visit forextended periods of time and were made to feelwelcome by staff and volunteers.

• One family whose relative was living with dementiatold us they had received conflicting information fromdifferent members of staff about the plans for theirrelatives care, and that they did not always receiveenough information from medical staff.

Emotional support

• There were a number of nurse specialists workingwithin medical services who could provide patientswith additional information and emotional support inrelation to their health conditions. This includedspecialist stroke nurses, respiratory, diabetes andcardiology nurses.

• On the 2015 Cancer Experience survey, the trustscored 84% which was below the national average of90% for the percentage of patients who were given thename of the specialist nurse who would support themduring their treatment. However, the trust scoredabove the national average for the percentage ofpatients who found it easy to contact their specialistnurse. The trust also scored 74% for the percentage ofpatients who were given information about localsupport groups which was below the national averageof 83%.

• Staff we spoke with understood the emotional impactthat care and treatment had on patients and theirfamily members. We observed staff providingreassurance and comfort to patients.

• On the stroke ward, staff completed assessments foranxiety and depression. The stroke team workedclosely with the Stroke Association and referred

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patients or their relatives to them for emotionalsupport and advice. They had also worked together tosupport a patient through applying to a televisionprogramme for help with home alterations.

Are medical care services responsive?


At our last inspection we rated responsive as requiresimprovement. We have maintained the rating at thisinspection because:

• The service continued to experience challenges inrelation to patient flow. The number of patientsexperiencing a delayed transfer of care had increasedwhen comparing data from 2015 to 2016. This wasdespite a reduction in the overall number of patientadmissions to medical services.

• At our last inspection we told the trust it must reducethe number of patient bed moves. When we compareddata from 2015 to 2016 we saw that more patientsexperienced bed moves. This meant that the trust hadnot reduced the number of patient bed moves andthat this issue had increased rather than decreased.Many of the ward moves happened overnight.

• Bed occupancy rates were high across all medicalwards. Between November 2016 and February 2017,six wards had over 99% occupancy. When bedoccupancy rates are high, the quality of care providedand orderly running of the hospital can be affected.

• There was limited personalisation of care plans in therecords we reviewed. Plans were largelypre-determined. An audit of patient records in January2017 showed that only 26% of patients had apersonalised dementia care plan in place.

• Complaints were not always responded to in a timelyway. In January 2017, there were 96 complaints openand the average length of time these complaints hadbeen open was 175 days.

• The average length of stay for elective andnon-elective admissions was two days longer than the

national average. The risk of readmission for electivepatients was worse than the expected level and forone speciality the risk of readmission was double thatexpected.

However:

• The trusts’ referral to treatment time (RTT) foradmitted pathways for medical services was betterthan the England overall performance. The latestfigures for January 2017 showed 90.9% of this group ofpatients were treated within 18 weeks.

• Medical patients outlying on other wards were caredfor by a named medical consultant. We reviewed thenotes of three medical outliers on surgical wards andsaw that they had been reviewed each day by amedical consultant.

• The environment on the Forget Me Not ward had beendesigned to be dementia friendly. An activityco-ordinator worked alongside volunteers to provideactivities and we saw patients being encouraged toengage in social interaction and meaningfuloccupation. Senior staff were proactive in theirapproach to managing difficult or challengingbehaviour in this patient group, continuously lookingfor ways to improve how patients living with dementiawere cared for.


• Medical services had been planned and developedwith a number of local partners and networks to meetthe needs of local people and also with considerationto the sustainability of services. For example, strokeservices in the area had recently been reorganised viathe stroke quality improvement group involvingclinical commissioning groups (CCGs), other localtrusts and the local stroke network. This meant thatthe hospital no longer offered a thrombolysis serviceto this patient group but continued to provide care topatients not eligible for thrombolysis or those needingrehabilitation.

• The service was also working with CCGs, local mentalhealth and community trusts to develop to developpathways and improve patient access to care in themost appropriate place at the right time.

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• Outpatients could directly access A7 to undergo apleural tap to reduce breathlessness. This meant thatpatients did not have to attend A and E.

Access and flow

• Patients were admitted to medical services via A andE, through GP referral to AMU or by pre-arrangedappointments for elective admissions and day caseendoscopy.

• There was a patient flow team which included bedmanagers and discharge facilitators. This team workedto improve patient flow in and out of the hospital. Bedmanagement meetings were held five times a day todiscuss the current bed state and predicted bedrequirements. Meetings were attended by matronsand senior nurses, allied health professionals,pharmacy, accident and emergency staff and infectionprevention and control staff. We observed a bedmanagement meeting and saw that informationabout bed status, patients awaiting admission from Aand E, delayed transfers of care and forthcomingdischarges was shared effectively.

• There was a trust wide escalation policy to which setout steps to be taken to manage bed capacity andpatient flow within the hospital. This also included afull capacity protocol which set out actions to takewhen bed capacity did not meet demand.

• The average bed occupancy rate across all medicalwards was 98.2% between November 2016 andFebruary 2017. Six wards had over 99% occupancyduring this time period. It is generally accepted thatwhen occupancy rates rise above 85%, it can start toaffect the quality of care provided to patients and theorderly running of the hospital. The CCU had thelowest occupancy rate at 91.9%.

• At our last inspection we told the trust it must reducethe number of patient bed moves. Between January2016 and December 2016, 64% of patients weremoved once or more. This was an increase of 14%when we compared figures from 2015 to 2016. Thenumber of patient moved two or more times hadincreased by 10% when compared with data from2015. This meant that the trust had not reduced thenumber of patient bed moves and that this issue hadincreased rather than decreased.

• In the six month period between July 2016 andDecember 2017, 1,866 patients were moved wardsafter 10pm. The majority of these moves were fromward A2. Senior staff told us that there had beendifficulties discharging patients earlier in the day dueto changes in the provision of patient transportservices and this had led to more overnight bed movesfor patients. The service was looking at alternatives tothis provision and used a private patient transportservice to supplement the provision of transporthome.

• At our last inspection we told the trust it must improvepatient flow in medical services at the hospital toensure patients are cared for on wards appropriate fortheir needs. The trust had reduced the numbers ofpatients being cared for in non-speciality beds whichmay not be best suited to meet their needs (alsoknown as outliers). The Cognitive Assessment Team(CAT) now identify suitable patients from assessmentareas for the Forget me Unit. This enables patients tobe transferred directly from assessment areas to theunit reducing a further patient move into the core bedbase.

• The hospital aimed to have no more than 10 patientsper day outlying on other wards. However, betweenSeptember 2016 and December 2016, there were 40days when the hospital exceeded this number ofoutliers. The number of outliers had been particularlyhigh during December 2016 with up to 38 being caredfor on wards that did not best suit their medical needs.The trust told us this was due to an increase indemand for non-elective medical beds during thewinter period. Where possible, patients were cohortedwith other medical patients on a surgical ward.

• Medical patients outlying on other wards were caredfor by a named medical consultant. We reviewed thenotes of three medical outliers on surgical wards andsaw that they had been reviewed each day by amedical consultant.

• On AMU, there was an assessment area that wasfrequently used as an escalation area with up to ninebeds when there were issues with access and flow.Senior staff told us this area had been in use almostdaily since December 2015 beds.

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• The trust had opened a discharge lounge the weekbefore our inspection which was staffed by nursesfrom the patient flow team. This area cared forpatients who were ready for discharge that day butwere awaiting transport or medication to take home.The trust was collecting data about the use of thedischarge lounge to assess the effectiveness of thisfacility and impact on patient flow.

• An estimated date of discharge was set for eachpatient on admission. The number of patientsexperiencing a delayed transfer of care (i.e. a delay totheir discharge) impacted on the flow of patientsthrough medical services at the hospital.

• On average there were 28 patients experiencing adelayed transfer of care between December 2016 andFebruary 2017. A delayed transfer of care is when apatient no longer requires an acute hospital bed but isstill occupying the bed. The overall number of delayedtransfers of care at the hospital in 2016 was 6,656, anincrease of 965 from the previous year. The mainreasons for delayed transfer during this period waspatient or family choice or that patients were awaitingan assessment of their needs. The trust have providedadditional information following the inspection. thereis a length of stay meeting held each week with allward manager, discharge facilitators, therapy staff andpartners in social care to review and plan for strandedpatients. This has enabled the safe discharge of somepatients with the greatest length of stay. The trust hasalso started to roll out the red to green daysmodel across the trust.

• The hospital collected data to monitor how manypatients were unable to access the Forget Me Not wardthat had been assessed and placed on the waiting list.Between April 2016 and February 2017, 67 patientshad been discharged home without receiving theircare on this ward.

• The coronary care unit provided level two care andwas a mixed sex ward. Patients were grouped on theward by gender where possible to maintain privacyand dignity as far as possible. A mixed sex breachwould occur on this ward when a patient no longerrequired level two care but was still being cared for onthe ward with patients of the opposite sex. Any mixedsex breech was reported as an incident. There hadbeen a total of 15 mixed sex breaches on CCU that

were not clinically justified between August 2016 andNovember 2017. The most common reason for thisbreach was a lack of availability of a bed on analternative ward. Trusts can be fined when a mixed sexbreach occurs.

• Between December 2015 and November 2016 thetrusts’ referral to treatment time (RTT) for admittedpathways for medical services had been better thanthe England overall performance. The latest figures forJanuary 2017 showed 90.9% of this group of patientswere treated within 18 weeks versus the Englandaverage of 89.1%. With the exception of August 2016,the trust has been performing better than or the sameas the England average.

• Between December 2015 and November 2016, theaverage length of stay for medical elective patients atthe hospital was 4.6 days, which was higher than theEngland average of 4.1 days. Of the top threespecialties for elective patients, respiratory medicinehad the highest average length of stay with 6.8 dayscompared to the England average of 3.6 days.

• For medical non-elective patients, the average lengthof stay was 8.9 days, which was higher than theEngland average of 6.7 days. For non-elective patientsgeriatric medicine had the longest average stay with13.9 days compared to the England average of 9.7days.

• There were low waiting times for diagnosticendoscopy. The average wait for an endoscopy wasaround two weeks between November 2016 andJanuary 2017 with no patients waiting over five weeksduring this time period.

• Patients attending for a day case endoscopy weregiven information about what to expect following theirprocedure, when to seek medical advice and who tocontact during and out of hours.

• On discharge from a ward, patients were providedwith a discharge card that contained details of who tocontact in an emergency and contact details for thedischarging ward.


• Patients with suspected dementia or cognitiveimpairment were referred to the cognitive assessmentteam. This was a team of nurses specifically trained to

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assess patients with cognitive impairment and provideadvice and support to wards. This team also assessedpatients against clear admission criteria to determineif admission to the Forget Me Not ward, a specialistdementia ward, was appropriate. Wards hadvulnerable adult link nurses who acted as a source ofinformation for staff on the ward and attended regularupdate meetings.

• The electronic patient record system could be used toflag patients living with dementia or those with acognitive impairment. There was no way of flaggingpatients with a learning disability.

• The environment on the Forget Me Not ward had beendesigned using the recommendations set out by TheKings Fund to be dementia friendly. The ward wasdesigned to appear less like a hospital ward andfeatured colour coded bay areas and a lounge anddining area designed to look like a home environment.There was access to an enclosed garden and a quietroom.

• Most ward areas we visited had dementia friendlysigns in place. There was a challenging behaviour careplan available to use where patients may displaybehaviour that was difficult to manage along withguidance to staff to identify non-pharmacologicalways of managing these behaviours. The serviceencouraged staff to use an ABC chart (antecedent,behaviour, consequence) to identify triggers and waysto minimise these.

• On the Forget Me Not ward, an activity co-ordinatorworked alongside volunteers to provide activities andengage patients in in social interaction andmeaningful occupation. We saw patients beingencouraged to join in with games such as cards anddominoes, and a singing group in the lounge area thatwas attended by five or six patients.

• The ward had also begun a three month trial wherestaff would wear ‘pyjamas’ to provide visual cues ofnight time as a method of reducing behavioural orpsychological disturbance overnight.

• The hospital supported John’s Campaign whichchampions the rights of carers to stay with peopleliving with dementia whilst they are being cared foroutside of their usual environment.

• There was no named lead for learning disabilitieswithin medical services. Senior staff recognised thiswas a gap in within the service. This meant that staffmay have difficulty accessing advice, support andtraining to enable them to meet the needs of patientswith a learning disability and may mean that theneeds of this patient group were not considered whenplanning and developing services.

• We saw communication aids for use with patients whoexperienced difficulties communicating.

• Where patients were living with dementia, the serviceused a “This is me” document. “This is me” is aninformation document developed to support peoplereceiving care who have any form of cognitiveimpairment or difficulty communicating their needsand is a way of supporting person centre care. Theservice also used “passports” outlining preferencesand how best to care for patients with a learningdisability.

• There was limited personalisation of care plans in therecords we reviewed. Plans were largelypre-determined. An audit of patient records in January2017 showed that only 26% of patients had apersonalised dementia care plan in place.

• There was access to face to face, telephone or writtentranslation services 24 hours a day. Staff also hadaccess to a local deaf persons’ organisation thatprovided sign language interpretation when required.

• The endoscopy department had introduced the use ofEntonox as an alternative to traditional anaestheticdrugs. This had increased patient satisfaction with theservice as they no longer needed a relative or friend tostay with them overnight following the procedure.

• Equality and diversity training had been completed by93% of nursing staff and 65% of medical staff. The trusttarget was set at 85%.

• There was a multi-faith prayer room and chapel at thehospital and access to chaplaincy services 24 hours aday.


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• Most patients we spoke with knew how to raise aconcern or make a complaint. Information about howto make a complaint was displayed at ward entrancesor on corridors.

• In endoscopy, we saw the department also displayedinformation about changes they had made as a resultof complaints or concerns, for example displayinginformation about any delays to appointment timesand which staff were on duty.

• The trust had recently reviewed the way complaintswere handled and agreed a new complaints andconcerns policy, including a reduced time scale of 30days for responding to complaints and allocatingcomplainants an agreed point of contact in the patientexperience team.

• Between January 2016 and December 2016 there were176 complaints about medical services. The trust tookan average of 145 days to investigate and closecomplaints. This was in line with their last complaintspolicy, which states complaints should be closedwithin six months.

• In January 2017, there were 96 complaints which werestill open. The average length of time thesecomplaints had been open was 175 days which waslonger than the previous target.

Are medical care services well-led?


We rated well-led as requires improvement because:

• The clinical governance structure within the acutecare division was not sufficiently embedded intopractice. We saw no evidence that governancemeetings were held in most of the clinical businessunits and no evidence that information from the trustwide governance meeting was shared with clinicalbusiness units via the divisional meeting.

• We saw no evidence that risk, risk management andquality measurement was discussed within mostclinical business units. Risks on the risk register did nothave complete details of actions taken to mitigaterisks or documented evidence of the outcome ofprogress reviews.

• There had been insufficient oversight of compliancewith the Mental Capacity Act (2005). Monitoring ofcompliance with trust policy had been insufficient toidentify widespread failure to act in accordance withthe law.

• Divisional objectives did not clearly set out targets tobe achieved to allow the service to identify if they hadsucceeded in meeting these objectives.

However:

• There was a positive and open culture. Staff describedcommunication as good and leaders wereapproachable and visible. The appointment of a newchief nurse was seen as a positive development.

• The service was working in innovative ways to improvethe sustainability and quality of the services itprovided, including developing new roles andnetworks of care.


• The majority of medical care was managed within theacute care division via four separate clinical businessunits. Some medical care such as rheumatology,endoscopy and gastroenterology was managed bybusiness units within the Surgery and Women’s andChildren’s Health division. This change inmanagement structure had come into effect in April2016. Services had been allocated to CBU based on apatient pathway rather than the traditional hospitalmodel of medicine and surgery. Each CBU was led bya nurse, doctor and operations manager.

• The acute care division was led by a chief of servicesupported by an associate director of nursing and anassociate director of operations.

• A consultants meeting was held in each CBU. Somemedical staff who were managed within the Surgeryand Women’s and Children’s Health division hadrequested that they still had the opportunity to attenda meeting of the medical specialty. An additionalmeeting was set up and supported by the Chief ofService to address this need.

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• Leaders in each CBU were being supported to developtheir leadership skills through internal and externalcourses. Staff told us that leaders at this level and atdivisional level were strong, supportive andapproachable.

• Nursing staff told us the appointment of the new chiefnurse had been a positive influence on the nursingrepresentation at board level and there had beennoticeable changes in this aspect of the service.

• Staff felt there was good communication within theservice. Senior staff “walked the wards” and werevisible.

• Senior staff told us that the executive team wasapproachable and they felt confident in raising issueswith the team if required.

• Senior staff told us that some consultants had beenresistant to holding daily board rounds on wards todiscuss patient care and discharge plans. This hadbeen introduced as part of the safer patients’ initiative.When we asked divisional leads what action had beentaken to ensure consultants carried out a board round,they told us that consultants on ward A8 hadcommitted to a board round that day.

• Matrons and ward managers held a weekly meeting. Amonthly staff meeting was held in endoscopy, on B12and the Forget Me Not ward. Minutes were used as arecord of meetings and these were circulated torelevant staff. We reviewed the minutes of theendoscopy unit and saw that these meetings followeda set agenda and were well attended.

• Senior staff in the urgent and emergency care CBU hadplans to change the GP assessment area on AMU intoa clinical skills lab and patient dining area. There hadpreviously been plans to develop this area into anambulatory care unit but this had been unsuccessfuldue to the reliance on the unit as an escalation area.At the time of our inspection, there were no crediblealternatives to free up this space on a permanentbasis.


• The trust mission was to provide high quality, safe andintegrated healthcare. There were an established set

of values at the trust that were to work as one,excellence, accountable, role models and embracechange. Pin badge awards were issued to staff whodisplayed these values consistently.

• Although not all staff were fully aware of the trustmission and values, most were aware that providinggood quality care was central to this.

• There were divisional objectives focussed around thetrust's key focuses of quality, people andsustainability. We noted that although there wereobjectives and associated actions in place, there werenot always specific measureable outcomes attachedto these objectives. For example, one of the measuresof success was listed as a reduction in delayedtransfers of care and there were no targets defined forthe reduction in nursing or medical vacancies.


• There was a defined clinical governance structurewithin the service and a system of feeding keyinformation up and down within the trust. Eachclinical business unit (CBU) had an allocatedgovernance lead with a dedicated governancemanager within the divisions. However, this was a newstructure with a recently introduced “quality bilateral”where key governance information from each CBUcould be discussed.

• There was a monthly clinical governance meeting heldwithin the division with a standard agenda althoughwe noted that this meeting was described as“informal” in the information provided by the trust. Wereviewed the minutes of the most recent meetings andsaw that incidents, NICE guidance and clinical auditwere discussed at these meetings. Senior staff told usthat information was shared at this meeting from thetrust wide governance meeting and cascaded back tostaff through CBU meetings and team meetingshowever when we reviewed the minutes the trustprovided we did not see evidence that this hadhappened.

• Senior staff told us there were monthly CBUgovernance meetings. We requested the minutes ofthese meetings but the trust only supplied theminutes of meetings from the airways, breathing andcirculation CBU. We noted that at the most recent

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divisional meeting in February 2017, the chief ofservice and associate director of operations haddiscussed the need to ensure these meetings wereheld within the CBUs with adequate attendance andwere quorate, suggesting that meetings had not beenheld.

• There was a medical cabinet of senior doctors whomet every three months that was chaired by themedical director and attended by around 25 seniordoctors. We asked the trust to provide us with theterms of reference for this group to determine whatthe function of the cabinet was but they did notprovide this information during the inspection.However following on from inspection, the trustprovided the terms of reference for the medicalcabinet, and confirmed that these were available atthe time of the inspection. The trust confirmed thatthe medical cabinet meet every 2 weeks. The cabinetis a trust wide group, not just a medical care group.

• A divisional dashboard was in use to monitor quality,patient experience and performance along withinformation about staff vacancies and sickness andfinance. Key metrics were displayed on this dashboardand rated as green, amber or red depending oncompliance against each metric.

• There was a divisional and departmental risk registerin place. Risks were managed using a process set outin a trust wide risk management policy. Risks weregiven a risk rating based on the likelihood of an eventhappening and the severity or impact this event wouldhave. Risks scoring 12 or above on this rating wereescalated to the divisional register.

• We reviewed the register and saw that key risks withinthe service had been identified. However, we notedthat risk mitigation actions were limited and therewere no progress reviews on any of the five actionplans we reviewed. For example, a patient safety riskdue to the number of nursing vacancies had beenincluded as a high risk on the register. The associatedaction plan did not contain sufficient informationabout what actions were being taken to reduce thisrisk and did not reflect the full range of actions seniorstaff and managers told us were taken. Although therisk had been reviewed in January 2017, there was nodocumented outcome of this review.

• We saw that risks and the risk register were discussedat the airways, breathing and circulation CBUmeetings including any new risks added or changes inrisk ratings during the previous month. Thesemeetings also included discussion of key safety issues,learning from incidents and complaints andcompliance or actions plans from clinical audit. Wedid not see any evidence from other CBUs.

• Senior staff recognised that one of the biggest risks inthe urgent and emergency care division was the use ofthe GP assessment unit for inpatient beds as part ofthe escalation plan.

• There had been insufficient oversight of compliancewith the trust Mental Capacity Act and DoLS policy.The policy set out the responsibility of the adultsafeguarding team and trust MCA lead to monitor thispolicy. We found that these responsibilities had notbeen completed in full. For example, the policy statedthat the adult safeguarding lead or patient safetymanager should monitor mental capacityassessments and applications for deprivation ofliberty safeguards and this should be undertakentwice yearly as part of safeguarding assurances. Thishad not been completed effectively to allowidentification of a widespread failure to follow trustpolicy.


• There was a positive and patient focussed culturewithin the service. Staff told us they would feelconfident to raise concerns and that there would be ano blame approach if something went wrong.

• Leaders in the urgent and emergency care CBU werekeen to foster a culture of positive learning. Theydescribed “amazing and awesome” as one of the waysthey were developing this culture, where success wascelebrated rather than only focusing on learning fromnegative events.

• The trust reported an average turnover rate of 9.6% fornursing staff. The turnover rate for medical staff was42.5% during the last financial year.

• The trust reported an average sickness rate for nursingstaff of 4.1%. This was lower for medical staff at 1.3%.Both these figures were below the trust target of 4.2%.

Public engagement

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• Wards displayed “how are we doing?” boards thatcontained information about staffing levels, patientexperience and general information about the ward.

• The endoscopy unit displayed information about howpatient feedback had been used to improve theservice. For example, patients had feedback that theyhad waited longer than expected to undergo theirprocedure and in response to this, the team hadreviewed how appointment times were offered.

• Patients were encouraged to complete the NHSfriends and family test survey. The endoscopy unitalso carried out a departmental satisfaction survey togain additional patient feedback.

• The Forget Me Not ward gained additional feedbackfrom relatives or carers during a patients' admission.In addition to this there was a steering group that wasattended by a patient representative in order to gainfeedback about performance or future developmentsto the service.

Staff engagement

• The acute care division had a social media accountthat could only be accessed by authorised staff. Thedivision shared information such as learning fromincidents or complaints, key feedback from meetingsor messages of thanks and congratulations with staffthrough this account. Senior staff were able to monitorhow frequently the page was accessed and by howmany staff and told us this had been a successful wayof engaging with staff.

• The trust used pin badge awards to recogniseindividuals who consistently displayed the trust's’values. Long service was recognised through thetrust's “Thank you” awards.


• The acute care division was actively managing thenumber of registered nurse vacancies using arecruitment and retention strategy, alongsidereviewing the roles of nurses on medical wards. Someof the changes they had implemented includedincreasing phlebotomy cover, ward clerk hours andband two healthcare workers to release time for thenurses to carry out registered nursing duties.

• The division was working with other local NHS trustsand partners to develop a frailty network which wasdue to be established in May 2016. A frailty projectmanager was in place and the division was in theprocess of recruiting a nurse consultant for frailty.

• The Forget Me Not unit had been nominated for acompassionate patient care award by the HealthService Journal in 2016 for the work the service hadundertaken in improving acute hospital care forpatients living with dementia.

• The physician associate role was in use within theurgent and emergency care CBU. The physicianassociate is an innovative new role that is used tosupport the medical team in patient diagnosis andmanagement.

• The stroke team had developed the Warrington strokescale. This is a scale used to categorise patients andcare for them on an appropriate pathway following astroke. The team were working with a local universityto validate the scale.

Medicalcare



Safe Good –––



Responsive Good –––



Information about the serviceWe visited Warrington general hospital as part of ourannounced inspection between 7-10 March 2017. We alsocarried out an unannounced visit on the 23 March 2017.

Warrington hospital carries out a range of surgical servicesincluding: urology, ophthalmology, trauma andorthopaedics and general surgery (such as colorectalsurgery). Hospital episode statistics showed that betweenOctober 2015 to September 2016, 29,590 patients wereadmitted for surgery at the trust across Warrington andHalton sites. The data showed that 18,069 (61%) of patientshad day case procedures, 4240 (14.3%) had elective surgeryand 7281 (24.6%) were emergency surgical patients. Thenumber of patients admitted for surgery had increased by8726 from the 2013/14 statistics.

As part of the inspection, we inspected the main theatres,ophthalmic day case unit, the surgical assessment unit(SAU), ward A5 (the urology and general surgical ward),ward A6 (the general surgical ward), and ward A9 (thetrauma and orthopaedics ward).

We spoke with 10 patients. We observed care andtreatment and looked at care records. We also spoke with arange of staff at different grades including nurses, doctors,consultants, ward managers, theatre co-ordinators thetheatre managers, matrons, the associate director ofoperations and the chief of service. We received commentsfrom our listening event and from people who contacted usto tell us about their experiences, and we reviewedperformance information about the trust.

Summary of findingsAt the previous inspection in January 2015, we rated thisservice as good. Following this inspection we havemaintained the overall rating because:

• We found there was a good culture of incidentreporting in order to learn and share good practice.

• Serious incidents were investigated fully to establishthe root cause, and lessons learnt were shared withstaff to avoid reoccurrence.

• All clinical areas and bed spaces on the surgicalwards we visited appeared visibly clean and cleaningschedules were maintained.

• Staff could identify and respond appropriately tochanging risks to patients, including deterioratinghealth and wellbeing or medical emergencies.

• Mandatory training compliance for nursing staffacross the division had improved following the lastinspection.

• We saw that the service took part in a range of localand national audits and results were discussed atclinical audit meetings and actions for furtherimprovements identified.

• All patients and relatives we spoke with told us thatthat all members of staff treated them with dignityand respect.

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• We observed many positive interactions betweenstaff and patients during our inspection. We saw thatstaff were professional and friendly and created arelaxed friendly environment.

• Patients we spoke with were very positive about theway staff treated them.

• Patients and those close to them told us that theywere involved in planning and making decisionsabout their care and treatment.

• Bed meetings took place four times a day to ensureflow was maximised across the hospital.

• The trust monitored the number of cancelledoperations on the day of surgery. Performance datashowed that the number of cancelled operations onthe day of surgery had improved from 11.9% inFebruary 2016 to 8.8% in January 2017.

• Between October 2015 and November 2016, theaverage length of stay for surgical elective patientswas better at the trust at 2.7 days, compared to 3.3days for the England average.

• There were a number of specialist nurses within thetrust to help support the care and treatment ofpatients.

• The trust’s referral to treatment time (RTT) for thepercentage of patients seen within 18 weeks was76.9%, which was better than the England average of71.5%.

• There was 24-hour medical cover on site to attend topatients who had deteriorating needs.

• Senior managers were clear on their strategy toprovide high quality services for patients, whichincluded working collaborative within theorganisation, and in partnership with other trusts todeliver high quality services.

• We saw that Local Invasive Standards for InvasiveProcedures (LocSSIP’s) had been developed inpartnership with the North West theatre network.The standards were in place to ensure high quality,safe care and treatment for all patients.

However:

• We found not all theatre equipment was clean.However, we saw on the unannounced inspectionthat all theatre equipment appeared clean and newcleaning schedules introduced with oversightprovided by managers.

• We found some omissions in the completion of dailychecks such as resuscitation equipment andanaesthetic machines. However, we saw on theunannounced inspection that new anaestheticlogbooks were in use, and daily checks recorded and,resuscitation equipment had been checked.

• We found in theatres that not all stock ready for usewas within its expiry date. For example, on theemergency airways trolley the suction catheter andflexible tracheal tube introducer commonly known asa bougie had past its expiry date.

• Vacancy rates for nurse staffing was variable acrossthe wards. All staff we spoke with reported this as aconcern and often meant they needed to movewards to provide safe staffing levels.

• In recovery, we saw that national guidance was notbeing adhered to ensure there were enough suitablyqualified recovery nurses on shift with advanced lifesupport training.

• Although ward staff had knowledge of capacityassessments and best interests meetings, we saw noevidence in three applicable records that this hadbeen applied for those patients who were unable toconsent to care and treatment.

• Theatre lists did not always run on time due to therenot always being available beds for patients postoperatively.

• Data provided by the trust showed that betweenSeptember 2016 to December 2016 there were 1180bed days lost to medical outliers on surgical wards.This number of medical outliers impacted on thenumber of available beds for surgical patients on thesurgical wards.

• Although there were formal audits completed thatincluded infection control, we saw no evidence thatmanagers had a formal system or process ofoversight, that ensured the cleanliness of equipment,

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and system checks were maintained. However,during the unannounced inspection we saw that theservice managers had reacted quickly to ourconcerns, and new systems and processesimplemented with management oversight to ensurecompliance with standards and policy.

Are surgery services safe?

Good –––

At the previous inspection in January 2015, we rated caringas good. Following this inspection we have maintained theoverall rating because:

• We found there was a good culture of incident reportingin order to learn and share good practice.

• Serious incidents were investigated fully to establish theroot cause and lessons learnt were shared with staff toavoid reoccurrence.

• All clinical areas and bed spaces on the surgical wardswe visited appeared visibly clean and cleaningschedules were maintained.

• We observed that all medicines were appropriatelystored in suitable locked cabinets, and a member ofqualified nursing staff held the keys.

• Staff could identify and respond appropriately tochanging risks to patients, including deterioratinghealth and wellbeing or medical emergencies.

• Mandatory training compliance for nursing staff acrossthe division had improved following the last inspection.

However:

• We found not all theatre equipment was clean.However, we saw on the unannounced inspection thatall theatre equipment appeared clean and new cleaningschedules introduced with oversight provided bymanagers.

• In recovery, we saw that national guidance was notbeing adhered to ensure there were enough suitablyqualified recovery nurses on shift with advanced lifesupport training.

• We found some omissions in the completion of dailychecks such as resuscitation equipment, anaestheticmachines and controlled drugs. However, we saw on theunannounced inspection that new anaestheticlogbooks were in use and daily checks recorded.

• We found in theatres that not all stock ready for use waswithin its expiry date.

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• Vacancy rates for nurse staffing was variable across thewards. All staff we spoke with reported this as a concernand often meant they needed to move wards to providesafe staffing levels.

• Mandatory training and safeguarding trainingcompliance for medical staff did not meet the trusttarget.

Incidents

• The hospital had an up to date trust incident reportingpolicy for staff to follow, which was available to themthrough the hospital intranet.

• All staff we spoke with at Warrington hospital had agood understanding of the reporting system and couldaccess the system from the ward or theatre. Allincidents, accidents and near misses were entered ontoan electronic system. Staff gave examples of the type ofincidents they reported. For example, delays in theatre.and insufficient staff on the wards.

• Data we received from the trust showed betweenJanuary 2016 and December 2016 there had been 7564incidents reported across the trust. Of these 1177 (16%)occurred within theatres or inpatient surgical wardsacross the Warrington and Halton sites.

• Data provided by the trust showed that approximately82% of incidents were reported within 0-14 days andonly 1.8% of incidents were reported within 61-90 days.This shows that the majority of incidents were reportedsoon after the incident occurred.

• Incidents were reviewed and investigated by theappropriate manager to look for improvements to theservice. Moderate and severe incidents were alsoinvestigated through a process of root cause analysis(RCA), with outcomes and lessons learned shared withstaff. We saw two RCA reports, which had beencompleted, with recommendations, action plans, andlessons learnt which confirmed the process.

• We saw evidence that hospital action reports wereshared across the division. These reports highlightederrors in practice and key action points. We also sawevidence that key learning with regards to incidents andadverse events were discussed in daily safety briefings.

• We reviewed the incident recording logs and found thatthere was a broad spread of incidents recorded. Theseincluded cancellation of surgery and wrong patientdetails identified. This showed that staff were reportingappropriate incidents that occurred at the hospital.

• The trust had reported one never event at the Haltonsite in 2016 relating to wrong site surgery. Prior to, andfollowing the inspection, two further never eventsoccurred at the Halton site in March 2017, relating towrong site surgery and retention of a swab followingsurgery. These were being investigated at the time of thereport. ‘Never events’ are serious, largely preventablepatient safety incidents, which should not occur if theavailable preventable measures have beenimplemented by healthcare providers. Although thenever events had occurred at Halton hospital, all staffwe spoke with at Warrington hospital were aware of theincidents which had occurred which demonstrated thatkey information and learning was shared across bothtrust sites.

• We saw that the debrief following surgery included allteam members and included what could be improvedto aid departmental learning.

• The trust reported two serious incidents in 2016 relatingto surgical services. We saw that a full RCA had beencompleted.

• The trust reported low numbers of surgical siteinfections (SSI) following surgery. Between April 2015 toApril 2016, there had been four incidents of SSI in kneereplacement surgery and three incidents of SSI in hipreplacement surgery. SSI’s were monitored by theorthopaedic department in-line with National Institutefor Health and Care Excellence (NICE) guidelines forquality standards for orthopaedic surgical sitesurveillance. The surveillance information collectedduring April 2015 to March 2016 showed there had been672 hip and knee operations and indicated that theorthopaedic joint replacement infections were minimaland mainly superficial infections.

• All incidents and adverse events were discussed at thequality and safety meeting and staff reported thatincidents were discussed at daily safety huddles.

• In ophthalmology, we saw that a governance review hadtaken place in January 2017, to review feedback andshare lessons to be learnt from incidents. We saw that

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the review included incidents by category that includedadministrative errors, communication and medicineerrors. Staff we spoke with confirmed that they wereaware of incidents relating to their service.

• From April 2015, all providers were required to complywith the Duty of Candour Regulation. The duty ofcandour is a regulatory duty that relates to opennessand transparency and requires providers of health andsocial care services to notify patients (or other relevantpersons) of certain notifiable safety incidents andprovide reasonable support to that person.

• Staff were aware of the duty of candour regulation;ensuring patients received a timely apology when therehad been a defined notifiable safety incident. We sawexamples of where duty of candour had been appliedwith regards to incidents and complaints.

Safety thermometer

• The safety thermometer is a tool for measuring,monitoring, and analysing patient harms and 'harmfree' care. Data was collected on each month to indicateperformance in key safety areas, for example, newpressure ulcers and falls.

• The trust monitored the incidence of pressure ulcers,falls, and venous thromboembolisms (VTEs). VTEs areblood clots that can form in a vein and have thepotential to cause severe harm to patients.

• From January 2015 to January 2016 the trust reportedthere had been no falls resulting in harm, and threehospital acquired pressure ulcers across the surgicaldivision. We saw that incidents regarding falls andhospital acquired pressure ulcers were reported by staffusing the electronic incident reporting system.

• The surgical wards displayed information with regardsto the number of falls, and pressure ulcers that hadoccurred on the ward to highlight their safetyperformance to patients and visitors. We saw that in allrecords we reviewed that an appropriate fallsassessment had been completed to ensure the safety ofpatients.

• Guidelines from the National Institute for Health andCare Excellence (NICE) recommend that all patientsshould be VTE risk assessed on admission andreassessed 24 hours after surgery. Data provided by thetrust indicated that the year to date performance up to

December 2016 for patients being assessed for VTE, was93%.This was not line with the trust target of 95%.However, performance in December 2016 was in linewith the target, and all records we reviewed indicatedthat patients were assessed for VTE.

• From July 2016 to December 2016, there had been 11incidents of VTE across the surgical division. Of theseseven had been with trauma and orthopaedics. Thetrust provided information to support that RCA’s hadbeen completed in 10 of the 11 incidents.

• In January 2017, an audit to identify the percentage ofpatients as requiring prophylaxis following VTE riskassessment, who are given the defined treatment withinrequired timescale was completed. The audit found thatthe trust was 86% compliant, against a target of 95%. Anaction plan had been developed to ensure futurecompliance. The action plan included investigation intothe electronic system providing an alert that VTE hadnot been completed. The action plan was to beimplemented by the 31 March 2017 and would highlightto staff if the VTE assessment had not been completed.All staff we spoke with were aware of the need ofchecking and completing VTE assessments.

• We saw that anti-embolism stockings were used onpatients following surgery to reduce the risk of themacquiring VTE.


• The hospital followed their infection control policy,which included hand hygiene, use of personalprotective equipment (PPE) such as gloves and aprons,to prevent the potential spread of infection.

• At the pre-operative assessment stage, staff screenedpatients for Meticillin-resistant Staphylococcus aureus(MRSA) and Meticillin-sensitive Staphylococcus aureus(MSSA). This is in line with Department of Health:Implementation of modified admission MRSA Screeningguidance for the NHS (2014). MRSA and MSSA areinfections that have the capability of causing harm topatients. MRSA is a type of bacterial infection and isresistant to many antibiotics. MSSA is a type of bacteriain the same family as MRSA but is more easily treated.

• If a patient was identified at the preoperativeassessment with carrying an infection such as MRSA orMSSA, they received treatment for the infection in the

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five days leading up to the surgery. The scheduling oftheatre lists allowed for patients who had infections tobe last on the theatre list. Patients identified with MRSAcould be isolated in their rooms to prevent crossinfection risks.

• Data provided by the trust showed that betweenDecember 2015 and December 2016 there had been noreported cases of MRSA and three cases of MSSAattributed to surgical wards A6 and A9. Data provided bythe trust showed that the MSSA was likely to be presenton admission to hospital; however, the MSSA wasapportioned to the wards due to sampling delays.

• Staff were able to explain that any patient who attendedor acquired an infection would be barrier nursed tominimise the spread of infection.

• All floor areas and bed spaces on the surgical wards andday case unit we visited appeared visibly clean. We sawthere were signed and dated cleaning to show thatareas were clean.

• Sluice rooms and storage areas across the surgicalwards and day case unit appeared clean and free fromclutter.

• We observed staff following the local policy andprocedure when scrubbing, gowning and gloving priorto surgical interventions. When a procedure hadcommenced, movement in and out of theatres wasrestricted. This minimised the infection risk. We saw thatall staff in theatres wore the correct attire; piercingswere removed, and saw that hair including facial hairwas covered. We saw that at the end of surgery gownswere removed ready to be laundered.

• We saw that waste was separated and in differentcoloured bags to signify the different categories ofwaste. This was in accordance with the HTM 07-01,control of substance hazardous to health (COSHH),health, and safety at work regulations.

• We saw that locked separate bins were in use forconfidential waste. This ensured that sensitive data andpatient identifiers were destroyed securely.

• We found equipment was visibly clean throughout thesurgical wards, and staff had a good understanding oftheir responsibilities in relation to cleaning and infectionprevention.

• In theatres, we found that not all equipment was clean.For example, we found many of the theatre trolleys haddust on them. These included anaesthetic equipmentstorage units, resus trolleys, and anaesthetic machines.All areas we found not clean were discussed withtheatre managers and immediately rectified.

• As part of the unannounced inspection, we revisited thetheatres and found that the department appeared tohave been thoroughly cleaned. All trolleys had newcleaning checklists, which had been signed and datedwith oversight from managers to ensure compliancewith all cleaning across the department. The trust alsore-established a theatre infection control group aimedat strengthening infection prevention and controlthroughout the organisation.

• In the recovery area, we found that cleaning scheduleswere completed weekly and all areas (seven bays) weinspected appeared clean.

• We reviewed the theatre cleaning audits for February2016. The audit showed an overall compliance rate of93%. The audit highlighted to domestic, nursing staffand to estates the actions that were required for fullcompliance. For example, the audit found dust on top ofa fridge, and trolleys and who was responsible forcleaning.

• Policies and procedures for the prevention and controlof infection were in place and staff adhered to “barearms below the elbow” guidelines. Hand gel was readilyavailable in all clinical areas and entrances to wards andwe observed staff using it appropriately.

• We saw Personal Protective Equipment (PPE), was usedon surgical wards on a regular basis in line with hospitalpolicy. PPE was also provided for visiting relatives whenneeded.

• The infection control matrons produced a monthlyinfection control report, which included results fromhand hygiene, commode, work wear compliance,environment cleanliness and high impact intervention(catheter care) audits. We looked at a report fromJanuary 2017, which showed there was a high level ofstaff compliance across the surgical wards. We saw fromthe audits that any areas of non-compliance wereaddressed immediately with the ward or theatre.

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• The hospitals Patient Led Assessment of the CareEnvironment (PLACE) audit for 2016 showed the hospitalscored 98% for cleanliness, which was in-line theEngland national average of 98%.


• The wards and theatre areas we visited were generallywell maintained, free from clutter and provided asuitable environment for treating patients.

• We saw all fire escapes were kept clear and signpostedfor use in an emergency.

• There was sufficient storage space on the wards in thetheatres. We saw that on all surgical wards, medicalconsumables such as syringes and dressings wereappropriately stored in tidy and well-organised storagecontainers.

• In theatres, we found a sharps bin was over full andneeded replacing and another had not been labelled.This potentially could result in a needle stick injury.

• Porters collected waste using entrances that were notused by patients or visitors. This ensured that waste wasnot taken through the ward to minimise the risk ofinfection or contamination.

• Records indicated that equipment was maintained andused according to manufacturer’s instructions. Therewas sufficient equipment to maintain safe and effectivecare. We saw service schedules were kept for allelectrical equipment with service dates for scheduledservicing.

• We saw that medical gases in theatres wereappropriately stored and secure.

• Managers informed us that upon failure of anyequipment an external contractor providedreplacements quickly to avoid delays in surgicalprocedures taking place.

• The service had arrangements with an externalcontractor for the sterilisation of reusable surgicalinstruments. Managers informed us that the contractorprovided a good service and any errors were rectifiedusually the same day. Records were kept of any errors inproviding suitable reusable equipment in order forsenior managers to monitor the ongoing contract.

• A theatre maintenance schedule was in operation toensure that quarterly, half-yearly and annualrevalidation of theatre maintenance was co-ordinated.The schedule included building maintenance and themaintenance of the air-handling units to ensureoptimum performance of air extraction.

• Daily morning surgical meetings were held to ensurethat all staff had the required equipment for thesurgeries planned for that day.

• Records indicated that resuscitation equipment for usein an emergency in operating theatres and ward areas,were generally regularly checked and documented ascomplete and ready for use. The trolleys were securedwith tags, which were removed and replaced followingchecking the contents of the trolley. However, we foundthat on both the ward and theatres there were someomissions in the recording that the daily checks werecompleted. This was highlighted at the time ofinspection for immediate action.

• At the time of inspection we found that the anaestheticmachines were not been checked in accordance withthe Association of Anaesthetists for Great Britain andIreland (AAGBI). Daily checks of anaesthetic machinesshould be recorded daily. This was highlighted to thetheatre manager immediately. At the unannouncedinspection we found that new anaesthetic recording logbooks had been introduced and completedappropriately with oversight of ensuring compliancefrom managers.

• In theatres, we found 12 out of date stocks out onvarious trolleys. For example, we found out of date stockon the emergency varices trolley, the intubation trolley,the emergency airways trolley and percutaneoustracheostomy trolley. This was highlighted immediatelyto theatre managers and all out of date stocks removedand replaced. Out of date equipment included suctioncatheters which expired December 2016 and trachealsection set which expired December 2016.

• There were systems to maintain, and service equipmentas required. Medical devices we looked at across thesurgical wards, theatres and day case unit indicated thatequipment had been tested appropriately to ensurethat it was safe to use. Portable Appliance Testing (PAT)is a process by which electrical appliances are routinelychecked for safety once a year.

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• Recording systems were in place to ensure that detailsof specific implants and equipment could be providedrapidly to the health care products regulator. An implantregister was kept within theatres of all cosmeticimplants and prosthesis, and serial numbers noted. Wereviewed the register and found that it was legible, up todate, and contained the necessary serial numbers ofimplants or prosthesis used.

• The surgical wards used electronic whiteboards toprovide information about patients. The electronicboard provided the nursing and medical team with thename of the consultant and enabled the staff team toknow where a patient was situated within the ward.

Medicines

• There were arrangements in place for managingmedicines and medical gases. Nursing staff were able toexplain the process for safe administration of medicinesand were aware of policies on preparation andadministration of controlled drugs as per the Nursingand Midwifery Council Standards for MedicineManagement. We saw that there was an up to datepolicy for the safe storage, recording of, administrationand disposal of medicines. This was available for staffon the intranet.

• Surgical wards did not have a dedicated pharmacist toassist the supply of medication or support on the ward.We were informed that a bleep system was used toenable the ward to access pharmacy support. Staff wespoke with reported this was due to a shortage ofpharmacists across the trust. However, the wardsreported that they received a good service from thepharmacy department and there was a ward basedpharmacy technician on the surgical wards to improvemedicine safety.

• We saw that medicines were ordered, stored anddiscarded safely and appropriately and medical staffwere aware of the policy for prescribing antimicrobialmedicines.

• We observed that all medicines were appropriatelystored in suitable locked cabinets, and a member ofqualified nursing staff held the keys.

• Records on the ward and theatres indicated thatcontrolled drugs were checked once daily as aminimum, and were signed as correct by two staff. Thiswas in line with the trust’s policy to ensure controlleddrugs were accounted for, and were in date.

• We observed that controlled medicines stocks were indate.

• Medicines that required storage at temperatures below8ºC were appropriately stored in medicine fridges.Records indicated that staff completed daily fridgetemperature checks in line with the hospital policy.

• We reviewed 11 prescription charts and found them tobe generally legible, dated and signed, allergiesdocumented and saw antibiotics were administeredappropriately. However, we found three examples wheremedicines reconciliation (checked and confirmed) wasnot completed within 24 hours of admission (NICEMedicines Optimisation Quality standard QS120). Thepatients’ allergy status had not been recorded on one ofthe charts we examined, and the indication andduration of antibiotic treatment had not been recordedfor two antibiotic prescriptions, although they had beenreviewed and stopped appropriately within 72 Hours.

• We saw evidence in patient records that the trustcompleted weekly antimicrobial stewardship wardrounds (NICE Quality Standard QS121 AntimicrobialStewardship) to ensure that patients were not onantibiotics unnecessarily to address the increasingconcern of multi-drug resistant bacterial infections.

• A quarterly medicine management report highlightedareas where medication incidents had occurred acrossthe division. The report was disseminated across thetrust to enable shared learning. The report highlightedmedication errors by location and by type in order toaddress compliance and training needs. For example,following an insulin incident further training for staff hadbeen arranged by the diabetic team. Staff we spoke withconfirmed that extra training was available following amedicine incident.

• Staff informed us that following a medication incident,lessons learnt were shared at the daily ward safety briefand individual staff completed a medicine competencyif a dispensing error was made. Additionally, the wardsreceived support from the medicines safety nurse toimprove medicines safety.

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Records

• The hospital staff followed their trust patient recordspolicy, which included confidentiality of patientrecords.

• The trust used a mix of electronic and paper patientrecords to detail the care and treatment of patients. Wefound that all records were securely stored in each areawe inspected. The trust was moving towards a paperfree records procedure to ensure records were secureand contemporaneous.

• Staff and managers we spoke with highlighted that thatthe electronic new system had functionality problemsas not all assessments and pathways were electronic.This meant that staff were required to use both thepaper and electronic system to record care andtreatment of patients and information was not allcontained in one place. Managers were aware of thefunctionality issues and work was being completed toprovide a single electronic record to ensure allinformation was contained in a single source.

• Staff highlighted to us there had been issues in patientsnot receiving follow up appointments, and newappointment letters had not always been issued,meaning some patients would not be seen in clinic. Wesaw that the trust had carried out a review in January2017. The review highlighted the numbers of patientsthat required either a follow up or new appointment sothat contact could be made and necessaryappointments booked. This was added to the riskregister and a risk mitigation plan and a steering groupdeveloped to ensure all patients received the necessaryappointments. We reviewed the steering group meetingminutes from February 2017 and saw that the meetingswere well-attended and provided updates withprogress.

• At the time of inspection, we saw patient personalinformation and medical records were managed safelyand securely, in line with the data protection guidelines.We observed no records left out on the ward or theatreand were stored in cabinets once used.

• Patient records we viewed were integrated to ensurethat they contained all information frompre-assessment, through to surgery, to the ward. Thisprovided staff with the necessary information as to thecare and treatment required for each patient.

• Records indicated the individual needs of the patientsthat included previous diagnosis of dementia, learningdisability or mental health related diagnosis.

• We saw in theatres that a perioperative care pathwaywas used to detail consent had been obtained andhealth related needs documented.

• We looked at the records for five patients. These werestructured, legible, complete and up to date.

• Patient records included risk assessments, such as forfalls, venous thromboembolism, pressure care andnutrition and were reviewed and updated on a regularbasis.

• Patient records showed that nursing and clinicalassessments were carried out before, during, and aftersurgery and we saw that these were documentedcorrectly.

• Standardised nursing documentation was kept at theend of patients’ beds. Observations were well recordedand the observation times were dependent on the levelof care needed by the patient.

• Patient records were audited on a monthly basis. Theaudit looked at a random sample of records across thesurgical division to ensure compliance with the trustmanagement of medical records. In January 2017, thesurgical division records audit showed a compliancerate above the trust target of 75%. The report providedan action plan for improvement in future audits thatincluded further training for ward staff. Staff we spokewith confirmed that they were confident in the use ofthe paper and electronic records.

Safeguarding

• The trust had a senior named nurse lead forsafeguarding for both adults and children. All staff wespoke with were aware of their safeguarding adults andchildren responsibilities and who to contact if guidancewas required.

• Staff received mandatory training in the safeguarding ofvulnerable adults and children. This included anawareness of female genital mutilation (FGM). We sawthat FGM information was posted on the walls intheatres as a reminder for the staff on the department.

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• Data provided by the trust showed that betweenJanuary 2014 to December 2016, 91% of nursing staffacross the division had completed safeguarding adult’slevel 1 training and 83% of staff had completedsafeguarding adult’s level 2 training.

• Between January 2014 to December 2016, 92% ofnursing staff across the division had completedsafeguarding children level 1 training and 75% ofnursing staff had completed safeguarding children level2 training. The trust target was 85%.

• Safeguarding training compliance for medical staff toDecember 2016 was poor, and did not meet the trusttarget in safeguarding adults or children. 78% of medicalstaff completed level 1 adults and children and 62%completed level 2 adults and children.

• All staff we spoke with were aware of how to identifyabuse and report safeguarding concerns.

• We saw from staff handovers that the needs ofvulnerable patients were discussed at the daily teambriefings. Staff reported that the handover wouldinclude handover of information for those patients withpsychological and emotional needs.

Mandatory training

• Mandatory training was made available to all staff toenable them to provide safe care and treatment topatients. Some of the training was completed throughe-learning, which staff could access at a time to best suittheir needs. Staff we spoke with told us that they weregiven time to complete training.

• Staff received annual mandatory training, whichincluded key topics such as infection control, equalityand diversity, fire safety, health and safety, dementiaand medicine management.

• In theatres, staff training was co-ordinated andmonitored by the ward manager and by a practiceeducator within to ensure staff training was completed.

• Data provided by the trust showed that up to December2016, the division met their target (85%) for compliancein five of the seven applicable mandatory trainingmodules for nursing staff.

• Mandatory training for medical staff for the same periodto December 2016 was below the trust target in allmodules, ranging from 75% in moving and handling to54% compliance with health and safety training level 1.

• Data provided by the trust showed varying performanceacross the surgical wards and departments. The daycase unit and surgical assessment unit staff trainingrates were consistently above the trust target, rangingfrom 89% to 100% across all mandatory trainingmodules.

• The surgical wards performance ranged from 57% to100% across the mandatory training modules.


• The service had introduced a nurse led pre-operativeservice, with pre-operative guidelines for staff to followto ensure pre-assessment practice for elective surgerywas underpinned by evidence-based guidance. Theguidelines provided staff with a clear framework for safepractices relating to pre-assessment, and set out thestandards and competencies expected to ensure staffwere able to competently assess patients.

• Pre-operative assessments were completed for eachpatient to ensure that they are fit to undergo ananaesthetic and therefore the planned surgicaloperation. The assessment was a clinical riskassessment that included for example, anycommunicable diseases, blood results, allergies, and infemale patient of childbearing age they were asked ifthey could be pregnant.

• We saw that patients with allergies wore coloured namebracelets to highlight to staff that the patient had anallergy.

• Staff we spoke with could identify and respondappropriately to changing risks to patients, includingdeteriorating health and wellbeing, or medicalemergencies.

• The trust used the National Early Warning Score system(NEWS). This is a national standardised approach to thedetection of a deteriorating patient and has a clearlydocumented escalation response, in line with NationalPatient Safety Agency (NPSA) 2007 guidelines. On theNEWS chart, staff recorded observations including

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oxygen saturations, blood pressure and temperatureand collated a total score. We saw that guidance wasavailable on the NEWS charts to show what escalationwas required for each trigger score.

• We reviewed five patients’ NEWS charts and found thatall observations had been completed appropriately andat the appropriate time required.

• A NEWS score audit had been carried out in December2016 to January 2017 and the results showed an 86%compliance rate in NEWS recording across a sample of80 patient records. This was above the 75% compliancerate target for the trust.

• A sepsis-screening tool was used to identify patientswho were identified of potential sepsis. There were flowcharts to support staff, with the procedures to follow,and patients were required to be immediately escalatedto the medical team for review. Staff we spoke with onthe wards reported they understood the escalation andguidelines to follow. Data provided by the trust showedthat compliance with training in summoning emergencymedical assistance on the surgical wards wasconsistently above the 85% trust target, ranging from85% to 100%.

• In theatres we saw that the sepsis pathway was postedon the notice board. The information board alsoincluded the name of the sepsis link nurse to provideadditional support to the staff.

• The hospital used a care and comfort round form, toensure their patients were safe and comfortable. Thecare and comfort round included assessing patient painscores, nutrition, and NEWS score. The care and comfortrounds were undertaken at least every two hours for allpatients to ensure patient safety.

• If a patient’s health deteriorated, staff confirmed theywere supported with medical input and were able tocontact the critical care outreach team if needed.

• In theatres there was an extended recovery bay for usewhen a patient may need an extended recovery phasepost-surgery, or a critically ill patient may be admittedto the recovery area for pre optimisation andstabilisation prior to transfer to theatre, a wardenvironment or intensive care. The critical care outreachteam oversaw the care of these patients.

• The service had a standard operating procedure in placeto ensure that patients were not kept in the extendedrecovery area for more than four hours. The records wereviewed showed the bay was only used for 55 patientsfrom 2016 to 2017. However, 21 of these patientsbreached the four-hour target. We were informed thiswas due to the availability of a suitable bed for thepatient to transfer to and included the travel time for thepatient if they transferred to a neighbouring trust.

• Staff we spoke with reported that they received timelyaccess to psychiatry services and safeguarding team forthose patients whose metal health deterioratedfollowing surgery.

• All patients were given a call bell so they were able tosummon help in an emergency. We observed thatpatients on all wards we visited had call bells, and wesaw these being used by patients to summon help fromnursing staff.

• A theatre team brief was held before each theatre liststarted. This meeting highlighted all procedures thatwere being undertaken and allowed staff to confirm thatthe appropriate equipment was available. We observedthat the briefing was well attended by theatre staff.

• We observed the theatre teams undertaking the ‘fivesteps to safer surgery’ procedures, including the use ofthe World Health Organization (WHO) checklist. Thetheatre staff completed safety checks before, during andafter surgery and demonstrated a good understandingof the ‘five steps to safer surgery’ procedures.

• We saw that an adapted WHO checklist was used in eyesurgery to ensure that safer surgery took place.

• A WHO audit was completed in July 2016. The datareviewed showed 100% compliance in 1251 patientsacross the Warrington and Halton sites.

• We observed the WHO checklist was performedappropriately at the Warrington site.

Nursing staffing

• Staffing levels and skill mix were planned and reviewedso that patients could receive safe care and treatment atall times, in line with relevant tools and guidance. Theward used an acuity tool to determine the numbers ofstaff that were required on a daily basis to provide safecare and treatment to patients. The service provided

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three shifts; a long day, an early shift and a night shift toensure adequate numbers of staff, and continuity forpatients. We saw that nurse staff numbers weredisplayed at the entrance to the ward so patients andvisitors could see how many staff were on shift. Wardstaff reported that acuity of patients was monitoredthroughout the day in order to escalate to seniormanagers if extra staffing resources were needed.

• In theatres, staffing was arranged to meet theAssociation for Perioperative Practice (AfPP) safe staffingguidelines. This ensured that there was adequatelytrained staff to provide safe surgical care to patients. Wesaw from the surgical procedures we attended therewas appropriate staffing levels for each theatre.

• In theatres, 16, band six registered nurses hadcompleted advanced life support training to be able toprovide emergency life support if a patient deteriorated.We were informed that further training for band fivenurses was going to be made available. The ALS courseteaches the knowledge and skills required to recogniseand treat the deteriorating patient using a structuredapproach; deliver standardised CPR in adults; andmanage a cardiac arrest by working with amultidisciplinary team in an emergency.

• In recovery, we saw that there were no recovery staff onshift who were ALS trained. The Association ofAnaesthetists of Great Britain and Ireland (AAGBI)guidelines states that there should be at all times, atleast one member of staff in recovery that is a certifiedALS provider. We were informed that eight of the 14recovery staff had this qualification, and they had allcompleted immediate life support training. Managersinformed us that there were always staff on thedepartment in close proximity who had completed ALStraining, and anaesthetists and other medical staff wereavailable to support with advanced life support.Following the inspection, we were informed that allrecovery staff had been booked on the ALS course andhad completed the training.

• The ward managers monitored staffing levelsthroughout the day and escalated staffing shortfalls dueto unplanned sickness or leave. Managers we spokewith told us staffing levels were based on thedependency of patients and this was reviewed daily.

Staffing levels on the wards were increased whennecessary so patients needing 1:1 care could beappropriately supported. At the time of inspection, wedid not see any patients that required 1:1 support.

• All wards we visited had a number of staff vacancies.Data provided by the trust for December 2016 showedthat the vacancy rate on the surgical wards ranged from-5% (ward A9) to 44% (ward A6). Managers informed usthat recruitment and retention of nurses was a priority.We saw from data provided by the trust that the vacancyrate on ward A6 in January 2017 had improved from44% to 21%.

• We saw that recruitment was taking place and seniornursing staff co-ordinated regular daily staffingmeetings to cover staffing shortages.

• Matrons across the division met regularly to discussshortfalls in staffing across the wards. An electronic dailystaffing review tool was used to ensure that the dailystaffing level was visible trust wide. This also enabledthe senior on call team out of hours to see the staffingplan for each ward. Due to staffing shortfalls, staff weremoved to other wards to be able to provide adequatecover on wards where staffing was insufficient. Staff wespoke with confirmed this.

• We reviewed data provided by the trust for December2016 with regards to the fill rates (percentage of thenumber of staff working on the department) across thesurgical wards and found that fill rates for registerednurses ranged from 77% to 100% through the day andranged from 97% to 100% through the night. The datashowed that although there were staff vacancies, themanagers generally ensured the surgical wards werestaffed to ensure the safety of patients.

• We reviewed the staffing hours reports for January 2017,and saw that on wards A5, A6, and A9 the total monthlyplanned and actual hours for registered nurses and carestaff at night were generally filled. However, the plannedand actual daytime hours filled showed there wereshortages in qualified nurses on the wards. For example,planned staffing hours on ward A9 was 1782.5 hours andthe actual was 1386.5 hours (fill rate 78%). We saw thatalthough there were shortages of qualified staff, extra

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care staff were provided to support the nursing team.However, this does not negate the need to havesufficient qualified nursing staff on the wards to providecare and treatment to patients.

• Staffing levels were maintained by staff workingovertime and with the use of agency staff. Trust datashowed that the average rate of use of bank and agencystaff for March 2016 ranged from 7% to 31%. High ratesof agency and bank staff were being used due to highstaff turnover (range from 0% to 25%) and sickness rates(range 1% to 6%).

• The ward managers told us they tried to use regularbank or agency staff and ensured temporary staff wereaccompanied by permanent trained staff wherepossible, so that patients received an appropriate levelof care. Agency staff underwent induction and checkswere carried out to ensure they had completedmandatory training prior to commencing employment.Nursing staff confirmed that they were often moved towards to ensure agency staff worked alongsidepermanently employed staff.

• We saw that nursing staff reported incidents where theyfelt there was insufficient nursing staff on the ward. Thisshowed a good culture of reporting of low staffing levelsto ensure quality and safety of the wards in which theyworked.

• Nursing staff handovers occurred at every shift handoverand included discussions about patient needs, and anystaffing, or capacity issues.

Surgical staffing

• All treatment was consultant led at the hospital.Following surgery the continued care of the patientremained the responsibility of the surgical consultant.

• The trust reported that the medical staffing vacancy rateup to December 2016 ranged from 0% to 30%. Managersinformed us that the vacancy rate was improving, as anumber of medical staff had been appointed thatincluded two colorectal surgeons, two ophthalmologysurgeons, two spinal surgeons, and one upper limbsurgeon.

• Data provided by the trust up to December 2016,showed that the medical sickness rate was low, rangingfrom 0% to 3%. However, medical staff turnover washigh ranging from 1% to 22%.

• There was on-call consultant cover over a 24-hourperiod and there was medical cover outside of normalworking hours and at weekends. The on-call consultantswere free from other clinical duties to ensure they wereavailable when needed. Nursing and junior medical staffconfirmed that they were able to access consultantsupport if required.

• As of October 2016, the proportion of consultant staffreported to be working at the trust was lower than theEngland average by 2% and the proportion of juniormedical staff was higher than the England average by6%. Junior doctors informed us that they felt very wellsupported by the senior medical staff and they hadsufficient opportunities for training.

• We saw that daily medical handovers took place duringshift changes and these included discussions aboutspecific patient needs.


• We saw there was a documented major incident planand business continuity plan that listed key risks thatcould affect the provision of care and treatment.

• Managers informed us that the fire alarm was regularlytested and in theatres had completed a fire drill.

• In theatres, we were informed that they were lookinginto providing tabletop scenario training to support staffin major incident awareness.

• The trust had back-up generators for if the power supplyfailed. We were informed that these were regularlytested. We saw from the 10-year capital plan that newback-up generators were needed and was added to therisk register.

Are surgery services effective?

Good –––

At the previous inspection in January 2015, we ratedeffective as good. Following this inspection we havemaintained the overall rating because:

• Care and treatment was delivered to patients in linewith the National Institute for Health and CareExcellence (NICE) guidelines.

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• Pain scores were regularly recorded and patientsinformed us that they were offered appropriate painrelief.

• Patients who required support and assistance witheating and drinking were identified using a coloured jugsystem and supported by staff in accordance with theirpersonal needs.

• We observed good multidisciplinary working witheffective verbal and written communication betweenstaff.

• We saw that the service took part in a range of local andnational audits and results were discussed at clinicalaudit meetings and actions for further improvementsidentified.

However:

• Although ward staff had knowledge of capacityassessments and best interests meetings, we saw noevidence that this had been applied for those patientswho were unable to consent to care and treatment.


• Care and treatment was delivered to patients in linewith the National Institute for Health and CareExcellence (NICE) guidelines. For example the nationalearly warning system (NEWS) was used to assess andrespond to any change in a patients’ condition. This wasin-line with NICE guidance CG50. Staff also assessedpatients for the risk of venous thromboembolism (VTE)and took steps to minimise the risk where appropriate,in line with venous thromboembolism: 'reducing therisk for patients in hospital' NICE guidelines CG92.

• The hospital used care pathways that had beendeveloped to meet best practice guidelines, which stafffollowed to ensure patients received safe care andtreatment. We saw that on the trauma and orthopaedicward, a care pathway was in place for patientsundergoing hip surgery. The pathway incorporatedpre-assessment through surgery to post-operative care.

• In theatres a perioperative care pathway was completedfor all patients undergoing a surgical procedure. Thepathway included the surgical safety checklist,preoperative site marking, baseline observations and apreoperative checklist.

• The surgical teams participated in clinical audits.Findings from clinical audits were reviewed at themonthly clinical audit meetings, divisional integratedgovernance group meetings, and any changes toguidance and the impact that it would have on theirpractice discussed. We saw from the meeting minutesthat these meetings were attended by consultants andjunior doctors to share learning.

• Staff told us policies and procedures reflected currentguidelines and were easily accessible via the trust’sintranet. We saw that policy and procedures were up todate and reviewed regularly.

• Discrimination, including on grounds of age, disability,gender, gender reassignment, pregnancy and maternitystatus, race, religion or belief and sexual orientation wasavoided when making care and treatment decisions. Atrust policy was in place regarding equality anddiscrimination. We observed staff to treated patientsindividually and without prejudice.

• The service contributed to national audits includingPatient Reported Outcome Measures (PROMS). Theseaudits were published nationally to provide evidence ofoutcomes of the service provided.

• We saw evidence of an audit programme that scheduledthe audits to be completed for the year 2016. Forexample, we reviewed the audit programme forophthalmology surgery and anaesthetics and foundthere was a broad range of audits had taken placethroughout the year.

• In theatres, a medical device implants register was keptto ensure there was a system to record all implants usedand to report defects.

• Following day surgery patients were provided withappropriate information and contact numbers in linewith the Royal College of surgeons (RCS) good surgicalpractice 2014.

• We saw that staff followed NICE guidelines QS86following a patient fall that included checking for injuryand medical examination following a fall.

• We saw that staff used anti embolism stockings onpatients following surgery to reduce the risk of themacquiring VTE. This was in line with NICE guidelines QS3statement 5.

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• We saw that the Association of Anaesthetists of GreatBritain and Ireland (AAGBI) guidance for day case/shortstay surgery was followed, as patient social, medicaland surgical factors were taken into consideration priorto surgery. For example, assessments were completedto ensure the patient was fit for surgery and we saw theearly mobilisation of patients following surgery toenable patients to return home with a reduced length ofstay in hospital.

Pain relief

• Pain scores were recorded as part of the NEWS. We sawthat pain scores were documented and that pain reliefwas given to patients at the specified times. Wereviewed five patient records and found pain had beenrecorded appropriately in all records.

• We saw that pain scores were recorded by nursing staffas part of the two hourly care and comfort rounds. Thecare and comfort round was used to ensure thatpatients were checked on a regular basis and that theirneeds had been met.

• Staff on the surgical wards and theatres were supportedby a team of acute pain specialist nurses that workedacross both hospitals. Ward staff reported that if apatient experienced pain they would escalate theirconcern to the medical team and refer to the specialistpain team for symptom control.

• All patients we spoke with told us that they thoughttheir pain was well managed.

• Patient records showed that patients received therequired pain relief and they were treated in a way thatmet their needs to reduce discomfort.


• We reviewed eight patient records and found thatMalnutrition Universal Screening Tool (MUST) scoreshad been recorded appropriately. The MUST score is afive-step screening tool to identify adults who are at riskof malnutrition.

• Staff followed guidance on fasting prior to surgery,based on the recommendations of the Royal College ofAnaesthetists (RCA), which states that food can be eatenup to six hours and clear fluids can be consumed up to

two hours before surgery. We saw that as part of theperioperative pathway, ward staff attended the theatreto provide a handover of patients, which included handover of starve times.

• Most patients we spoke with reported that they enjoyedthe food at the hospital.

• Patient records included assessments of patients’nutritional requirements and any allergies or foodintolerances.

• Patients who required support and assistance witheating and drinking were identified using a coloured jugsystem and supported by staff accordingly.

• A dietetic service was available for those patients whorequired specialist dietary support.

• There was a Trustwide multi-disciplinary nutritionsteering group to advise the clinical governance auditand quality subcommittee on issues relating to clinicalnutrition. The group also reviewed reports of incidents,patient experience or complaints relating to nutrition.

• Patient led assessments of the care environment(PLACE) showed that 84% of patients thought that thefood was good at the hospital. This was below thenational average of 88%. However, our feedback frompatients reported that the food was good.

Patient outcomes

• Information about the outcomes of patients’ care andtreatment was collected and monitored by the trust.Managers we spoke with were aware of theirresponsibilities to collect and disseminate the findings.We saw from clinical audit meeting minutes that auditdata was shared and outcomes for patients discussed.

• The Service participated in clinical audits through theadvancing quality programme. The advancing qualityprogramme aims to improve the quality of care patientsreceive in hospitals across the North West of England bymeasuring and reporting how well the hospitals areperforming. Performance data in the April 2015 to March2016 hip and knee audit showed excellent results acrossall six measures, ranging from 99% to 100%. Themeasures included appropriate antibiotics given onehour before surgery and VTE medication given for theright amount of time after surgery.

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• The service participated in a full range of national auditsto measure outcomes for the local population againstthe England average. The outcomes for patients wereused to ensure that the services offered providedpatients high quality safe services at the trust.

• From the April 2015 to March 2016, Patient ReportingOutcomes Measures (PROMS), hip replacement (EQVAS), knee replacement (EQ VAS and EQ-5D index) andvaricose vein (EQ-5D index) indicators showed morepatients’ health improving and fewer patients’ healthworsening than the England average.

• In the 2016 National Emergency laparotomy Audit(NELA), the trust achieved a green rating (good) for thenumbers of cases with pre-operative documentation ofrisk of death, the number of cases with access totheatres within clinically appropriate time frames, andnumber of highest risk cases admitted to critical carepost operatively.

• In the 2016 hip fracture audit, the risk adjusted 30-daymortality rate was 6.4%, which was within the expectedrange and was an improvement over the 2015 audit at7.1%. The percentage of patients having surgery on theday or day after admission, the perioperative surgicalassessment rate, and the proportion of patientsdeveloping pressure sores did not meet the nationalstandards, however, the trust had seen someimprovement over their 2015 results.

• In the national bowel cancer audit, the trust was inexpected range for the risk adjusted 90 daypost-operative mortality rate, the risk adjusted two yearpost-operative mortality rate, the risk adjusted 90 dayunplanned readmission rate and the risk adjusted 18month stoma rate. However, 72% of patientsundergoing a major resection had a longer length ofstay than the national aggregate. This performance wasan improvement over the 2014 data.

• Between September and October 2015, patients’relative risk of readmission for non-elective surgery wassimilar to the England average.

• Hospital episode statistics 2015/16 data showed thenumber of patients that underwent non-elective surgeryand readmitted to hospital within 30 days followingdischarge was similar to the England average for allspecialties. For patients undergoing elective surgery, thereadmission rates to hospital were similar with the

exception of urology readmissions, which was slightlyhigher (113 patients readmitted against an expected109). This was highlighted in our previous inspection in2015 where we were informed there were two factorsthat impacted on urology readmissions. All surgicalelective patients undertaken at Halton General Hospitalwere given information on discharge to attend thesurgical assessment unit at Warrington Hospital if theyhad any concerns. There was also a poorcommunity-based care infrastructure to supportpatients with urinary tract infections and catheterrelated problems, which meant these patients attendedthe emergency department or surgical assessment unitat this hospital.

• The trust provided the inspection team with an actionplan for reducing the readmission rates for urology. Theaction plan included monitoring readmission data, anddiscussion in governance and business meetings.However, although the trust was monitoring anddiscussing readmission rates the action plan did notprovide clear actions taken to reduce urologyreadmissions.

Competent staff

• Staff were able to access training internally andexternally. There was an online learning system acrossthe trust where staff could access training. All staff wespoke with reported that they were encouraged andable to access training to improve their skills andknowledge.

• In theatres, a practice educator monitored trainingcompliance across the department and supported thedevelopment of staff through teaching and organisingtraining.

• All qualified nurses who worked within theatres or theward for six months or more had recorded validation ofprofessional registration. This meant the hospitalconducted annual checks to make sure all nurses wereregistered with the Nursing and Midwifery Council (NMC)and is considered good practice. We saw that a nursingstaff validation report highlighted those staff thatneeded to revalidate within the next six months.

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• Appraisal rates were variable across the surgicalspecialties and theatres. Data provided by the trust forJanuary 2017, showed that that the numbers of nursingand medical staff receiving an appraisal ranged from71% to 95%. The trust target was 85%.

• Newly appointed staff had an induction and theircompetency was assessed before workingunsupervised. Agency and locum staff also hadinductions before starting work.

• The nursing and junior medical staff we spoke positivelyabout their learning and development opportunitiesand told us they were well supported by their linemanager.

• We reviewed three competency handbooks withintheatres. The handbooks were relevant to their rolesand responsibilities and included review and mid-wayreview meetings with mentors. However, we saw thatcompetencies were not always signed and dated toshow the staff member had completed the competency.

• In theatres, we saw that records were kept of staffprofessional qualifications, which was used to aidfurther education development.

• Additional role specific training was provided to staffbased upon their clinical practice. This includedsummoning emergency medical assistance. Compliancewith this training across the division was consistentlyabove the 85% trust target, ranging from 85% to 89%.


• We observed good multidisciplinary working witheffective verbal and written communication betweenstaff. Staff confirmed that there were good workingrelationships between staff that includedphysiotherapists, nurses, and consultants.

• We saw that the therapy team worked closely with theward staff to ensure that patients were seen quicklyfollowing surgery to further enhance their discharge.

• We observed nurses working alongside consultants.Interactions were positive and professional.

• We observed a theatre briefing and saw that it was wellattended by all levels of staff.

• We observed positive working relationships betweenmanagers and the staff groups. We observed managers

across the department to have close professionalrelationships with the staffing groups and providedthem with advice and guidance as required. In theatres,we saw senior staff provided mentorship to juniormembers and students.

• Ward staff liaised with a number of different serviceswhen co-ordinating a patients discharge. This includedhospitals, community services, and social servicesdepending on where the patient lived.

• Staff handover meetings took place during shift changesand safety briefings were carried out on a daily basis toensure all staff had up-to-date information about risksand concerns.

• Patient records showed there was routine input fromnursing and medical staff and allied healthprofessionals.

• The service had established links with a neighbouringmental health unit to ensure they were able to bestsupport the needs of the patients.

Seven-day services

• Theatres were scheduled to operate between Mondayand Friday on a weekly basis.

• The trauma theatre provided surgical procedures overthe weekend from 8.30am to 2pm on Saturday.

• There was a 24-hour service with dedicated emergencyand trauma theatres so any patients admitted over theweekend or at night that required emergency surgerycould be operated on.

• At weekends, a consultant saw newly admitted patients,and the ward-based doctors saw existing patients onthe surgical wards to ensure optimum levels of care.

• Microbiology, imaging (e.g. x-rays), physiotherapy andpharmacy support was available on-call outside ofnormal working hours and at weekends.


• The theatres department used an electronic system tocapture information about patient scheduling andtheatre performance.

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• Computers were available in the wards and theatreareas. All staff had secure, personal log in details andhad access to e-mail and all hospital systems. Weobserved that no computer terminals were leftunattended displaying confidential information.

• All staff had access to the trust’s policy and proceduresvia the intranet to support and guide professionalpractice.

• All relevant staff had access to patient recordselectronically or paper based, to enable a complete andcontemporaneous record of patients care andtreatment.

• Discharge summaries were sent to GPs on discharge toensure continuity of care within the community. We sawevidence that when a patient was discharged fromhospital they were given a copy of their discharge formand a copy was forwarded to the GP. We saw thatdischarge summaries included the type of surgicalprocedure and medication prescribed to highlight toGP’s their ongoing care needs.

• The division monitored that GP discharge summarieswere sent within 24 hours to the GP practice.Compliance up to December 2016 was 84%, which wasbelow the trust’s 95% target. Managers informed us thatthere were some issues relating to the new electronicsystem but improvements month on month were beingseen. We saw that compliance was improving and inDecember 2016 the compliance rate was 86%.

• The consultant and nurses names were on boardsabove the patients beds so that patients and theirrelatives knew who was responsible for their care.


• The hospital had a current policy for consent, mentalcapacity (MCA) and deprivation of liberty safeguards(DoLS). This was available for staff on the intranet.

• Staff were able to demonstrate their knowledge ofconsent and mental capacity and Staff told us if therewere concerns over a patient’s capacity to consent, theywould seek further advice and assistance.

• There was a trustwide safeguarding team that providedsupport and guidance for staff for mental capacityassessments, best interest meetings and deprivation ofliberties safeguards applications.

• From the records we reviewed, and our observations ofsurgical procedures, we saw that consent was obtainedprior to treatment.

• A consent audit was completed by the seniormanagement team in January 2017. The audit focussedon the two-stage consent process. Stage 1 is theprovision of information, discussion of options andinitial (oral) decision with the patient. At this stagepatient information leaflets should be given to thepatient and documented. The patient signs the topwhite copy indicating they have received theinformation; and the yellow copy is given to the patient.Stage 2 is confirmation that the patient wishes to goahead with the procedure and signs the documents andthe yellow copy is given to the patient.

• The audit found the trust to be 86% compliant with theuse of the two-stage consent form. Areas ofimprovement were recorded on an action plan, whichincluded ensuring patients are given a copy of theconsent form and document the information andleaflets given to patients. Staff we spoke with wereaware of these actions and we saw that informationprovided was documented.

• We reviewed three patient records that should haverequired a capacity assessment and best interestsmeeting. We found that capacity had been ascertained,but for those patients who lacked capacity to consent tocare and treatment, we saw no evidence of a bestinterest meeting contained in the patient record.

Are surgery services caring?

Good –––

At the previous inspection in January 2015, we rated caringas good. Following this inspection we have maintained theoverall rating because:

• All patients and relatives we spoke with told us that thatall members of staff treated them with dignity andrespect.

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• We observed many positive interactions between staffand patients during out inspection. We saw that staffwere professional and friendly and created a relaxedfriendly environment

• Patients we spoke with were very positive about the waystaff treated them.

• Patients and those close to them told us that they wereinvolved in planning and making decisions about theircare and treatment.

Compassionate care

• We spoke with 10 patients and relatives who all told usthat that they were treated with dignity and respect byall members of staff. Patients told us they found the staffpolite, friendly and approachable. Comments included;“Staff here are fabulous and the service is excellent”.

• We observed staff greeting patients and relatives. Staffwere polite friendly and helpful in their approach.

• Staff demonstrated flexibility and kindness whenmeeting people’s wishes. We were informed bymanagers and staff that the wishes of a terminally ill,dying patient to have Christmas with his youngdaughter were accommodated. The ward set out an endbay as a grotto with a Santa Claus in order to make hiswishes come true. The ward staff recently won a ‘thankyou’ award to thank the staff for their exemplary efforts.

• Care and understanding was given to patients livingwith a mental health disorder. The surgical division hadworked collaboratively with a local mental health unit tohelp reduce anxiety and fear. An action plan, andprocess had been established to be seen in adesignated area and receive treatment quickly.Following surgery the patient could be moved to anindividual side room and the carers invited to stay toprovide the additional support they need.

• We observed that staff respected patient confidentialityand ensured sensitive discussions took place in privacy.All patients we asked reported their dignity and privacywas maintained throughout their hospital stay.

• Staff made sure that patients’ privacy and dignity wasrespected, including during intimate care. We saw thatpatients on the ward had the curtains pulled aroundand sensitive conversations were held in private.

• On the day case unit we saw that staff welcomed peopleonto the department, introducing themselves in a politeand professional manner.

• We saw that the theatre nurses spoke calmly to patientsand introduced themselves to reassure the patientsprior to, and following a surgical procedure.

• Patient led assessments of the care environment(PLACE) showed that 79% of patients thought that theirprivacy and dignity had been maintained during theirtime at the hospital. This was below the nationalaverage of 84%. However, our observations and patientfeedback highlighted that privacy and dignity was beingmaintained.

• Staff supported patients to be mobile and independentpostoperatively. We saw that physiotherapistsencouraged patients to mobilise soon after surgery andpromoted independence. Patients informed us that theywere seen quickly after surgery and rehabilitationstarted soon after surgery.

• We observed many positive interactions between staffand patients during out inspection. We saw that staffwere professional and friendly and created a relaxedfriendly environment. Patients we spoke with were verypositive about the way staff treated them. Patients toldus staff were ‘excellent’, ‘friendly’, and ‘fantastic’.

• We saw that wards displayed their thank you cards.There were numerous cards that thanked the staff fortheir’ kindness’, ‘thoughtfulness’ and ‘care’ whilst inhospital.

• All ward areas we inspected were compliant withsame-sex accommodation guidelines, meaning thatmen and women were not receiving care and treatmentwithin the same hospital bays.

• In the NHS England Friends and Family Test (FFT)between December 2015 to November 2016, the trustscored about the same as the England average for thepercentage of people who would recommend the trustto family and friends.

• The wards displayed their friends and family test scoreseach month to highlight their achievements. Wereviewed the November 2016 for A5, A6, A9 and SAU andthe scores ranged from 89% to 98%.

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• From our observations, it appeared clear that thenursing team had a good rapport with the patients andtook the time to spend with patients to ensure theyprovided the care they required.

Understanding and involvement of patients and thoseclose to them

• We saw that staff communicated with patients so thatthey understood their care, treatment and condition.Patients confirmed that staff explained their care andtreatment and kept them up to date with any requiredinformation.

• Patients and families were encouraged to participatethrough feedback and surveys. This showed that theycared about ‘getting it right’ for the patients.

• Patients and those close to them told us that they wereinvolved in planning and making decisions about theircare and treatment. We observed that patients wereinvolved in decision-making records indicated thatpatients were involved in the next step in the care andtreatment process.

• Visiting times were flexible on the ward to take intoaccount the needs of the patient’s relatives. Wards hadvisiting from 12pm until 8pm to ensure relatives couldvisit. Ward staff informed us that visiting times could bealtered to allow flexibility for families if needed.

• On the day case unit, patients informed us that theywere provided with all the information they needed andfelt were informed about their care.

• Staff recognised when patients and those close to themneeded additional support to help them understandand be involved in their care and treatment. This washighlighted in the preoperative assessment soreasonable adjustments could be made. For example,an individual room could be made available for thosepatients with a mental health condition.

• There were many health and social care supportservices available to provide advice, care and treatmentif needed. This included social workers and specialistnurses.

• For those patients with a learning disability or dementia,health passports or ‘this is me’ documents were used tosupport the needs of the patients. Staff reported thatthis helped them understand the individual need of thepatients to best understand and support them.

Emotional support

• We saw from records and our observations that staffcompleted regular observational checks of patients intheir care, to ensure that they were comfortable, and toanswer any questions they may have. Theseobservational checks also ensured that patient personalhygiene, nutritional, hydration, and pain needs wereaddressed regularly.

• Throughout our visit, we observed staff givingreassurance to patients with additional support givenwhen it was required, especially if patients wereapprehensive or anxious.

• A team of chaplains visited wards on a daily basis andwere available to give confidential spiritual care andsupport at times of need or distress. Chaplains used anon call system for if an urgent visit was required,especially for those patients at the end of life. Staffinformed us that the chaplain service reacted quickly toany referrals.

• The trust had a chapel and a prayer room, which weremulti faith and always open to patients and theirfamilies.

• Holy communion was available to patients at thebedside, if they were unable to attend the chapel.

• Counselling services were available to those thatneeded psychological support. Counselling was alsoavailable to the staff to support them through stressfultimes.

• For those patients that were at the end of life, apalliative care team offered practical and emotionalsupport to patients and their families.

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Are surgery services responsive?

Good –––

At the previous inspection in January 2015, we ratedresponsive as good. Following this inspection we havemaintained the overall rating because:

• A variety of surgical procedures were available withinthe service, including cosmetic surgery, orthopaedicsand general surgery to meet the needs of the localpopulation.

• Bed meetings took place four times a day to ensure flowwas maximised across the hospital.

• The trust monitored the number of cancelledoperations on the day of surgery. Performance datashowed that the number of cancelled operations on theday of surgery had improved from 11.9% in February2016 to 8.8% in January 2017.

• Between October 2015 and November 2016, the averagelength of stay for surgical elective patients was better atthe trust at 2.7 days, compared to 3.3 days for theEngland average.

• There were a number of specialist nurses within thetrust to help support the care and treatment of patients.

• The trust’s referral to treatment time (RTT) for thepercentage of patients seen within 18 weeks was 76.9%,which was better than the England average of 71.5%.


However:

• Theatre lists did not always run on time due to there notalways being available beds for patients.

• Data provided by the trust showed that betweenSeptember 2016 to December 2016 there were a total of1180 bed days lost to medical outliers on surgical wards.This number of medical outliers impacted on thenumber of available beds for surgical patients on thesurgical ward.


• The services provided at the hospital reflected theneeds of the population they served, and they ensuredflexibility, choice and continuity of care. A variety ofsurgical procedures were available within the service,including cosmetic surgery, orthopaedics and generalsurgery. The procedures carried out were determined inconjunction with the local clinical commissioninggroups to best serve the local population.

• There were arrangements in place with neighbouringtrusts to allow the transfer of patients for surgicalspecialties not provided by the hospital, such asvascular surgery.

• As part of the preoperative assessment process, patientswith lower risk medical conditions could elect to havesurgery at the trust's neighbouring site at Halton. Thishelped the service plan care and treatment for patientsand ensure waiting times were kept to a minimum.

• The hospital used a total of seven operating theatres.This included an elective orthopaedic theatre that wasmainly used for elective patients that were assessed ashigher risk and would not be suitable to have surgery atthe Halton site.

• One theatre was closed and was in the process of beingtransformed into a simulation suite, in order to providefurther training to all medical and junior staff.

• There was an emergency general surgery and traumatheatre that was staffed 24-hours, seven day per week sothat patients requiring emergency surgery including outof hours and weekends could be operated on promptlywithout the need to transfer to a neighbouring trust.

• In theatres, there was an extended recovery area tosupport those patients who required level 3 care. Thearea had a standard operating procedure to ensurepatients received the appropriate care. The area wasused if a patient deteriorated, until either surgery wasperformed, a bed could be utilised on intensive care, ortransfer to a neighbouring trust.

• Elective surgery usually finished at 4.30pm, however, theservice did operate some spinal surgery once a week upuntil 7pm.

• Surgical lists were planned four weeks in advance toprovide patients with enough time to organise theiradmission to hospital.

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• The trust held nurse recruitment and open days topromote their theatre services and encourage peopleinto nursing. We were informed that the open daysincluded simulations of surgery that included childrenfor future recruitment possibilities.

Access and flow

• The trust had 29,590 surgical admissions betweenOctober 2015 and September 2016. Emergencyadmissions accounted for 7281 (24.6%), 18,069 (61%)were day admissions, and the remaining 4240 (14.3%)were elective admissions.

• Patients could be admitted for surgical treatmentsthrough a number of routes, such as pre-planned daysurgery, via accident and emergency or via GP referral.

• Surgical services had a surgical assessment unit (SAU)that was used to assess and triage patients for surgicalprocedures up to 10.30pm, seven days per week. Wevisited the unit as part of the inspection and staffinformed us that at times the unit was being usedinappropriately, as non-surgical patients were beingadmitted to the unit whilst waiting for a bed. Staffreported that it was common that the unit was not ableto close on time, which meant they were unable to leavethe unit.

• Admission times for elective surgery were staggeredthroughout the day so that patients did not have to waitfor a long period once admitted to the ward. Bystaggering admission times the hospital was able toensure those patients with the most urgent needs wereprioritised. For example, patients with diabetes wereplaced at the beginning of the theatre lists so that theyhad their surgery as quickly as possible.

• During our inspection, the theatre lists did not alwaysrun on time. We were told this was due to a shortage ofbeds. Staff we spoke with reported that this was themain cause of delayed or cancelled surgery. The trusthad developed a standard operating procedure toprovide guidance for staff to follow to ensure patientstransferred from the ward to theatre reception whenbed pressures were reported, to minimise theatre delaysor cancellations.

• Bed meetings took place four times a day to ensure flowwas maximised across the hospital. The meetingincluded senior managers to support and expeditetimely discharges. Senior managers confirmed theyattended these meetings.

• The patients we spoke with did not have any concernsin relation to their admission, waiting times or dischargearrangements. Staff explained to us that they gaveapologies to patients if theatre schedules were runninglate, and on SAU we saw that staff updated patients asto delays in transferring to in-patient beds.

• Between October 2015 and November 2016, the averagelength of stay for surgical elective patients was better atthe trust at 2.7 days, compared to 3.3 days for theEngland average.

• For surgical non-elective patients, the average length ofstay was also better than the England average at 4.4days compared to 5.1 days.

• Overall, the Warrington hospital had a slightly longeraverage length of stay than the trust average at 3.4 days,however this is in line with the England average.

• Between December 2015 and November 2016, thetrust’s referral to treatment time (RTT) for thepercentage of patients seen within 18 weeks was 76.9%,which was better than the England average of 71.5%.The trust was consistently above the England averagefor the whole period.

• The trust monitored the number of last minutecancellations of operations. If a patient has not beentreated within 28 days of a last minute cancellation thenthis is recorded as a breach of the standard. FromOctober to December 2014 through to July toSeptember 2016, the trust had significantly reduced thenumbers of cancelled operations and not treated within28 days, from 142 to 16. Of these 16 patients, only fourwere not treated in 28 days. We were informed the mainreason for cancelling surgery was due to non-availabilityof surgical beds on the inpatient wards.

• The trust monitored the number of cancelledoperations on the day of surgery. Performance dataprovided by the trust showed that the number ofcancelled operations on the day of surgery hadimproved from 11.9% in February 2016 to 8.8% inJanuary 2017. We were informed that performance had

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improved partly as a result of using space in the SAU asa forward waiting area, meaning patients could bebrought in to hospital without initially having a vacantbed. Following surgery these patients could betransferred to vacant beds on the ward through the day.

• From April 2015 to September 2016 the bed occupancyrate across the trust was over 85%. Evidence shows thatwhen bed occupancy rises above 85% it can start toaffect the quality of care provided to patients and theorderly running of the hospital. Although the bedoccupancy rate was in line with the England averageduring this period, it did highlight that due to thedemand on beds, patients transferred to wards outsidetheir speciality. On the surgical wards A5, A6 and A9 thebed occupancy from December 2016 to February 2017was consistently above 95%.

• At the time of the inspection we were informed thatthere were five medical patients outlying on surgicalwards. This means that medical patients (also known asoutliers) are receiving care and treatment on surgicalwards that did not necessarily specialise in the care theyrequired.

• Data provided by the trust showed that betweenSeptember 2016 to December 2016 there were 1180 beddays lost to medical outliers on surgical wards.

• From September 2016 to February 2017, the trustreported that there were a low number (166) surgicaloutliers. This meant that 166 surgical patients werepotentially receiving care and treatment on wards thatwere not suited to their needs.

• We saw that a plan was in place to ensure that medicaland surgical outliers were seen on a daily basis andincluded an escalation pathway to ensure that medicalreviews occurred. Records we reviewed and staffconfirmed that the medical team routinely reviewedmedical and surgical outliers.

• The service had introduced a ‘red and green bed days’visual management system to assist in the identificationof wasted time in a patient’s journey. A red day is when apatient receives little or no value adding acute care. Forexample, a planned investigation that does not occur. Agreen day is when a patient receives value adding acutecare that progresses the patient towards discharge. Forexample, when tests and investigations are completedas planned without delay. Red or green symbols were

used on the electronic patient whiteboard to show ifpatients were receiving either value added acute care orno value added acute care. This helped staff to focus onensuring that any constraints identified in converting ared day to a green day could be proactively managed atthe daily board rounds, ensuring patients received thecare they needed without any delays.

• The trust monitored the number of delayed dischargesacross the surgical wards. From August 2016 to January2017, the trust reported there had been 165 patients onsurgical wards that were medically fit to leave but werenot able to. The main reason for delays in patients beingdischarged was due to waiting for further non-acuteNHS care such as rehabilitation or patient or familychoice of care setting.


• There were plans in place that ensured there wasmedical staff available should an unplanned return totheatre be needed. Surgeons and anaesthetistsremained on call 24 hours per day and there was astaffed emergency theatre.


• Services were planned and delivered to take account ofthe needs of different people. Individual needs wereconsidered at preoperative assessments to ensure theirneeds could be met prior to surgery. This includedallergies and pre-existing conditions.

• All areas of the ward were wheelchair accessible, and allinpatient side rooms and shared bathrooms had levelaccess showering facilities.

• There were a number of specialist nurses within thetrust to help support the care and treatment of patients.These nurses specialised in a specific area. For example,there were palliative care nurses, diabetes nurses andpsychiatric nurses to support patients with mentalhealth needs.

• There were a number of link nurses to help supportpatients on the ward. These link nurses were trainedand had a special interest in a specific area. Forexample, there were link nurses on the inpatient wardfor dementia and diabetes.

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• Information leaflets about services were readilyavailable in all the areas we visited. Staff told us theycould provide leaflets in different languages or otherformats, such as braille, if requested.

• There was an interpreter service available for patientsfor whom English was not their first language. Staff wereaware of the service and how to access it.

• Staff used a ‘this is me’ document for patients admittedto the hospital with dementia. This was completed bythe patient or their representatives and included keyinformation such as the patient’s likes and dislikes. Wesaw evidence of this in the patient records we looked at.

• A discreet symbol was used on the ward whiteboards tohighlight any additional needs of patients and colouredwristbands were used to denote allergies. We saw thatpatients with additional needs were discussed at theteam safety briefs that included any safeguardingconcerns.

• Staff could access appropriate equipment such asspecialist commodes, larger beds or chairs to supportthe moving and handling of bariatric patients (patientswith obesity) admitted to the surgical wards andtheatres.

• Adapted cutlery was available for those patients withhand motor skills difficulties to aid their independence.

• Wards provided individual side rooms for patients withcommunicable diseases to minimise the spread ofinfection.

• On the ophthalmology day case unit, patientinformation leaflets were on bright coloured paper withlarge writing for those patients with vision impairment.

• Although there was not a learning disability lead nursewithin the trust, ward staff referred patients to thesafeguarding team to flag the admission to hospital.Staff informed us that often they were able to provide anindividual room and provide access to allow family orcarers to stay overnight to support their individualneeds. This service was also available for patients withmental health needs and those patients living withdementia.


• The chief executive was the person responsible for allcomplaints in the trust which was delegated to thepatient experience team under the leadership of thedeputy director of governance and quality.

• The wards had information leaflets for patients and theirrepresentatives on how to raise complaints. Thisincluded information about the Patient Advice andLiaison Service (PALS).

• Between April 2016 to February 2017, the divisionreported they had received 185 complaints. The numberof complaints per month was low ranging from 11 to 21complaints a month.

• A complaints audit was undertaken in February 2017.The audit examined eight patient complaintquestionnaires. The findings of the report highlightedthat of the eight patient questionnaires, five patientsreported they were unaware of how to make acomplaint, six patients reported they did not receive anacknowledgement within three working days and sixpatients reported they did not receive a resolution in atime period that was relevant to my particular case andcomplaint.

• The Trust told us that there had been recently changestaking place in the divisional structure and staffinglevels within the patient experience team, whichimpacted on complaints being investigated andresponded to within the agreed timescales. We saw thatan action plan was in place and improvements hadbeen made in the time taken to respond to complaints.

• Data provided by the trust showed that 90% ofcomplaints in the division were responded to within theexpected parameters (usually 30 working days). Thetrust target was 90%.

• Information from the trust clinical operational boarddashboard showed that in December 2016 there hadbeen 11 complaints with regards to the surgical services.The main reasons for complaints were cancellation andwaiting times followed by care and treatment.

• From our observations in SAU, we saw that staffprovided patients with updates when waiting times hadbeen increased.

• The patients we spoke with were aware of the processfor raising their concerns with the trust.

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• Notice boards outside the ward included informationsuch as the number of complaints received during themonth.

• Managers informed us that they endeavoured to resolvecomplaints quickly at ward level and met with patientsand their families to rectify any concerns they hadimmediately.

Are surgery services well-led?

Good –––

At the previous inspection in January 2015, we rated wellled as good. Following this inspection we have maintainedthe overall rating because:

• Senior managers were clear on their strategy to providehigh quality services for patients, which includedworking collaborative within the organisation, and inpartnership with other trusts to deliver high qualityservices.

• There was a clear governance structure to supportgovernance and risk management and staff had clearlydefined roles, responsibilities and reporting structure.

• On the wards and theatres, there were daily briefings todiscuss day-to-day issues, share information regardingincidents and risk areas, to increase staff awareness andavoid reoccurrence.

• We saw that Local Invasive Standards for InvasiveProcedures (LocSSIP’s) had been developed inpartnership with the North West theatre network. Thestandards were in place to ensure high quality, safe careand treatment for all patients.

• All staff we spoke with were positive about theirrelationships with their immediate managers. Staff feltthey could be open with colleagues and managers andfelt they could raise concerns and would be listened to.

However:

• Although there were formal audits completed thatincluded infection control. We saw no evidence thatmanagers had a formal system or process of oversight,that ensured the cleanliness of equipment, and systemchecks were maintained. However, during theunannounced inspection we saw that the service

managers had reacted quickly to our concerns, and newsystems and processes implemented with managementoversight to ensure compliance with standards andpolicy.


• The senior managers had the skills, knowledge,experience and integrity that they needed to leadeffectively. The new divisional structure was embeddedand led by a senior management team and were awareof their current performance and direction of the trust.

• The new divisional and clinical business unit structurehad been developed in 2015. The new structure createdtwo divisions and eight clinical business units (CBU’s) tooversee clinical and business activity. The CBU’s wereled by clinicians, managers and senior nurses to providea robust clinical, operational and nursing alignment.Managers informed us that this provided a betterbalance and involvement in relation to the direction ofthe service as the structure contained both cliniciansand managers.

• Ward managers, overseen by matrons, led the surgicalwards and there were theatre co-ordinators and atheatres manager in place to oversee the day-to-dayrunning of theatre services.

• Theatres and ward-based staff told us they clearlyunderstood the reporting structures and they receivedgood support from their line managers.


• The hospital had a clear mission, vision and strategy,which was to provide high quality, safe integratedhealthcare for all patients. We found the hospitalstrategic direction was well described by the seniormanagement team and were focused on quality ofservices, the people delivering them, and thesustainability of the service through the financialpressures the trust faced. We saw that the vision andvalues of the trust were posted on the walls around thehospital.

• Senior managers were clear on their five year plan,which included a cost improvement programme andworking collaborative within the organisation, and inpartnership with other trusts to deliver high qualityservices.

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• Staff we spoke with were clear on the direction of theirservice and the financial pressures the trust faced.


• There was a clear governance structure to supportgovernance and risk management and staff had clearlydefined roles, responsibilities and reporting structure. Atward level staff reported they were aware of thereporting structure.

• Senior managers, nurses and clinicians were clear onthe risks associated to their division. These includedbalancing finances with quality, ensuring they met thecost improvement programme target, and staffingshortages across the division.

• Managers reported that quality impact assessmentswere completed and approved by the board prior to anycost improvement plan was introduced, and there wassupport from a transformation team pre and postchanges to monitor, and evidence the quality of anychanges.

• There was a clinical governance system in place thatallowed risks to be escalated to divisional and trustboard level through various committees and steeringgroups. There were action plans in place to address theidentified risks.

• We reviewed the divisional risk registers and saw thatkey risks had been identified and assessed with reviewdates specified.

• In ophthalmology we saw that an action plan had beendeveloped to ensure that patients received a follow upappointment. The action plan had been developedfollowing a delay in follow up appointments for patientsundergoing eye surgery. We saw that the action planincluded the introduction of telephone reminders topatients.

• On the wards and theatres, there were daily briefings todiscuss day-to-day issues and to share information onincidents and risk areas.

• All managers across both operating sites highlightedthey had monthly managers meetings to discussperformance of the division and share knowledge andexperience.

• We saw that the monitoring of audits took placemonthly, and there were clinical audit meetings todiscuss findings and results.

• We saw that Local Invasive Standards for InvasiveProcedures (LocSSIP’s) had been developed inpartnership with the North West theatre network. Wesaw that these procedures included a standard for thesafety briefing prior to commencement of an operatingtheatre list and the WHO checklist. We saw theappropriate standards followed throughout ourinspection at Warrington.

• We saw examples of local safety standards to ensure thesafety of patients undergoing treatment. For example,we saw a standard operating procedures for theapplication of topical anaesthesia for cataract surgeryprovided a step by step process to follow to eliminateany surgical errors.

• Although, there were safety standards in place toeliminate errors in surgical procedures, the trust hadtwo never events in March 2017 at the Halton site. Thesewere currently under investigation by the trust as to theroute cause of the errors.

• We saw that the service leaders had taken immediateaction to ascertain the reasons for the never events andextra support, training and guidance given to all staff toensure future compliance with the standard operatingprocedures. The trust provided an action plan of thesteps they were taking to minimise the occurrence ofnever events that included a review of their standardoperating procedures.

• Although there were formal audits completed thatincluded infection control, We saw no evidence thatsenior managers had a formal system or process, thatthe cleanliness of equipment and system checks weremaintained to ensure safe care and treatment forpatients.. However, during the unannounced inspectionwe saw that the service managers had reacted quicklyto our concerns, and new systems and processesimplemented with management oversight to ensurecompliance with standards and policy. We saw theaction plan included a daily theatre cleanliness andequipment check by the lead nurse/matron.

• Performance information was relayed to wards throughperformance dashboards. The dashboards providedsenior nurses with information regarding workforce

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statistics such as budget expenditure, workforce profile,recruitment and staff sickness. Although the dashboardsprovided good information about the workforce theydid however, lack any patient centred measures, Forexample, VTE assessment compliance, infection controlcompliance, incidents and falls. The focus of adashboard is to engage staff, empowering them toimprove quality of patient care by being able to monitorperformance and compliance using the dashboard overa specified period.


• All staff we spoke with were positive about theirrelationships with their immediate managers. Staff feltthey could be open with colleagues and managers andfelt they could raise concerns and would be listened to.

• Staff at all levels were aware of the duty of candour inregards to being open and honest with patients and wesaw that open and honest letters were sent to patientsfollowing complaints or incidents.

• We saw that a full range of incidents were reportedusing the trust electronic system, and staff told us thatthey were encouraged to report incidents so thatlessons could be learnt.

• Staff told us that there was a friendly and open culturewithin the trust and many staff had worked there manyyears and progressed through training opportunities.

• In the NHS staff survey 2016, the percentage of staff bothwhite and black and minority ethnic (BME) groups whoreported experiencing bullying from staff in the last 12months was 18% and 22%. This was below the averagemedian for acute trusts.

• The survey also reported that 93% of both white andBME groups believed the organisation provided equalopportunities for career progression or promotion. Thiswas significantly better than the average median fortrusts.

Public and staff engagement

• Trust board meeting minutes and papers were availableto the public online, which helped them understandmore about the hospital and how it was performing.

• The trust had news releases on its website pages tokeep members of the local community up to date withcurrent events. We observed that the news releases onthe website were current and up to date.

• The trust had Facebook and Twitter accounts to shareinformation with patients and receive feedback. We sawthat stopping smoking and information on their latestdrop in session was provided.

• The hospital participated in the NHS friends and familytest, giving people who used services the opportunity toprovide feedback about care and treatment. The friendsand family test showed the percentage of patients andfamilies that would recommend the service. We sawthat all surgical wards displayed this information at theward entrances.

• The trust’s friends and family test performancemeasured the percentage of people who were likely torecommend the trust to friends and family. Resultsshowed that scores were generally about the same asthe England average between December 2015 toNovember 2016.

• Information on the number of incidents, complaints andgeneral information for the general public was displayedon notice boards in the ward and theatre areas weinspected.

• The trust participated in the NHS staff survey to gathertheir views. The survey asks 34 questions and the resultsanalysed and compared with other trusts acrossEngland. The results from the 2016 NHS staff surveyshowed that the trust performed better than othertrusts in 10 questions, about the same is 17 questionsand worse in seven questions. Areas that the trustperformed better included staff satisfaction with theirlevel of responsibility and involvement and supportfrom their immediate managers. Areas where the trustscored worse included the quality of non-mandatorytraining and the response rate in the survey, which was33%. The England average was 41%.

• The service had introduced a patient feedbackmechanism ‘Your Ideas’ and in response to feedbackhave made some changes. For example, from feedbackrelating to a ward being noisy at night, the service haddeveloped a ‘Have a good night’ poster. The poster

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provided staff, visitors and patients with advice tosupport patients to have a restful night. This included,mobiles to be switched to silent and for staff to offerpatients ear plugs and to wear soft soled shoes.

• At the time of inspection there was a theatreconsultation taking place with regards to theoperational working patterns at night from a shiftsystem to an on call system for the emergency theatre.From our discussions with staff this had been on-goingfor over 12 months and had an impact on their moraleand some reported they felt de-motivated. Seniormanagers informed us that a new formal consultationhad started in May 2016 and had not yet been resolved.

• The trust carried out a divisional temperature checkaudit during 2016 in which staff were asked eightquestions in relation to the service. This included howlikely they were to recommend the trust as a place towork. We reviewed the data provided by the trust forspecialist surgery. The data showed that 96% of staff feltthey had been treated fairly and consistently in the lastmonth, however only 71% of staff would recommendthe trust as a place to work.


• We saw that leaders and staff strived for continuouslearning, improvement and innovation. Managers weresited on the current clinical and financial pressures, and

looked for ways to develop effective clinical networkingand integrated partnerships with other trust services.For example, in theatres we saw that local safetyprocedures for invasive procedures had been developedby working within a North West collaborative.

• In Ophthalmology they had commenced cataractsurgery under local anaesthetics and eye stents inglaucoma surgery, improving efficiencies and patientexperience.

• The trust was rated as one of the best in the North Westby the Advancing Quality Alliance (AQuA for providinghip and knee replacement care, with a score of 97.7%.

• A patient safety initiative was introduced inOrthopaedics. The introduction of the ‘Red Cast’;The redband around the cast is intended to act as a visualhighlight that extra care needs to be taken with thepatient, remind staff to frequently change their position,and encourage patients to be mobile to relieve pressureon the cast.

• In trauma and orthopaedics the service had beenredesigned to offer protected beds on ward A9 to reducethe occurrence of these beds being used for medicaloutliers. The redesign also included increased ortho-geriatrician cover on the trauma ward and seven daytrauma specialist nurse support.

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Information about the serviceCritical care services are divided into two main areas. Themain intensive care unit is an open area which has a totalof 14 bed spaces. The high dependency area has six beds,including two isolation rooms that produce positive ornegative pressure.

There are 20 bed spaces, although the unit is normallyfunded for the use of 18. However, between January 2016and December 2016, only 16 bed spaces had beenavailable due to shortages in nursing staff. This wasincreased back to 18 in January 2017.

The unit is part of the Cheshire and Mersey Critical CareNetwork (CMCCN). Between April 2015 and March 2016there had been approximately 800 admissions to theservice from the local area.

We visited the service as part of our announced inspectionwhich took place between the 7 and 10 March 2017. Wealso undertook an unannounced visit on the 23 March2017.

During our visit we looked at all areas that made up criticalcare services. We also visited the recovery area in theatre aspatients were sometimes managed in the ‘stabilisationbay’. This was used when there was no immediate criticalcare bed available.

We took time to interview different grades of staff, includingmembers of the management team as well as patients andrelatives.

Summary of findingsWe rated this service as ‘requires improvement’because:

• We were not assured that critical care services wereable to provide a member of staff who was up to datewith advanced life support training on every shift.Advanced life support training for adults was notprovided for any nursing staff. Additionally, only 55%of medical staff and 79% of acute response teamstaff had completed training updates.

• At the time of inspection there was limited evidencethat sufficient controls were in place to prevent theservice exceeding full capacity. This was becausecritical care services were not currently using aformal escalation policy.

• We found that appropriate actions had not alwaysbeen taken in a timely way to mitigate the level ofrisk and there were a number of risks that had notbeen formally identified.

• Records indicated that between January 2016 andDecember 2016, there had been 75% delayeddischarges (greater than four hours following thedecision being made that a patient is fit for dischargeto a ward).

However,

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• The unit used a combination of best practice andnational guidance to determine the care that theydelivered. These included guidance from theNational Institute for Health and Care Excellence(NICE) and the Intensive Care Society (ICS).

• The most recently available and validated ICNARCdata (April 2016 to September 2016) showed that thepatient outcomes and mortality were similar tobenchmarked units nationally.

• Staff treated patients in a caring and compassionateway; maintaining their privacy and dignity at alltimes. Both relatives and patients were positiveabout their time in the unit and spoke highly of theway in which they had been cared for.

• Staff informed us they felt that there was an openand honest culture within the department. Weobserved all team members working well togetherduring the inspection.

Are critical care services safe?


We rated safe as ‘requires improvement’ because:

• We were not assured that critical care services were ableto provide a member of staff who was up to date withadvanced life support training on every shift. Advancedlife support training for adults was not provided for anynursing staff. Additionally, only 55% of medical staff and79% of acute response team staff had completedtraining updates at the time of inspection.

• At the time of inspection we were not assured that therewere sufficient controls in place to prevent the serviceexceeding full capacity. This was because critical careservices were not currently using a formal escalationpolicy.

• We were not always assured that the service hadprovided appropriate numbers of nursing staff to matchthe dependency of patients.

• Level 3 safeguarding training for children had not beenprovided for any critical care staff despite proceduresbeing in place to admit adolescents (16 to 18 year olds).This was not in line with the intercollegiate document(safeguarding children and young people; roles andcompetencies for healthcare staff, 2014).

• We had concerns that incidents of mortality were notalways being reviewed thoroughly or in a timely way.

• We found that patient records had not always been fullycompleted. This was because in a sample record check,the time that a patient had been admitted and a fullmedical review had not always been documented.

• There had been several occasions in February 2017 thatfridges which were used to store medication had notalways been checked in line with the medicinesmanagement policy.

However,

• There was evidence of a positive culture of reportingmost types of incidents, both clinical and no-clinical.Critical care services had not reported any seriousincidents or never events between January 2016 andFebruary 2017.

• All care and treatment was led by a ConsultantIntensivist.

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• Records indicated that between April 2016 andSeptember 2016, the number of hospital acquiredinfections had been similar to other services nationally.

• Controlled drugs were managed in accordance withnational guidance. General medicines and patient’s ownmedication were stored securely.

• Records indicated that overall compliance withmandatory training for nursing staff was 97%. This wasabove the Trust target of 90%.

Incidents

• The Trust had a policy for incident reporting which wasavailable to all staff on the intranet. Staff knew how tolocate this and were able to access it when required.

• Critical care services had not reported any seriousincidents or never events between January 2016 andFebruary 2017. Never events are serious patient safetyincidents that should not happen if healthcare providersfollow national guidance on how to prevent them. Eachnever event type has the potential to cause seriouspatient harm or death but neither need have happenedfor an incident to be a never event.

• Incident reports were completed electronically and staffknew how to use the system. All staff, including agencynurses and locum doctors, had access to this system.Staff gave us examples of types of incidents that hadbeen reported, which included both clinical andnon-clinical incidents.

• None of the staff that we spoke to were able to tell usabout examples of near miss incidents having beenreported. Near miss incidents are those which have notactually happened, but if they had, would havepotentially caused harm to a patient, relative or amember of staff. Additionally, on reviewing incidentreports between January 2016 and December 2016there were no examples of these. This meant that therewas a possibility that there had been missedopportunities for learning. However, the trust haveprovided evidence that some near misses are beingreported and also that these have led to changes.

• We had concerns that incidents of mortality were notalways being reviewed thoroughly or in a timely way.The service held monthly mortality review meetings thatwere used to review all patient deaths that had occurredin the unit. However, the management team informedus that four out of twelve of these meetings had beencancelled due to operational demand. Mortality reviewsare important as they are used to identify any areas of

improvement by reviewing the diagnosis as well as thecare and treatment that had been delivered to thepatient. Additionally, mortality reviews were notundertaken with members of multidisciplinary teamswho had also been involved in the care of the patient.This meant that there was potential for learningopportunities to be missed.

• Between April 2016 and September 2016, there hadbeen 97 incidents reported in total. Out of these, 59 hadbeen graded as no harm, 37 as low harm and onereported as moderate harm. We found that these hadbeen reviewed by the critical care services managementteam and had been allocated to appropriate people forfurther investigation when needed.

• There was no formal guidance detailing timescales inwhich a reported incident should be actioned andclosed, although members of the management teaminformed us that they would do this as soon as possible.We reviewed how long this process had taken forincidents that were reported between October 2016 andFebruary 2017 and found that there were someoccasions when this had not been done in a timelymanner. On 19 occasions it had taken 30 days or moreto complete this process. On two occasions it had taken40 days, and on one occasion, 125 days. This meant thatwe were not always assured that actions were taken toprevent further incidences of a similar nature in a timelymanner.

• We found that a small number of incidents had beeninvestigated in more detail using a concise investigationreport or a route cause analysis (RCA) methodology. AnRCA is a tool that is used to investigate an incident inmore detail, helping staff identify the main causes of theincident and make improvements when needed. Wereviewed a sample of completed RCA’s and found thatthey had been completed in a timely manner, hadaction plans for areas that required improvement andtimeframes within which they were to be completed.

• Staff confirmed that they had received feedback whenthey had reported an incident and were able to give usexamples of when learning had been disseminatedthrough meetings such as safety huddles which tookplace at the beginning of every shift.

• The Trust had a duty of candour policy which wasavailable on the intranet. The duty of candour is aregulatory duty that relates to openness andtransparency and requires providers of health and socialcare services to notify patients (or other relevant

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persons) of certain ‘notifiable safety incidents’ andprovide reasonable support to that person. Themanagement team understood this requirement butwere unclear on when it should be formally discharged.

Safety thermometer

• Critical care services recorded incidents of hospitalacquired harm including pressure ulcers, falls, catheterassociated urinary tract infections and venousthromboembolism (blood clots).

• The service did not currently have a formal quality orsafety dashboard that monitored patient harm.However, a monthly performance report was producedfrom the airway, breathing and circulation clinicalbusiness unit which included this information and wasused to inform senior managers of any incidences orconcerns. Data contributions were also made everyquarter to the intensive care national audit and researchcentre (ICNARC) which allowed comparison with similarunits nationally. Results from April 2016 to August 2016showed that there had been a low number ofincidences, which was similar to other units.

• The unit had an ‘how are we doing’ board whichdisplayed the number of incidences of patient harm thathad occurred in the unit. This was visible to members ofthe public as well as members of staff.

• There were examples of when the management teamhad taken positive action to reduce the numbers ofpatient harms. For example, there had been a highnumber of incidences of ventilator acquired pneumonia(VAP) in 2015. The management team had implementeda VAP ‘always event’ (always events are protocols whichstaff should follow for every patient). Subsequently, thenumber of reported VAP incidences had significantlyreduced in 2016.


• There was a trust-wide infection and prevention controlpolicy that was available on the intranet and staff knewhow to locate it when needed.

• The trust had an infection control lead and there was aninfection control link nurse who was involved inmanaging infection control in the unit. Themanagement team completed a monthly infectioncontrol report which was presented to the Trust

infection and prevention control sub-committee. Thisidentified any incidences of hospital acquired infectionas well as compliance with mandatory training andresults from monthly audits.

• The unit submitted data on a regular basis to theIntensive Care National Audit and Research Centre(ICNARC). The latest validated report for the period April2016 to September 2016 showed that there had been noreported incidents of methicillin-resistantstaphylococcus aureus (MRSA) or clostridium difficile(CDIFF). There had been one reported blood streaminfection. These results were better than comparableunits nationally.

• The management team had introduced a process forreducing incidences of methicillin sensitivestaphylococcus aureus (MSSA) in 2014. Recordsindicated that between April 2016 and December 2016,there had been no reported incidences of MSSA.

• Patients were screened regularly for infection and wesaw that if tests returned positive that they were movedand managed in an appropriate doored cubicle.

• A housekeeper was available during normal workinghours and was responsible for the general cleanlinessand upkeep of the unit. We found the unit to be visiblyclean and tidy. The housekeeping team communicatedwith the nursing staff so that the correct cleaning agentswere used after a patient had left, and that they worethe correct personal protective equipment (PPE) whenneeded. Additionally, nursing staff were responsible forcleaning any equipment that had been used. Weobserved ‘I am clean’ stickers being used onceequipment had been made ready for use.

• We observed a number of occasions when bed spaceswere cleaned appropriately following patients beingmoved to a different area.

• Hand gel dispensers were located at all entrances tocritical care and staff consistently reminded visitors touse them when entering and exiting the unit.

• We found that staff were compliant with ‘bare below theelbow’ guidance and that personal protectiveequipment (PPE) was used on a regular basis in line withtrust policy. PPE was also provided for visiting relativeswhen needed.

• Sink units were available in every bed space and we sawstaff washing their hands before and after treatingpatients.

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• The unit completed hand hygiene audits on a monthlybasis. Records indicated that between the periods ofJanuary 2016 and December 2016 levels of compliancewere high, 100% on most occasions.


• Critical care was located on the first floor of the hospital,in close proximity to theatres. The service was securedwith swipe card access and visitors had to gain accessvia an intercom.

• The main intensive care unit (ITU) was open plan andprovided a spacious and light environment for patientsrequiring level 3 care. The high dependency area (HDU)was a separate six bedded area that included two roomswhich produced positive or negative pressure, both ofwhich had their own gowning areas for staff to wear theappropriate personal protective equipment (PPE) beforeentering. These were used to either isolate infectiouspatients or to manage patients who had a compromisedimmune system and were at risk of infection.

• The ITU and HDU areas met HBN-04-02 buildingstandards. These are the building standards for criticalcare units as designed by the department of health. Allof the bed spaces had equipment to manage a patientwho required level 3 care so the environment could be‘flexed’ to meet the needs of the patient. This was inaccordance with the Department of Health (2000)guidelines.

• We sampled a range of medical equipment and foundthat appropriate service and portable appliance test(PAT) stickers were in place and in date. The Trust hadan electronic biomedical engineering department(EBME) who were responsible for all equipment that wasused within the service. Equipment servicing wasmonitored through the use of a spreadsheet whichlisted expiry dates for individual pieces of equipment.

• However, the service did not have a capital replacementplan for equipment. This meant that an individualbusiness case had to be submitted for equipment thatneeded replacing. Additionally, the risk of equipmentfailure had been highlighted on the critical care riskregister for over 12 months and the management teamhad recognised the need for two ventilators to bereplaced as well as five monitors. A business case forthese had not yet been submitted.

• The management team informed us that if there was anequipment failure, there was portable equipment that

could be used, although not for a long period of time.This could potentially have an impact how manypatients the service could safely manage. This had beenhighlighted on the departmental risk register.

• Critical care had four hemofiltration machines whichwere used to treat patients who required dialysis. Staffinformed us that there were sufficient numbers of theseto meet the needs of patients.

• The unit had several resuscitation and difficult airwaytrollies available for use. We found that all

equipment was in date and that they had been checked ona regular basis.

• Clinical waste was managed and stored appropriately.There were bins available for both domestic and clinicalwaste which were easily identifiable. There was also aseparate system for infectious waste which wasdisposed of in a separate area.

• Sharps bins were appropriately stored and clearlylabelled.

• There were hoists available to support staff whenmoving and handling patients. Moving and handlingtraining was included for all staff in their annualmandatory training update.

Medicines

• The Trust had an up to date policy for the safe storage,recording of, administration and disposal of medicines.Staff were aware of this and were able to access it whenneeded.

• Incidents involving medicines management wererecorded using the incident reporting system. Recordsindicated that between April 2016 and September 2016,there had only been 11 incidents reported. Examples ofthese included the incorrect route of administration,drugs not given and prescription errors. Eight of theseincidents had been graded as no harm and three as lowharm.

• Critical care services had access to a 0.5 whole timeequivalent (WTE) pharmacist. The intensive care societyguidelines (ICS) state that the standard should be 0.1WTE per level 3 bed or per two level 2 beds. This meantthat there was a shortfall of 0.8 WTE. There were nocurrent plans to improve this.

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• Staff informed us that the pharmacist for critical careservices visited the unit three times per week to reviewpatients’ medication. They were also available outsideof these times, which included an on call facility bothduring the night and at the weekend.

• We checked a sample of seven prescription cards andfound that allergies were documented, that they had allbeen completed correctly and that there was evidenceof pharmacist review in all cases.

• We observed three members of staff administeringmedicines. This was done following the correctprocedures on all occasions.

• The unit had two locked clinical areas where generalmedicines were stored securely. A pharmacy technicianvisited the unit regularly to complete a stock check,reconcile any discarded medicines and re stock whenneeded. The hospital had an electronic medicinesmanagement system which allowed staff to source adrug from another ward if there was a shortage and apharmacist was unavailable.

• Controlled drugs were managed in accordance withnational guidance. We took time to check cupboards,finding that the quantity of drugs tallied with what wasrecorded in the register and that they were in date.Additionally, all records had been countersigned andthe amount administered and disposed of had beenrecorded.

• Patient’s own medication was stored appropriately inlockable cupboards which were available at eachpatient bedside. This medication was added to thepatient’s prescription card and administered by amember of staff. If a patient had a controlled drug, thiswas stored and recorded in one of the appropriatecontrolled drugs cupboards.

• Drugs requiring refrigeration were stored appropriately.Fridge temperatures were within normal ranges and onchecking a sample of medicines we found that theywere all in date. However, the medicines managementpolicy stated that fridges should be checked daily. Wefound that for the month of February 2016, these checkshad not been completed on 6 occasions in the mainintensive care unit and on 12 occasions in the highdependency unit.

Records

• All patient records in critical care were paper based. Thisincluded admission and discharge forms, observationrecords, medical notes and risk assessments. When a

patient was admitted, there was a designated memberof staff who was responsible for adding the correctrecord templates to patient records for staff tocomplete.

• The hospital had recently introduced an electronicrecords system, but this had not yet been implementedin critical care. The management team informed us thatthere were plans for this in the near future and all staffwere to receive appropriate training in its use.

• Patient records were stored securely at each patientbedside. All staff were responsible for updating theseregularly, particularly when they had provided care andtreatment or if anything regarding the patients’ careplan had been amended.

• We sampled seven patient records and found that theyhad not always been completed correctly. For example,the time of admission was not documented in six of therecords, which also meant that we were unsure ifpatients had been admitted within the 4 hour standardfollowing the decision to admit was made. We alsoobserved a consultant ward round, finding that medicalnotes were not being updated after the patients hadbeen reviewed. This meant that it was unclear what theoutcome of the patient review was.

• However, we found that patient observations, adiagnosis and management plan and the summary ofevents leading to admission were completedappropriately on all occasions.

• The Trust wide audit team completed a monthly recordsaudit. However, the management team were unable totell us about results from this. This meant that if therehad been areas for improvement, there was a risk thatthe management team would have been aware and therequired improvements would not have been made.

• When a patient was discharged from the unit, nursingand medical staff were responsible for completingseparate discharge information sheets. This included allpertinent information, for example, about any pressureulcers, mobility issues, nutritional needs and prescribedmedicines. We observed two discharges from the unitand found that these records were completed fully onboth occasions.

Safeguarding

• The Trust had an up to date safeguarding policy whichwas available on the intranet. Staff knew how to accessthis.

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• The hospital had a safeguarding matron who wasresponsible for reviewing safeguarding referrals as wellas providing support and advice to staff if they had anysafeguarding concerns. We observed the safeguardingmatron following up a patient that had been referred ina timely manner during the inspection.

• There was also a designated safeguarding link nurse forthe unit. There were contact numbers for the on calllocal authority safeguarding team if referrals needed tobe made during these times.

• We spoke to seven members of staff, all of who wereable to give us examples of what they considered to be asafeguarding concern. We were informed that in theevent of a concern, this would be escalated to the nursein charge. When reviewing a sample of incident reports,we were able to find examples of when patients hadbeen referred and reviewed appropriately.

• All critical care staff were required to completesafeguarding level 2 training for adults and children.Records indicated that 97% of staff were up to date withthis at the time of inspection.

• There was a standard operating procedure for themanagement of adolescents (16 to 18 year olds). Wewere informed that on the rare occasion that anadolescent was admitted to the unit, a referral wasmade to the safeguarding matron and that they wouldbe managed in a side room. However, no critical carestaff (nursing or medical) had access to level 3safeguarding training. This meant that if an adolescentwas admitted to the unit for any length of time, theywere not always cared for by a member of staff who hadcompleted the appropriate training. This was not in linewith the intercollegiate document (safeguardingchildren and young people; roles and competencies forhealthcare staff, 2014).

• Staff in the unit did not currently have access to anelectronic safeguarding flagging system that was beingused in other parts of the hospital as all patient recordswere paper based. This would be used to alert staff ifthere was a safeguarding concern about a patient. Staffinformed us that they were reliant on the nurse andmedical handovers to transfer this information as part ofthe admission and discharge procedure. Safeguardingconcerns were also discussed during the twice dailysafety huddle.

Mandatory training

• There was a dedicated practice education facilitator forcritical care services. They were responsible formonitoring compliance with mandatory training for allnursing staff.

• Training was available in two ways. Some modules werecompleted face to face and others on the intranet viae-learning. The Trust target for all training was 90%.

• Records indicated that overall compliance withmandatory training for nursing staff was 97%. Thisincluded topics such as hand hygiene, fire awarenessand manual handling. Staff were required to completethese every twelve months.

• Immediate life support training for adults and childrenwas included as part of the mandatory trainingprogramme for all staff. Staff completed this yearly andrecords indicated that 97% of staff were up to date withthis.

• However, we were not assured that critical care serviceswere able to provide a member of staff who was up todate with advanced life support training on every shift.Advanced life support training for adults and childrenwas not provided for any nursing staff. Additionally, only55% of medical staff and 79% of acute response teamstaff had completed training updates at the time ofinspection.

• In addition to mandatory training, staff had beenidentified to complete role specific training. Compliancewith this was generally high and included modules suchas dementia awareness, mental capacity and conflictresolution training. However, records indicated that only79% of staff had completed blood transfusion training.


• Nursing and medical staff in critical care were trained inmanaging the deteriorating patient. A paper chart waskept at the end of every bed and included the patients’physiological signs such as blood pressure and pulserate. This was used to identify if a patient haddeteriorated over a period of time.

• There was an acute care response team (ACT) whichincluded a number of doctors and nurses. They were ledby members of the management team from critical care,providing 24 hour cover, seven days a week and wereresponsible for responding to deteriorating patients andmedical emergencies throughout the hospital.

• The Trust used a track and trigger system to identifydeteriorating patients. There was an operating policy forthis which was available on the intranet. This system

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used the national early warning score (NEWS) which wascalculated using a range of basic physiological signssuch as blood pressure, pulse rate and respiration rate.There were clear guidelines to follow for all staff in thehospital about when to escalate a deteriorating patient.For example, if a patient had a NEWS of 5 to 6, staff wereto contact the ACT team immediately.

• Compliance with the track and trigger system wasaudited on a quarterly basis. Records indicated thataudit results between September 2015 and March 2016had been mixed. For example, there were areas of goodcompliance which included the NEWS being calculatedcorrectly on 92% of occasions. However, patients hadonly been escalated to the ACT team appropriately on25% of occasions. Additionally, observations had beenincreased accordingly for the same group of patients ononly 45% of occasions.

• An action plan had been implemented to improve areasof low compliance. However, we found that the actionsfor improvement were not robust. Subsequently, wereviewed a similar audit undertaken between April 2016and July 2016, finding that the areas of low compliancehighlighted in the last report had not improved.

• There were two critical care outreach nurses whoworked within the ACT team. They had support from aconsultant intensivist and were available between7.30am and 8pm, 7 days a week. Their roles andresponsibilities in addition to those of the ACT teamwere following up discharged patients from critical carewithin 24 hours, as well as following up specific cohortsof patients such as those who had undergone surgeryfor a fractured neck of femur, had sustained fracturedribs, had an acute stage 3 kidney injury and patientswho had a tracheostomy or laryngectomy. The mainaim of patient follow ups was to prevent admission orreadmission to critical care by managing a patients’condition on the ward.

• Records indicated that between January 2016 andDecember 2016 there had been 653 patients who hadrequired follow up by the outreach team. For this period,only 82% of these patients had been seen. It wasunclear if these patients had received a follow up visitwithin 24 hours as there was limited audit dataavailable. The management team informed us thatthere were no formal plans to introduce this type ofaudit.

• All patients who had deteriorated in the hospital andrequired ventilation were managed in a stabilisation bay

that was located in theatre recovery. There was a clearstandard operating procedure (SOP) in place for staff tofollow when this area was used. The SOP stated thatpatients should not be managed in this area for morethan four hours and that all admitted patients shouldhave input from a consultant intensivist.

• Most admissions to critical care had been completedwithin 4 hours from the decision being made to admit.However, there had been a number of occasions whenadmission had been delayed, which was mainly due tocapacity issues.

• Records indicated that between January 2016 andDecember 2016, 37 patients had been managed in thestabilisation bay. Out of these, only 12 patients hadbreached the four hour standard, all of who weresubject to an extended stay in this area which rangedbetween eight and 24 hours. This was important as it isrecognised that delayed admission to critical care whenneeded is associated with a significant increase in bothmortality and morbidity.

• We checked a sample of records for these incidences,finding that all patients had been reviewed by aconsultant intensivist, in line with the SOP.

• Transfer equipment including a portable ventilator wasavailable for use if a patient required transferring toanother unit. Patient transfers were anaesthetist led andthere was an operating department practitioner (ODP)who would support the transfer. All ODP’s in theatre hadundergone transfer training.

Nursing staffing

• There were sufficient numbers of staff at the time ofinspection to provide safe care and treatment forpatients who required both level 3 and level 2 care.Patients requiring level 3 care needed a staff to patientratio of one to one and those needing level 2 care, oneto two. The unit had been established to provide 13registered nurses, a supernumerary co-ordinator, 3healthcare assistants (daytime) and 2 healthcareassistants (evening), 24 hours a day, seven days a week.

• Critical care was also established for a supernumeraryco-ordinator on every shift. This was compliant withintensive care society (ICS) guidelines which state thatthere should be a supernumerary member of staff for allunits with more than 10 beds.

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• At the time of inspection we were not assured that therewere sufficient controls in place to prevent the serviceexceeding full capacity. This was because critical careservices were not currently using a formal escalationpolicy.

• This was important as an escalation policy identifies keyactions that are taken in the event of the serviceapproaching full capacity. The aim of this is to prevent asituation where there are insufficient numbers of staff tocare for patients and to ensure that alternativearrangements are made for any potential emergencyadmissions when the unit is at full capacity. Themanagement team were able to provide evidence of anescalation policy that was in draft, but had not beenfully implemented at the time of inspection.

• Between January 2016 and December 2016, critical careservices had reduced the number of available beds from18 to 16. The management team informed us that thiswas because of a significant shortfall in the registerednursing establishment.

• The management team also informed us that they hadstruggled to meet the planned establishment on regularoccasion and that they had informally reduced theplanned number of staff from 13 to 12 registered nurses.However, the number of required registered nurses thathad been specified in the admission policy had notbeen altered to reflect this.

• This meant that between October 2016 and December2016, we were not always assured that the correctnumber of staff had been available to care for patients.During this period, there had been a number ofoccasions when occupancy rates had increased above100%. The trust provided additional information for theperiod January to July 2017 to demonstrate that therewere 11 further shift when the staffing did not meet theminimum numbers.

• The number of beds available had been increased backto 18 in January 2017, as there had been a successfulrecruitment drive for a significant number of registerednurses. However, at the time of inspection, 7 of thesehad not yet started. The management team informed usthat despite the recent recruitment, there were still 2.46WTE registered nurse vacancies.

• In January 2017 and February 2017, the correct numberof staff had matched patient dependency on only 80%of occasions. We were informed that during periods of

high occupancy, the co-ordinator or the nurse educatorwere used to uplift the staffing numbers when available,although there was no evidence of this on staffingreports.

• Additionally, the management team had calculated thatthere was a need of a further 8 WTE registered nurses toensure that the correct number of staff were availableon all occasions. This had been discussed informally,but a business plan for this had not yet been completed.

• Critical care services were also funded for three healthcare assistants for every shift. However, recordsindicated that between October 2016 and January 2017,this had not been achieved on most occasions. Staffinformed us that the role of healthcare assistants wasimportant as they completed jobs such as providingdomestic care to patients, supporting them at mealtimes and assisting with repositioning patients. Therewere currently 3 WTE health care assistant vacancies.

• Staff sickness levels had reduced from 7.9% in February2016 to 2.6% in January 2017.

• Critical care had relied on a high percentage of bank andagency staff between January 2016 and February 2017.The use of bank staff who were employed by the Trusthad varied between 8% and 16%. However, the use ofagency staff had reduced from 12% in January 2016 to4% in February 2017 which was as a result of a recentrecruitment drive.

• All agency staff received an induction which wascompleted by a member of the management team or asenior nurse. This included an orientation and anintroduction to the systems and processes that werefollowed in the critical care service. All agency nursesthat were used had critical care backgrounds.Compliance with mandatory training as well asdisclosure and barring service (DBS) checks werecompleted by the agencies that they were employed by.

• We attended a safety huddle that all nurses attended atthe beginning of every shift and was led by the shiftco-ordinator. We found that this was well structured andwas used to disseminate any issues or updates that staffneeded to be aware of. Additionally, nurses thencompleted a handover of individual patients that theywere responsible for.

Medical staffing

• Critical care had been established to provide eightconsultant intensivists who covered 24 hours a day,seven days a week. The service planned to provide two

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consultants between 8am and 5pm, Monday to Fridayand one consultant between the same hours at theweekend. Outside of these hours a consultant wasavailable on call and had sole responsibility for criticalcare. We were told that they were easily contactable andmet the intensive care society (ICS) standard of beingable to attend within 30 minutes if required.

• At the time of inspection, there was a consultant onmaternity leave and there was one WTE vacancy whichhad been advertised for the last 12 months, butrecruitment for this had been unsuccessful. This meantthat all shift patterns had to be filled by six consultants.Medical staff informed us that they felt under pressureto fill these extra shifts.

• We reviewed medical rotas between October 2016 andJanuary 2017, finding that the planned establishment ofconsultants had been met on most occasions. However,there had been a small number of times when theservice had only been able to provide one consultantwhen the planned number had been two. Additionally,the consultant to patient ratio increased to 1:18 out ofhours and at the weekend as there was only oneconsultant available. On these occasions, the ICSguideline of between 1:8 and 1:15 had not been met.

• Medical staff informed us that consultants were easy tocontact out of hours, although it had been rare that theyhad to attend.

• There was not always evidence of patients having beenreviewed twice a day by a consultant. This was not inline with ICS standards. All medical staff attended amorning ward round, 7 days a week. However, in theevenings, patients were not always reviewed fully. Wesampled 42 completed day sheets for seven differentpatients, finding evidence of patient review on only 60%of occasions.

• Consultants were supported by a team of junior andmiddle grade anaesthetic doctors, two of who werealways available 24 hours a day, seven days a week.

• The service met the ICS standard of having a maximumresident doctor to patient ratio of 1:8 available at nighttime. There were two resident anaesthetic doctors whowere had sole responsibility for critical care.Additionally, there were two further on call anaestheticdoctors covering other specialities who were able toprovide support if required.

• Critical care did not currently use locum doctors, but theTrust had an induction programme in place if needed.


• The Trust had an up to date business continuity policyas well as a local emergency preparedness resiliencepolicy. Within this, there were specified roles that criticalcare staff would undertake in the event of a majorincident. There were action cards which includedspecific prompts for staff to follow. However, the paperversions of these that staff knew how to locate had beenout of date since 2007. Additionally, major incidenttraining had not been provided for critical care staff toattend.

• All staff were required to complete fire safety as part oftheir annual mandatory training update. This includedevacuation plans in the event of an emergency. Therehad been checks completed by the fire warden and riskassessments were up to date. However, no scenarioshad been undertaken, for example, to simulate thepracticalities of evacuating a ventilated patient.

• There was access to a back-up power generator in caseof a power failure. We were informed that this wassubject to regular testing by the hospital maintenanceteam.

Are critical care services effective?

Good –––

We rated effective as ‘good’ because:

• The unit used a combination of best practice andnational guidance to determine the care that theydelivered. These included guidance from the NationalInstitute for Health and Care Excellence (NICE) and theIntensive Care Society (ICS).

• The most recently available and validated ICNARC data(April 2016 to September 2016) showed that the patientoutcomes and mortality were similar to benchmarkedunits nationally.

• The unit had an induction policy and a robust inductionprogramme for new staff to complete. All new staffcompleted a corporate induction and were assigned anamed mentor. They were also given a list of keycompetencies to complete.

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• There were a number of nursing and medical handoverseach day. These included safety huddles which wereused to disseminate any important information to staff.We attended one of these and found it to be bothstructured and informative.

• Staff gave appropriate examples of when a mentalcapacity assessment was required and how this wouldbe completed. They were also able to describe theprocess to instigate a DoLs, although this did not applyto critical care patients on a regular basis.

However:

• There were a range of local policies, standard operatingprocedures and clinical guidelines that were out of date.This meant that there was a risk of them not reflectingup to date guidance.

• Critical care did not have a formal multidisciplinaryteam meeting in which all members of the team wouldattend. Additionally, all team members did not attendthe daily ward round. This meant that nursing andmedical staff had to handover patient informationinformally when needed.

• Staff had an awareness of the Mental Capacity Act (MCA)and DoLs. However, we saw that on one occasion therehad been no consideration to undertake a full MCAassessment.

• We found that the malnutrition universal screening tool(MUST) was not consistently being used.


• The unit used a combination of best practice andnational guidance to determine the care that theydelivered. These included guidance from the NationalInstitute for Health and Care Excellence (NICE) and theIntensive Care Society (ICS).

• There were a range of local policies, standard operatingprocedures and clinical guidelines that were availablefor staff to follow. We checked a sample of these, findingthat the majority which were paper based were out ofdate, with the date of expiry varying between 2012 and2015. This meant that there was a potential risk thatthese did not always reflect up to date guidance. Amember of nursing staff was currently in the process ofgoing through all of the standard operating procedures,updating them and adding them to the electronicsystem for staff to access.

• Critical care had an annual audit programme.Compliance with most evidenced based guidance wasmeasured through a number of audits whichbenchmarked performance against the requiredstandard.

• Results from these were positive in the majority of areas.For example, between January 2016 and December2016, compliance with urinary catheter insertion was100% and compliance with peripheral cannula insertionwas 95%. However, there were areas of variedcompliance, such as compliance with ventilator bundlesand standards of tracheostomy care. A formal actionplan to make improvements had not beenimplemented, although we did see that some positiveactions had been taken. This included reminders tofollow the tracheostomy care checklist that wasavailable for all staff to follow.

• However, audits measuring compliance with nationalguidelines such as NICE CG83 (rehabilitation after criticalillness) had not been undertaken fully. This meant wewere unsure how effective rehabilitation had been in thepast 12 months and that there was the potential formissed opportunities for learning which could lead toservice improvement. However, an audit measuringcompliance with this had recently started, althoughthere had not been any official results or actions forimprovement produced at the time of inspection.

• The unit made regular data contributions to theIntensive Care National Audit and Research Centre(ICNARC). This meant that the service compared thecare delivered and mortality outcomes with similarservices throughout the country. The unit had an auditclerk who was responsible for collecting and makingdata contributions.

• The service was also a member of the Cheshire andMersey Critical Care Network (CMCCN). This meant thatthey were subject to an annual peer review whichassessed a range of standards applicable to critical care.

• A peer review had been undertaken for 2016/17, but thishad not yet been published. The 2015/16 report statedthat the service was 94% compliant with the requiredservice specifications. This was similar to other serviceswithin the network. The review had highlighted areas forimprovement. These included recommendations toimprove flow from critical care, reduce delayeddischarges, employ a full time practice educator andincrease the number of allied health professionals,

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particularly physiotherapists and dietitians. Themanagement team were able to identify these gaps,although a formal action plan for improvement had notbeen devised.

• Critical care had adopted the sepsis 6 tool that hadbeen implemented trust wide in response to a nationalconfidential enquiry into patient outcome and death(NCEPOD 2015). Staff were aware of their responsibilityto seek urgent medical review for patients who showedsigns and symptoms of sepsis.

Pain relief

• We reviewed a sample of seven patient records andfound that all patients in the unit had been assessed inregard to pain management. Staff used a pain scoringtool alongside observing for the signs and symptoms ofpain.

• Pain management was led by the consultantintensivists. Additionally, the Trust had a specialist painmanagement team who were available for support andadvice throughout the week.

• Patients and relatives that we spoke to confirmed thatthey felt pain had been managed appropriately.


• Guidelines were available for nutritional support for allpatients on admission. This was to ensure that theyreceived adequate nutrition and hydration. There wasfluid balance monitoring for patients which includeddaily totals of input and output. We reviewed sevenpatient records and found that these had beencompleted appropriately.

• We were informed that there was access to a dieteticservice and there was usually one WTE dietitianavailable for critical care. This indicated a 0.5 WTEshortfall against ICS standards. Additionally, thedietitian was currently on long term absence. Staffinformed us that because of this, a dietitian only visitedthe unit to review patients twice per week and thatreferrals had to be made if support was required outsideof these times.

• We found that the malnutrition universal screening tool(MUST) was not consistently being used. We saw oneexample of a patient who was acutely unwell. Despitemedical consideration that a naso-gastric tube (a tubewhich is inserted into the stomach) should be insertedto assist with feeding, an appropriate referral to the

dietetic service had not been made and that the MUSThad not been completed. However, we were assured bystaff that the patient was receiving appropriate levels ofnutrition.

• If a dietitian was unavailable, there was a folderavailable for staff to use providing clear guidance andprotocols to follow including guidelines for the use ofprabinex, which was the main nutritional supplementused for patients.

• All patients had their weight measured on admission.This was done as an actual weight if the patient wasmobile. Otherwise, a patients’ weight was estimatedfollowing best practice guidance.

Patient outcomes

• The most recently available and validated ICNARC data(April 2016 to September 2016) showed that the patientoutcomes and mortality were similar to benchmarkedunits nationally.

• Between April 2016 and September 2016 the unitperformed similar to comparable trusts for earlyreadmissions to the unit (within 48 hours of discharge).The unit’s performance for late readmissions (after 48hours) was also consistently similar to other trusts. Thiswas important as it measures how safely patients weredischarged from critical care and how effectively theyhad been managed outside of the unit, particularly ifthey have had a period of deterioration.

• Records indicated that the number of times patientshad received cardiopulmonary resuscitation wasconsistently similar to that of comparable units.

Competent staff

• There was one whole time equivalent (WTE) practiceeducation facilitators that were employed by the unit.They were responsible for organising staff training(including mandatory training) and appraisals.

• All nursing staff that worked in the unit were assigned toa team that had a band 7 lead and were responsible forcompleting appraisals for their staff. Nursing staff had anappraisal every year so that they had the opportunity todiscuss their progress and training needs. We saw that85% of nursing staff were up to date with this at the timeof the inspection. This met the trust target which wasalso 85%.

• The unit had an induction policy and a robust inductionprogramme for new staff to complete. All new staffcompleted a corporate induction and were assigned a

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named mentor, had a list of key competencies tocomplete and were given between a four and six weeksupernumerary period (this meant that they were notincluded in the daily staffing numbers to look afterpatients so that they could learn). Following this period,all nursing staff were required to complete ICU step onecompetencies over a period of 12 months. This includeda number of assessments that included topics such asthe use of equipment and the safe administration ofmedicines.

• All nursing staff were subject to an annual check of theirregistration with the Nursing and Midwifery Council(NMC).

• 48% of the trained nurses on the unit had achieved apost registration award in critical care. The IntensiveCare Society standard was 50%. The management teaminformed us that a critical course was held at a localuniversity. However, they had only secured two placesfor staff to attend on the next available course despitesubmitting a business case for eight members of staff.

• Critical care staff had access to a simulation suite thatwas based at the Halton site. This was used to simulatescenarios such as managing the deteriorating patientand resuscitation.

• The use of agency staff had varied between January2016 and December 2016. We were informed thatregular staff were used when possible so that they wereaware of local policies and procedures. We sawevidence of local induction checklists being completedfor agency staff.

• Members of the outreach team ran training sessions thatincluded topics such as managing the deterioratingpatient and tracheostomy care. Staff from otherdepartments told us that this training enabled them tomanage patients that had been discharged from theunit with confidence. This was available to staff of alllevels from the unit and throughout the rest of thehospital.

• Regular training days for medical staff were facilitatedon a rotational basis by the trust wide educational team.Medical staff stated that they were well supported andhad a good appraisal and revalidation process withgood opportunities for training.


• There were a number of nursing and medical handoverseach day. These included safety huddles which wereused to disseminate any important information to staff.We attended one of these and found it to be bothstructured and informative.

• A member of the management team attended ahospital bed meeting in the morning and furthermeetings through the day if required. This supportedwith access and flow in critical care services, althoughstaff informed us that it was difficult to facilitate timelydischarges on a regular basis.

• A member of the critical care outreach team wasresponsible for following patients up who had beendischarged to a ward. We spoke to a number of staff onvarious wards, who spoke highly of the support thatthey received from the outreach team. Staff informed usthat they felt that the outreach service was effective atstabilising and managing patients outside of criticalcare. However, audits were not currently beingcompleted to measure the effectiveness of this service.

• There was a microbiology ward round which took placein the afternoon, between Monday and Friday. Amicrobiologist was also available on call 24 hours a day,seven days a week if advice was needed. Microbiologyward rounds are important as the use of antibiotics arereviewed, as well as compliance with infection controlmanagement. However, the service did not currentlyinclude an antimicrobial audit as part of their annualaudit plan.

• Referrals were made for patients who required inputfrom an occupational therapist or a speech andlanguage therapist. These services were availableMonday to Friday, during normal working hours. Therewere protocols in place for staff to follow when theseservices were unavailable, for example if a swallowingassessment needed completing.

• Patients who had undergone surgery received regularinput from surgical staff during their stay in critical care.Additionally, there was input from medical staff ifrequired.

• Critical care did not have a formal multidisciplinaryteam meeting in which all members of the team wouldattend. Additionally, all team members did not attendthe daily ward round. This meant that nursing andmedical staff had to handover patient informationinformally when needed. The management team hadnot made any plans to introduce multidisciplinary teammeetings.

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Seven-day services

• A consultant intensivist was available seven days aweek, including on call outside of normal workinghours.

• There were pharmacy, dietetic and physiotherapyservices available between 9am and 5pm from Mondayto Friday. Outside of normal working hours, there was anon call facility for these services if required.

• Additionally, there were speech and language therapistsas well as occupational therapists available duringnormal working hours. However, they did not visitcritical care routinely. This meant that referrals had tobe made if patient input was needed.

• Staff informed us that there were no problems inobtaining diagnostic or laboratory support whenrequired. The service met the most of the NHS services,seven days a week priority clinical standards. Thesestate that there must be access to services such asultrasound, computerised tomography (CT) andmagnetic resonance imaging services (MRI). However,the hospital were unable to provide a seven days a weekservice for echocardiography (a scan of the heart).


• Critical care used paper based records. This includedpatients’ physiological signs, medication charts and allmedical notes.

• The Trust were in the process of introducing a newelectronic records system. However, at the time ofinspection, this had not been implemented in criticalcare. The management team informed us that planswere in place for this and that staff would receivetraining prior to its implementation.

• Staff had access to care bundles and patient pathways.When a patient was admitted, the necessary paperworkwas added to patient records. There were paper copiesof policies and procedures available, although staff werein the process of updating and adding these to theintranet.

• Staff were able to access diagnostic test results such asx-rays and blood test results on an electronic system.

• On discharge from the unit, a paper nursing andmedical summary was completed and handed over tothe relevant medical teams. It was the responsibility of

the ward staff to transfer any relevant information on tothe electronic system if a patient was transferred to anarea of the hospital that used the electronic recordssystem.

• If a patient was discharged home, they were providedwith a discharge letter. A copy of this was also sent tothe patients’ GP. This included information about thecare and treatment that had been provided, as well asany new medications that had been prescribed.


• There was a Trust policy for best interest decisions,mental capacity and deprivation of liberty safeguards(DoLs). This was available on the intranet and staff wereable to locate this.

• Staff gave appropriate examples of when a mentalcapacity assessment was required and how this wouldbe completed. They were also able to describe theprocess to instigate a DoLs, although this did not applyto critical care patients on a regular basis. Mentalcapacity act training was available for all nursing andmedical staff.

• However, we saw on one occasion there had been noconsideration to undertake a full two stage mentalcapacity assessment for a patient, despite them havingregular periods of confusion and refusing treatment. Amental capacity assessment is used to evaluate if apatient is able to retain and use the information given tothem when making a decision about their treatment.

• Light restraint was used if a patient became agitatedduring their stay. We saw that incidences had beenreported regularly using the electronic reporting systemin line with the Trust policy. However, staff had notreceived formal training in the use of light restraint. Thismeant that there was a potential risk of avoidablepatient injury, although staff informed us that theysought support from security who had undergoneappropriate training if required.

• Hand mitt restraints were used for agitated patients andthere was an operating procedure that met nationalguidance for their use. These were designed to preventpatients from removing tubes and wires that wereattached to them.

• The unit used a confusion assessment method forintensive care units (CAM-ICU). This was used inassociation with the Ramsay score (RSS) which measurethe agitation or sedation level of a patient. The CAM-ICU

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tool uses yes and no questions for non-speakingmechanically ventilated patients. We reviewed sevenpatient records, finding that this had been usedcorrectly on two out of three occasions when it wasrequired. The management team had not audited theuse of this tool.

• Sedation breaks were implemented when appropriate.A sedation break is where the patient’s sedative infusionis stopped to allow them to wake and has been shownto reduce mortality and the risk of developing ventilatorrelated complications. The sedative was then re-startedif the patient became agitated, was in pain or showedsigns of respiratory distress.

Are critical care services caring?

Good –––

We rated caring as ‘good’ because:

• Staff treated patients in a caring and compassionateway; maintaining their privacy and dignity at all times.Both relatives and patients were positive about theirtime in the unit and spoke highly of the way in whichthey had been cared for.

• Staff communicated with patients and relativeseffectively ensuring that they understood all aspects ofthe care and treatment that was being provided.

• The Trust held an annual memorial service for relativesand friends of patients who had passed away in criticalcare services. Staff informed us that this had been wellattended.

• We saw positive examples of staff providing emotionalsupport to relatives, explaining information about apatients’ condition in a way in which that they were ableto easily understand.

Compassionate care

• Staff took steps to ensure that patients’ privacy anddignity were maintained at all times. We saw that whentreating a patient the curtains were fully drawn aroundthe cubicle. The side rooms also had curtains aroundthe bed spaces and were used when required.

• We saw both nursing and medical staff comforting andcommunicating with patients on a regular basis. Theunit tried to ensure that patients’ were looked after bythe same members of nursing staff and this was donewhenever possible.

• We saw examples of patients regaining consciousnessand staff managing them in a compassionate wayensuring that they did not become agitated.

• We spoke to a number of relatives who all spoke veryhighly of the quality of care that their loved ones hadreceived. One relative told us that “staff were excellentand that they would do anything to help”.

• There was a member of staff who had recently beenawarded employee of the year by the Trust. They hadco-ordinated and facilitated a complicated discharge fora patient who had been in critical care for a long periodof time.


• Staff communicated with relatives on a regular basis,discussing treatment plans and allowing them to beinvolved in their relatives care. Relatives that we spoketo told us that they were aware of their loved onescondition and that this information had beencommunicated in a clear manner.

• We reviewed a sample of patient records and founddocumented evidence that care and treatment hadbeen discussed with family members. During theinspection we also saw examples of relatives beinginvolved in decision making processes.

• The unit had introduced the use of patient diaries whichwere used for patients who were sedated. Intensive Carepatient diaries are simple but valuable tools which helprecovering patients come to terms with their experienceof critical illness. The diary is written by healthcare staff,family and friends. Research has shown that patientdiaries help prevent depression, anxiety andpost-traumatic stress.

• There was an annual memorial service held for friendsand relatives of patients who had passed away in criticalcare. Staff informed us that this had been well attended.We saw examples of when relatives had providedpositive feedback about this, thanking staff foreverything that they had done.

Emotional support

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• Conversations regarding a patient’s condition, care andtreatment and prognosis were managed in a sensitiveway. We saw an example of treatment being withdrawnand relatives being communicated with in a clear andcompassionate manner by members of staff.

• Staff provided emotional support to patients who werehaving their levels of sedation reduced. Staff recognisedthat patients could become agitated during this periodand provided constant reassurance to them.

• There were a number of private rooms that were used togive relatives privacy when needed. We saw examples ofthese rooms being used by staff when discussinginformation about patients with visiting relatives.

• The trust had a chaplaincy service who offeredemotional support to patients and relatives. This servicewas available 24 hours a day, 7 days a week.

Are critical care services responsive?


We rated responsive as ‘requires improvement’ because:

• Between March 2016 and December 2016, occupancyrates had been consistently high, with monthly averagesranging from between 78% and 96%. We also found thaton a high number of occasions, daily occupancy hadexceeded 100%.

• The unit had struggled to meet the standard set by theDepartment of Health in managing mixed sexaccommodation appropriately. We saw examples of thisduring the inspection.

• Records indicated that between January 2016 andDecember 2016, there had been 75% delayeddischarges (greater than four hours following thedecision being made that a patient is fit for discharge toa ward).

• Critical care were unable to provide accommodation forrelatives. However, staff informed us that they hadaccess to folding beds if required, although there was noaccess to facilities such as a shower room for relativeswho wanted to stay.

• There had been a low number of complaints madeabout critical care services between January 2016 andDecember 2016. However, we found that these had notalways been managed in a timely way.

However:

• We saw a positive example of staff interacting andmanaging a patient with learning disabilities. Thisincluded providing extra support and resources for theduration of their stay.

• The palliative care team had undertaken trainingsessions for medical and nursing staff and wereavailable to provide additional support to staff whenmanaging patients who were at the end of life.

• The trust provided a chaplaincy and a bereavementservice to support relatives and patients when required.


• The unit had struggled to meet the standard set by theDepartment of Health in managing mixed sexaccommodation appropriately. This standard statesthat this criteria does not apply to patients who requirelevel 2 or level 3 care. However, when a patient requireslevel 1 care and a decision to discharge the patient hasbeen made, they should be provided with same sexaccommodation.

• This was a regular issue because of the design of theunit and a high number of delayed discharges. We sawfour examples of this during the inspection. There wasaccess to two doored cubicles, which were oftenunavailable to support staff in managing mixed sexaccommodation. However, when these incidences hadoccurred, they had been escalated and reportedappropriately using the electronic reporting system.Additionally, the service had recently introduced anescalation plan for staff to follow in the event of adelayed discharge. This was to support staff in reducingthe number of mixed sex breaches.

• Also, there was limited access to bathroom facilities forpatients. These were located near the main entrance,which meant that if patients from the high dependencyarea required the bathroom, they had to walk throughthe open plan intensive care area.

• Staff discussed the possibility of same sexaccommodation on admission so that they were awarethat there had been breaches of this standard. Whenpatients were subject to same sex accommodation, theywere asked to complete an impact questionnaire whichhad been designed to measure how much they beenaffected by this. Staff informed us that there was a clearmental impact to patients. This was because they wereable to observe other critically ill patients during theirwait.

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• There were two rooms for relatives that were availableto use as waiting areas or meeting rooms. These areaswere used to maintain the privacy of friends andfamilies, either while they were waiting to see a patientor if medical and nursing staff wanted to speak to themprivately.

• Critical care were unable to provide accommodation forrelatives. However, staff informed us that they hadaccess to folding beds if required, although there was noaccess to facilities such as a shower room for relativeswho wanted to stay.

• There was limited access to a nurse led follow up clinicfor patients who had been discharged from critical care.The management team informed us that the processhad been recently changed as the attendance of theseclinics had been low. The current criteria for attendancewas for patients who had required level 3 care and hadstayed in the unit for three days or more. However, asthere was only one nurse available to run this service,not all patients who met the criteria were givenappointments. When a clinic was facilitated, a memberof the psychology team also attended so that a furtherreferral could be made if required.

• The service had links with a local home ventilation unit.Home ventilation units are used for patients that requirelonger term care or have problems weaning (copingwith the withdrawal of artificial ventilation).


• There was a nurse lead for delirium management.However, there had not been a specific audit of the totalnumber of incidences of delirium or compliance withthe use of the CAM-ICU tool which was used to measurethe confusion and agitation levels of patients. Wereviewed incident reports between January 2016 andDecember 2016, finding that there had been a highnumber of patients who had become agitated duringtheir stay in critical care. When asked, the managementteam were unaware of this. This meant that there wasthe potential for service development opportunitiesbeing missed as well as incidences of delirium thatcould have potentially been avoided.

• However, we found that staff were aware of the issuesaround sensory and sleep deprivation in the critical careenvironment and adjusted the lighting to simulate thedifference between day and night time. Additionally,

monitors were silenced to reduce the noise duringprotected sleep times for patients which was in line withthe standard operating procedure (SOP) for deliriumprevention and management.

• All patients who required care and treatment in the unitfor over 72 hours were provided with a patient diary.Patient diaries had been developed to support patientsreflecting retrospectively on their period of beingsedated during critical illness. Patient diaries are writtenfor patients during their time of sedation andventilation. It is written by relatives, nurses and others.The patient can read their diary afterwards and is moreable to understand what has happened.

• The Trust had a strategy for supporting patients wholived with dementia. Records indicated that 56% of staffhad completed dementia awareness training. However,‘this is me’ documentation was not currently beingused, despite this being implemented across the Trust.

• We saw a positive example of staff interacting andmanaging a patient with learning disabilities. Thisincluded providing extra support and resources for theduration of their stay. However, there was no evidenceof a learning disability passport being used. This wasimportant as patient passports travel with patients andinform staff of their individual need, such as how best tocommunicate with them and any other specialrequirements that they may have.

• The palliative care team had undertaken trainingsessions for medical and nursing staff and wereavailable to provide additional support to staff whenmanaging patients who were at the end of life. Astandardised document had been introduced forpatients, which replaced all other documentation whenthey had been placed on this pathway. This documentcontained important aspects of care, including nutritionand hydration, mouth care and regular repositioning.

• We saw one occasion when this documentation hadbeen used, however, we found that it had not alwaysbeen completed correctly. This was because there was alimited documentation of patient checks having beencompleted at the required intervals.

• The trust provided a chaplaincy and a bereavementservice to support relatives and patients when required.Chaplains visited critical care to support patients andrelatives when needed and there was a multi faith roomavailable for patients and relatives to use.

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• There was a translation service available and aninterpreter was able to attend the unit if needed. Adviceleaflets in a range of different languages were availableon request.

Access and flow

• Critical care services had an admission and dischargepolicy which was available on the intranet. Theadmission policy listed the procedures for staff to followfor elective and emergency admissions as well as themanagement of maternity admissions.

• A member of the management team attended dailyhospital bed meetings to discuss access and flow to andfrom the service. Staff informed us that access and flowissues in critical care were usually as a result of thewider problems that the hospital faced.

• Between March 2016 and December 2016, occupancyrates had been consistently high, with monthly averagesranging from between 78% and 96%. We also found thaton a high number of occasions, daily occupancy hadexceeded 100%.

• Between January 2016 and December 2016, there hadbeen 37 occasions when patients requiring ventilationhad experienced a delay in admission to critical care. 12of these patients had experienced delays between fourhours and 24 hours. 11 of these patients hadsubsequently been transferred to another critical careservice.

• If an agreed admission to critical care had been delayed,patients requiring ventilation were managed in the‘stabilisation bay’ which was located in theatre recovery.There was a standard operating procedure (SOP) forstaff to follow in the event of this happening.

• Additionally, theatre staff informed us that there hadalso been a low number of occasions when there hadbeen a delay for patients requiring level 2 care (patientswho were not ventilated) following surgery.

• Between January 2016 and December 2016, there hadbeen 5% of operations (four out of 79) cancelled as aresult of critical care being at full capacity. This was inline with the NHS standard which states that no morethe 5% of elective surgical procedures should becancelled.

• Records indicated that between January 2016 andDecember 2016, there had been 75% delayeddischarges (greater than four hours following thedecision being made that a patient is fit for discharge toa ward). The majority of these patients waited for more

than four hours but less than 24 hours. However, out of653 discharges, 116 patients had been delayed forbetween 24 hours and 48 hours and 38 patients hadwaited for longer than 48 hours.

• During the same period, there had been 27 out of hoursdischarges (between 10pm and 7am). This data hadbeen submitted to the Intensive Care National Audit andResearch Centre (ICNARC). Results indicated that thiswas better than similar services nationally.

• A small number of patients were able to be dischargedhome following their stay. There were protocols in placefor staff to follow in the event of this happening.

• The management team informed us that if there wascapacity, level 1 patients were accepted from otherareas of the hospital, particularly at times when theyfaced high demand. Examples of this included patientswho required non-invasive ventilation. This was as aresult of the respiratory ward being at full capacity.However, there was no formal procedure for admittingand managing these types of patients in the admissionspolicy.

• The management team informed us that they hadconsidered ways in which to alleviate the pressure fromcritical care. However, there was no evidence of anyformal plans for improvement. Additionally, access andflow had not been identified as a formal risk and hadnot been highlighted on the departmental risk register.


• The Trust had an up to date complaints policy that wasavailable on the intranet. Staff were able to access thiswhen needed.

• We were informed that any concerns or complaints wereescalated to the nurse in charge. There was writteninformation available in waiting areas informingrelatives of the process to follow if they wanted to makea complaint.

• There had been a low number of complaints madeabout critical care services between January 2016 andDecember 2016. However, we found that these had notalways been managed in a timely way. An example ofthis was a complaint being logged in June 2016, butremained open in November 2016. All formalcomplaints were investigated by the Trust wide team.

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• The management team informed us that whencomplaints had taken an extended period of time toinvestigate, any learning was disseminated as soon aspossible through daily safety huddles which all staffattended.

• Between January 2016 and December 2016, nocomplaints had been referred to the Parliamentary andHealth Service Ombudsman (PHSO). Referrals ofcomplaints to the PHSO are made if the person makingthe complaint feels that the outcome of an investigationundertaken by the Trust has been unsatisfactory.

• We saw evidence of complaints and concerns havingbeen discussed as part of the monthly governancemeetings. This was a set item on the agenda.

Are critical care services well-led?

Good –––

We rated well-led as ‘good’ because:

• The Trust had an overall vision and strategy. Themanagement team in critical care were able to identifywith this.

• Critical care services had a clear leadership structure. Allleaders were visible during the inspection and staff toldus that they were both approachable and supportive.

• Staff informed us they felt that there was an open andhonest culture within the department. We observed allteam members working well together during theinspection.

• Staff said that patient care was the priority and that theyfelt this view was shared by staff throughout thedepartment.

However,

• We found that on occasions appropriate actions had notalways been taken in a timely way to mitigate the levelof risk and there were a number of risks that had notbeen formally identified.

• We found that on a number of occasions betweenOctober 2016 and February 2017 there were occasionswhen reported incidents had not been actioned andclosed in a timely manner.


• The Trust had an overall vision and strategy. The threecore elements to this were quality, people and

sustainability. Additionally, the Trust had a five yearforward plan which highlighted key areas forimprovement. The management team in critical carewere able to identify with this.

• Critical care had a formal vision and strategy to improvethe services provided. This was included as part of thedivisional business plan. However, it was unclear howthis strategy was being monitored and measured. Thiswas because the management team informed us thatthey were unaware of plans to implement a formalimprovement strategy.

• Staff informed us that they were not sure what the visionand strategy for critical care was but were able to givesome examples of improvement initiatives. Staff felt thatthey provided an excellent service for patients.


• Critical care had access to an electronic riskmanagement system which held the departmental riskregister. This had been reviewed periodically during2016. A member of the critical care nursing team wasresponsible for adding identified risks and puttingmitigating actions in place. All identified risks werescored and had a date for further review. Themanagement team were able to identify the key risksthat were listed on the system.

• However, we found that appropriate actions had notalways been taken in a timely way to mitigate the levelof risk for those which had scored highly. An example ofthis was the risk of medical device failure which couldimpact on patient safety. This had a risk score of 15 andhad been identified in February 2016, although noformal actions had been taken to reduce the level of riskposed at the time of inspection.

• Additionally, there were a number of risks that had notbeen identified. For example, a risk of delayedadmission to the service due to poor access and flow,breaches of the mixed sex accommodation standardand low levels of compliance with advanced life supporttraining. Also, the risk to patient safety by reducing thenumber of beds in critical care during 2016 had notbeen considered as a formal risk.

• Despite these risks not being formally highlighted, therewas evidence that the management team had taken

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some actions. For example, there was a draft escalationpolicy which was in the process of being implementedand there was an escalation plan in place for staff tofollow in the event of a delayed discharge.

• If a risk in critical care scored above 12, it was added tothe divisional risk register, although this system wasreliant on all risks being identified at departmental level.We were therefore unsure if the senior managementteam were fully aware of all the issues that critical carecurrently faced.

• The unit held several divisional and departmentalmeetings every month which discussed a variety oftopics. We sampled minutes of the managementmeetings, finding that they had been well attended andwere well structured. There had been discussions abouttopics such as incidents, complaints, safeguardingconcerns and adherence to NICE guidance.

• Monthly performance reports were produced by theairway, breathing and circulation clinical business unit(CBU). This included some safety information for criticalcare services and was sent to the senior managementteam for review.

• All clinical incidents that had been reported wereinvestigated by a member of the management team.The critical care management team were supported bya risk manager from the airway, breathing andcirculation CBU as well as the Trust risk managementteam.

• However, we found that on a number of occasionsbetween October 2016 and February 2017 there weresome occasions when this had not been done in atimely manner. On 19 occasions it had taken 30 days ormore to complete this process. On two occasions it hadtaken 40 days, and on one occasion, 125 days. Thismeant that we were not always assured that actionswere taken to prevent further incidences of a similarnature in a timely manner.

• There was an audit calendar for critical care serviceswhich was primarily based on data that was required forsubmission to the Intensive Care National Research andAudit Centre (ICNARC). This included compliance withcare bundles such as the insertion of catheters andcentral lines. However, the management team did notcollect data for other key areas. For example, there hadnot been formal audits measuring the effectiveness ofthe critical care outreach team, compliance with NICEguideline CG83 (rehabilitation after critical illness) anddelirium prevention which included the use of the

CAM-ICU tool. This meant that the management teamhad limited oversight of these areas and also meant thatthere was the potential for missed learningopportunities.


• Critical care operated under the clinical business unit(CBU) of airway, breathing and circulation. The CBU hada clinical lead, a risk manager and a newly appointedoperations manager.

• The service had a matron and a consultant clinical leadwho were responsible for overseeing critical care andreported into the CBU. They both had a critical carebackground and had worked in the unit for a number ofyears. They also ran the acute care team (ACT) who wereresponsible for responding to emergencies andfollowing up patients that had been discharged from theunit.

• The service had a practice educator facilitator who hada critical care background and was responsible foroverseeing training and development within thedepartment.

• All leaders were visible during the inspection and stafftold us that they were both approachable andsupportive.

• Critical care was established for a supernumeraryco-ordinator on every shift. They were responsible formanaging the operational aspects of the unit on a dailybasis. This was in line with and met the Intensive CareSociety (ICS) guidelines. However, staff informed us thatduring periods of high occupancy, they were sometimesincluded in the overall staffing numbers which meantthat they were not able to undertake there supervisoryresponsibilities effectively during these times.

• In addition to the management team, there were anumber of band 7 nurses who had been allocated teammembers, including two band six nurses and a numberof band 5 nurses. The band 7 nurses worked closely withthe management team and were responsible fordisseminating information and completing theappraisals for the members of their team. They werealso named mentors for new starters.


• Staff informed us they felt that there was an open andhonest culture within the department. We observed allteam members working well together during theinspection.

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• Staff said that patient care was the priority and that theyfelt this view was shared by staff throughout thedepartment.

• We were informed that over the last 12 months therehad been a high use of agency and bank staff which hadbeen due to staffing shortages. Additionally, the servicehad been consistently close to full capacity and that thishad sometimes been exceeded. Staff told us that thishad made critical care a stressful place to work.However, they were more positive following a recentrecruitment drive as they had seen a difference instaffing numbers.

• This was reflected in sickness rates decreasing from7.9% in February 2016 to 2.6% in January 2017.Additionally, during the same period, staff turnover hadalso consistently decreased from 7.9% in February 2016to 4.1% in January 2017.

• Between January 2016 and December 2016 results fromthe trust-wide friends and family test showed that 96.5%of staff that completed the survey would recommendcritical care as a place to work. However, the number ofstaff that had completed this on a monthly basis waslow.

Public engagement

• The unit had undertaken patient and relativesatisfaction surveys to improve the services that wereprovided. This data was submitted to the Cheshire andMersey Critical Care Network (CMCCN) on a bi-yearlybasis. The results from a survey undertaken in March2016 were not available at the time of inspection.Questions that were usually asked as part of this surveyincluded ‘were you kept up to date with your relativescondition’ and ‘did you feel that your relatives’ privacyand dignity was maintained’.

Additionally, all patients were given a Trust satisfactionsurvey to complete when they were discharged from thehospital.

• Staff gave patients an impact questionnaire to completeif they had been subject to a breach of the Departmentof Health mixed sex standard. This was used to assesshow much they had been affected by this. Results fromthis were used when possible to improve servicedelivery.

Staff engagement

• The management team had organised a ‘Big ICU Day’event which was held on an annual basis. This eventhad been used to discuss the service with all staff andhad been well attended. Following the last event, themanagement team had agreed and implemented two‘always’ events, for the prevention of ventilator acquiredpneumonia (VAP) and a checklist for the care of patientswith tracheostomies. These were both in use at the timeof inspection.

• Information was cascaded to staff through a number ofdifferent methods. It was done by email, information instaff areas, daily huddles, team meetings andappraisals. However, we were informed that there was amonthly nurses meeting but this had not beenfacilitated regularly due to the unit being at full capacity.

• The management team completed an annual‘temperature check’ to measure satisfaction of staff whoworked in the unit. Additionally, any staff who left criticalcare were asked to complete a leavers interview.However, staff informed us that in 2016, there had notbeen any leavers who had attended this. Leaversinterviews are important as it helps the managementteam understand if there are specific reasons why staffwant to seek employment elsewhere.


• The practice education facilitator had developed a newrecruitment programme for nursing staff. They wererequired to undertake a simulated exercise using thesimulation suite as part of the process to test if they hadthe correct competencies for the role. This had beenpresented at the British Association of Critical CareNurses (BACCN) conference and had received positivefeedback.

• The service had been recently shortlisted in the NursingTimes Awards for its vision, leadership and commitmentto delivering enhanced patient safety in the ICU througha 5-year vision.

• The management team had not always considered thelong term improvement of critical care services. Forexample, there was an established tier of senior middlegrade doctors within the service. However, there was noevidence of consideration to how this could besustained and improved in the future.

• The service currently had 48% of registered nurses whohad achieved a critical care nursing qualification. Thiswas slightly below the Intensive Care Society (ICS)

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Critical care


standard of 50%. The management team informed usthat a business case had been submitted for eightplaces on a university course for further nursing staff toattend. However, due to financial restrictions, only two

places had been agreed. This meant that if there was acontinual turnover of nursing staff, there was a risk thatthe number of staff who had completed this coursewould fall significantly below the ICS standard.

Criticalcare

Critical care



Effective Requires improvement –––





Information about the serviceWarrington and Halton NHS Foundation Trust offerspregnant patients and their families’ antenatal, deliveryand postnatal care in the Warrington and Halton areas.

The maternity facilities are based at the Warrington site.The services provide antenatal and post-natal care(inpatient and outpatient), labour ward, ultrasoundscanning, two obstetric theatres and an AlongsideMidwifery Led Unit (AMU), which is in its early developmentstage.

The AMU offers intrapartum and immediate postpartumcare to low risk patients. It is distinct from, but co-locatedto, the main labour ward. The AMU consists of three ensuitebirthing rooms, furnished and equipped to promotenormal birth with no medical intervention. Two of therooms have a fixed birthing pool. The rooms are homelyand inviting, and offer families a ‘home from home’environment with facilities to promote normal birth andearly bonding between families and their babies. The AMUopened in April 2015.

A team of community midwives also provide antenatalcare, homebirth and postnatal care.

Between October 2015 and September 2016, 2,754 patientsdelivered their babies at the trust. This number haddecreased by 275 births since April 2013 to April 2014. Theservice is managed through the Trust’s Women’s andChildren’s Health division and is led by a Clinical Directorand a Head of Midwifery (HoM).

Gynaecology services are based at both the Warrington andHalton sites.

Gynaecological theatre procedures are undertaken in themain theatre suites at Halton or Warrington sites. Mostelective gynaecology surgery are undertaken at the Haltonsite.

The service does not undertake routine termination ofpregnancy, these are commissioned to an external localprovider specialising in termination. However, the trustdoes undertake termination of pregnancy for fetalanomalies and chromosomal problems. Sixteen TOP’s werecarried out between April 2015 and March 2016.

During our visit, we spoke with 14 patients, seven junior, sixconsultant doctors and 44 staff including senior and juniormidwives and nurses, health care support workers, wardclerks, domestic staff and housekeepers, sonographers andpharmacy staff across both sites.

We observed care and treatment to assess if patients hadpositive outcomes and looked at the care and treatmentrecords for 15 patients. We also reviewed 11 medicineprescription charts. We reviewed information provided bythe trust and gathered further information during and afterour visit. We compared their performance against nationaldata.


Maternity and gynaecology


Summary of findingsAt the last inspection in January 2015, we rated theservice as Required Improvement overall. Following thisinspection we have maintained the rating of requiresimprovement because:

• Staffing levels and skill mix remained a day-to-dayissue within the service. However, staffing levels hadimproved and the midwife/patient ratio hadincreased from 1:31 to 1:29 since the last inspection.

• Shift leaders on the labour ward and other wardswere often not supernumerary due to staffing levelsand workload.

• We observed and staff informed us that duringcertain times, especially at staff handover and shiftchanges, patients were not actively cared for byspecifically allocated staff in the induction bay area.This was due to the uncertainty among staff on thematernity ward (C23) and labour ward around whohad responsibility of care.

• Staff informed us that labour ward had ultimateresponsibility for caring for patients in the inductionbay area but due to reduced staffing levels andincreased workload, this was not always possible.However, the decision of care was only confirmedafter each handover, leaving a period of time whencare was minimised and unknown. This had anadverse effect on staffing levels on ward C23, asstaffing numbers did not take into account caring forpatients on induction bay.

• The emergency call bell system in the induction baywas not adequately heard on ward C23, therefore,raising concerns about patient safety, especially in anemergency.

• The maternity services did not have a current robustdata collection system, such as a maternitydashboard, to benchmark outcomes, review clinicaland quality performance and implement clinicalchanges to improve patient care. However, astandardised regional maternity dashboard wasunder review for implementation.

• The risk register did not provide assurance thataction plans were comprehensive, robust andadequate to improve patient safety, riskmanagement and quality of care, as many risks werestatic in their ratings.

• There was no dedicated Triage area or Triage team inthe maternity unit.

• Due to medical staffing levels and access and flowissues, there were often delays in patients beingadmitted, reviewed and /or discharged from hospital.

• Outlier patients posed access and flow issues on thegynaecology ward.

• There was no dedicated obstetric staff for the dailyelective caesarean section list. This led tocancellations and delays in treatment and care.

• The service did not record staff competencies formedical devices training.

• Patient records were not securely stored in lockedtrolleys.

• Breastfeeding initiation rates of less than 60% werebelow the national rate of 83%.

• Home birth rate was 0.1%, which was below thenational rate of 2.3%.

• We observed privacy and dignity concerns in boththe obstetric theatre and gynaecology wards, whichdid not meet the individual patient’s needs.

• The Termination of Pregnancy service did not audittheir performance.

However:

• There had been some improvements since our lastinspection in January 2015: working relationshipsbetween medical staff and midwifery staff, overallculture was improving, WHO checklist and consentforms, laparoscopic hysterectomies were undertakenand mandatory training for nurse and midwiferycompliance rates had improved.

• The appointment of the new Head of Midwifery had apositive effect on staff and the future of the service.




• The Alongside Midwifery Led Unit (AMU) was in itsearly stages of development but there was a realfocus on normal labour and birth.

• The service had recently relaunched the MaternityServices Liaison Committee (MSLC) with a newlyappointed chair.

• Staffs were caring, kind and patient and werecommitted to providing good care to patients.

Are maternity and gynaecology servicessafe?


We rated safe as requires improvement because:

At the previous inspection in January 2015, we rated safe asrequires improvement mainly due to frequently low safestaffing levels, shift leader unable to be supernumerary,levels of mandatory attendance below trust target,unsecure storage of records, security system on postnatalward and regular safety checks for emergency equipmentnot completed. We have maintained this rating followingthis inspection because:

• Staffing levels and skill mix remained a day-to-day issuewithin the service, especially on the combined antenataland postnatal ward (C23) and gynaecology ward (C20).However, midwifery staffing levels had improved andthe midwife/patient ratio had increased from 1:31 to1:29 since the last inspection One to one care on labourward was not affected by reduced staffing levels, thiswas managed well my team leaders.

• We observed and staff informed us that shift leaders onthe labour ward and other wards were notsupernumerary on a daily basis due to staffing levelsand workload.

• We observed and staff informed us that during certaintimes, especially at staff handover and shift changes,patients in the induction bay area were not activelycared for by specifically allocated staff. This was due tothe uncertainty among staff on the maternity ward (C23)and labour ward around who had daily responsibility ofcare.

• Staff informed us that labour ward had ultimateresponsibility for caring for patients in the induction bayarea but due to reduced staffing levels and increasedworkload, this was not always possible. However, thedecision of care was only confirmed after eachhandover, leaving a period of time when care wasminimised and unknown. This also had an adverseeffect on staffing levels on ward C23, as staffing numbersdid not take into account caring for patients oninduction bay.




• The emergency call bell system in the induction bay wasnot adequately heard on ward C23, therefore, raisingconcerns about patient safety, especially in anemergency. This was highlighted to staff during theinspection. However, no immediate action was taken toaddress this at the time.

• There was no dedicated obstetric staff for the dailyelective caesarean section list. The on call medical teamcovered the elective operative work as well as coveringthe labour ward and gynaecology emergencies. Thisstretched the service especially as the middle tiermedical cover was below national numbers. Staffinformed us that this sometimes led to cancellationsand delays in treatment and did not assure us that thetrust were doing all that was reasonable to mitigate risk.

• There was no dedicated Triage area or Triage team inthe maternity unit. Antenatal day assessment unit(ANDU) saw some patients but did not have officialtriage status, while the majority of patients were seen onthe labour ward.

• The service did not record staff competencies formedical devices training. This was highlighted to seniorstaff during the inspection.

• There were some gaps in the daily checking ofequipment. The required safety checks for emergencyequipment were highlighted as a concern at the lastCQC inspection.

• Patient records were not securely stored in lockedtrolleys. This was also highlighted at the last CQCinspection.

• We observed identifiable patient information displayedon the IT system in a public corridor within a ward area.This was highlighted to staff during the inspection butcontinued to remain a concern throughout the week.

• Not all gynaecology clinic staff that cared for patientsunder 16 years old had completed appropriatesafeguarding training.

• Antenatal clinic did not have an emergency call bellsystem. This did not assure us that patient safety wasmaintained at all times or that the premises were safe touse for the purpose intended.

However:

• There were clear systems and processes in place for staffto report incidents.

• The maternity service had a good practice educationprogramme for midwifery and nursing staff.

• All areas were clean and tidy and infection controlpractices were followed.

• Medicines were safely stored and checked daily.

• Records were completed to a good standard andavailability of records was good for all clinical areas.

• Staff attended daily safety brief meetings and safetyhuddle meetings to discussed workload, staffing andlessons learnt.

• We observed good safeguarding practice within thematernity service. Compliance rates for nursing andmidwifery staff were above the trust target rate.

• We observed dedicated theatre staff in all theatres.

• All surgical WHO checklists were fully completed, online.

• Theatre and anaesthetic equipment were routinelychecked and recorded. This had improved since the lastCQC inspection.

• Community midwives had new customized home birthkits bags, which include baby resuscitation equipmentand other essential equipment for a home birth.

• Community midwives stored and transported oxygenand Entonox for homebirths according the trust andnational guidelines.

Incidents

• Between January 2016 and December 2016, there were724 incidents recorded within the Women’s HealthDivision. Of these, there were 157 gynaecologyincidents; all graded either as minor or negligible harm.

• Between January 2016 and December 2016, there wereno incidents classified as Never Events for maternity andgynaecology. Never Eventsare serious, largelypreventable patient safety incidents that should notoccur if the available preventative measures had beenimplemented.




• Between January 2016 and December 2016, inaccordance with the Serious Incident Framework 2015,the trust reported 11 serious incidents (SIs) in maternityand gynaecology.

• One serious incident in gynaecology was reported inApril 2016. We requested the Root Cause Analysis (RCA)for this. The trust informed us that the RCA wasunavailable as the investigation report was still in draft.It was due to be reviewed at a panel meeting later inMarch 2017.

• We observed a good reporting culture for incidents viathe trusts electronic system. Staff confirmed that thesystem for reporting incidents was easy to access andthey were clear about their responsibilities with regardto reporting incidents.

• Sharing of learning from incidents was via staffnewsletters, meeting minutes, staff safety brief meetingsand scenarios used in mandatory training.

• Staff informed us that the service sent incident relatednewsletters to staff containing updates and outcomes.

• Monthly multidisciplinary incident reporting groupmeetings took place. We were provided with meetingminutes from November and December 2016 andJanuary 2017. Attendee numbers were between four tofive staff. Items on the agenda included incidentsreported, 72-hour rapid reviews and incident casestudies. Actions were highlighted and a named lead wasassigned to each action.

• Monthly Perinatal meetings took place to review specificpatient cases and discuss action plans from previousmeetings. This provided assurance that the service wasdiscussing all the aspects of recent stillbirths andneonatal deaths, possible causes and avoidable factorsin order to prevent deaths in the future. It also providedan opportunity to acknowledge good care andmanagement.

• Some staff we spoke to were unsure about the Duty ofCandour. The Duty of Candour is a regulatory duty thatrelates to openness and transparency and requiresproviders of health and social care services to notifypatients or other relevant persons of ‘certain notifiablesafety incidents’ and provide reasonable support to thatperson.

Safety thermometer

• Noticeboards outside clinical areas included ‘How areWe Doing’ information. This included safetythermometer information about pressure ulcers, falls,infections, complaints and incidents. The informationwas current however, there were no numbers includedto represent how many times specific incidentsoccurred. Incidents that occurred were highlighted byone red dot or green dots if no incidents occurred. Staff,we spoke to, were unclear how this information wasused to improve practice.

• A gynaecology safety thermometer dashboard, providedby the trust, contained detailed information aboutstaffing levels. It did not contain information such aspressure ulcers or falls to help improve, measure,monitor and analysing patient harms and 'harm free'care.


• There were no methicillin-resistant staphylococcusaureus (MRSA), methicillin-sensitive staphylococcusaureus (MSSA), clostridium difficile (C.diff) or Escherichiacoli (E.coli) reported by the service between April 2016and December 2016.

• From January 2016 to October 2016, there were 16recorded surgical site infections on the gynaecologyward (Ward C20). All infections were categorised as“wound” infections.

• All areas were visibly clean and well organised.Wall-mounted hand gel and sanitizers were readilyavailable on entry to clinical areas and staff weobserved used sanitizing hand gels and hand washingprocedures prior to providing patient care. All staff weobserved adhered to the ‘bare below the elbows’ policyin clinical areas.

• Personal protective equipment (PPE) was readilyavailable and included gloves and aprons. Postersdisplaying ‘hand washing techniques’ were displayedthroughout the department. Sharps bins were securelystored in the locked utility room.

• Cleaning schedules and checks for piped oxygen andsuction were in place and clearly displayed in the lockedutility room. Since January 2017, there had been eightomissions in signature checks. Equipment included “Iam clean” stickers.




• Washable privacy curtains did not display dates whenlast changed. Staff informed us that the curtains werechanged when needed including when a deep cleanwas necessary. Some curtains were changed during theinspection.

• Staff compliance rates for infection control training were88.7%. The trust target 85%.

• A total of 12 hand hygiene audits were carried out onthe gynaecology ward at Warrington, between 2015 and2016 with an average score of 99.6% overall.

• Gynaecology theatre scrub room had latex free glovesavailable and instructions on good “scrubbing”technique displayed.

• Hand hygiene audits between April 2016 and March2017, showed midwives had a compliance rate of 99%to 100%.

• The trust provided us with a labour ward cleaning auditfrom October 2016. The outcome score was 96%. Asimilar audit also took place in January 2017 on labourward, scoring 91%.

• The trust also provided us with one health & safety auditfor antenatal clinic (ANC) from January 2017. Theoutcome scored 100%.


• We observed and staff informed us that during certaintimes, especially at staff handover and shift changes,patients in the induction bay area were not activelycared for by specifically allocated staff. This was due tothe uncertainty among staff on the maternity ward (C23)and labour ward around who had daily responsibility ofcare.

• Staff informed us that labour ward had ultimateresponsibility for caring for patients in the induction bayarea but due to reduced staffing levels and increasedworkload, this was not always possible. However, thedecision of care was only confirmed after eachhandover, leaving a period of time when care wasminimised and unknown. This also had an adverseeffect on staffing levels on ward C23, as staffing numbersdid not take into account caring for patients oninduction bay.

• During our inspection, we observed that the emergencycall bell system in the induction bay only rang out on

the labour ward. It was not directly connected to theward C23. Staff on the ward C23 said, “They could justabout hear bell to attend to a patient”. During our visit,we tested the volume of the call bell on ward C23:neither CQC staff, a paediatric doctor who was workingat the far end of the ward area or ward midwives couldhear the bell. This was highlighted to staff at the time.This did not assure us that patient safety wasmaintained at all times or that the premises were safe touse for the purpose intended.

• However, the trust provided evidence, since theinspection, which suggested they had recognised thatthe environment was not optimum in the induction oflabour area and that it needed development.

• The service did not record staff competencies formedical devices training. During the inspection, wespent time on a ward with various levels ofmanagement staff to local a training competency tool orspreadsheet but staff informed us, that such a tool didnot exist, as this information was not collected. This didnot assure us that staff were competent and trained touse all equipment in a safe manner. This washighlighted to senior staff during the inspection.

• However, the trust submitted evidence, since theinspection, to demonstrate work that had commencedto improve the recording and monitoring of medicaldevices and staff competencies. This needed to beembedded into practice, assessed and monitored toevaluate the impact.

• Antenatal clinic did not have an emergency call bellsystem. Staff said they had highlighted this to seniormanagement on previous occasions as a concern butno action had been taken. This did not assure us thatpatient safety was maintained at all times or that thepremises were safe to use for the purpose intended.

• There was no dedicated High Dependency (HDU) roomon the labour ward, even though staff did call one oftheir rooms a “HDU” room. Senior staff confirmed that itwas used for higher levels of monitoring for patientswith conditions such as raised blood pressure(pre-eclampsia). We were informed that labour wardstaff were supported by the Medical Emergency Team(MET). Most midwives on the labour ward were notpreviously nurse trained or had specific HDU training.




• There were no established transitional care facilitiesavailable for babies on the maternity wards, whichmeant babies who required treatment such asphototherapy, or intravenous antibiotics weretransferred to the neonatal unit. This was not in line withbest practice as it meant the mother and babies wereseparated.

• Outpatient’s gynaecology clinic had a separateddedicated seating area. One waiting area includedpatients for colposcopy & hysteroscopy appointmentsand early pregnancy assessment unit (EPAU)appointments. However, maternity staff informed usthat sometimes if the antenatal clinic waiting area wasbusy, maternity patients could sit near to gynaecologypatients in one of the waiting areas. Staff told us thatthis was inappropriate and insensitive to patient’sneeds.

• At Warrington, on the gynaecology ward, the trustselectronic board system showing the location ofpatients was located on the corridor. We were told theboard should not show patient names, however; due totechnical problems, patient names were visible at time.

• At Halton hospital, on the gynaecology day-case ward,the electronic board was in a clinical room, however;there was a ‘wipe-clean’ board on view in the ward withpatient’s details on public view.

• Signage to the gynaecology department was not clear.We assisted a patient, who was unfamiliar with thename of the ‘Women’s Health’ area, to locate thedepartment she was looking for.

• The gynaecology ward at Warrington (C20) had 14inpatient beds and a separate dedicated bay for clinicpatients, however; this was used as an escalation baywhen bed shortages in the hospital. The ward hasprovision for emergency attenders who required amedical review.

• The Early Pregnancy Assessment Unit (EPAU) andGynaecological Rapid Access clinics were situated at theend of the area in a separate space. The ward alsoconsisted of outpatient procedure rooms for colposcopyand hysteroscopy and scan facilities.

• The main gynaecology outpatient clinic was a dedicatedoutpatient area with a dedicated scanning room fromJanuary 2017.

• The labour ward had five birthing rooms with “jack andJill” style bathrooms (shared bathroom with two doors).

• The Alongside Midwifery led Unit (AMU), which originallywas part of the labour ward, consisted of three deliveryrooms. Two birthing pools were available on the AMU.Equipment for the evacuation of a patient in anemergency was provided.

• There was a large ensuite bereavement room forfamilies to stay after the loss of their baby, situatedprivately beside the labour ward.

• The labour ward had a resource training room for stafftraining.

• Staff we spoke to, in all areas, told us there wasappropriate and adequate equipment available forconsultations and treatments includingcardiotogography (CTG) monitors for monitoring baby’sheartbeat.

• However, we observed that there was a lack ofequipment for (overweight and obesity) patients. Forexample, there was only one CTG monitor that cateredfor overweight patients. This was shared within theentire maternity unit. Staff said could be a delay inmonitoring if the monitor was in use in another area.Staff informed us that they had sent patients to theultrasound scan department in the past, if there was apotential cause for concern around the safety andwellbeing of the baby.

• However, the trust provided evidence, since theinspection, which indicated an increase in specialequipment available.

• Maintenance arrangements were in place to ensure thatspecialist equipment were serviced and maintained asneeded.

• Emergency resuscitation equipment was available inthe gynaecology ward and shared with the outpatientareas, which included antenatal clinic, situated across ashort corridor. The contents of the trolley were securedwith a security tag. There were daily checks carried outfor items not tagged. There was a full monthly check ofthe trolley unless items used in-between to treat apatient. Since January 2017, there had been nineomissions in daily checks.




• There were two obstetric theatres, one used for dailyelective surgery and the other was set up for emergencywork.

• Most resuscitation equipment on the maternity wards,including labour ward and obstetric theatres werechecked daily. However, we did see some gaps in thechecking of neonatal resuscitation equipment inJanuary and February 2017, in the antenatal dayassessment unit (ANDU).

• All treatment items such as, needles, dressings andintra-venous fluids were all stored securely in lockedrooms or store cupboards.

• Fridge temperatures were checked daily, all recordingswere within the normal temperature range.

• At Warrington, there was a separate gynaecology theatreavailable for emergency procedures, within the trustmain theatre suite.

• Recovery area in the gynaecology and obstetricstheatres were in a designated space and care wasprovided by trained dedicated theatre staff.

• Security systems in and out of the maternity wards weresecure. Staff said they were vigilant to visitors enteringand leaving the ward and CCTV was available in thecorridor leading to the wards. This was an improvementfrom the previous CQC inspection.

Medicines

• There were processes in place for management andstorage of medicines in the gynaecology and maternitywards. Pharmacy staff visited at designated times tomonitor the stock levels.

• Medicines were stored appropriately in lockedcupboards including controlled drugs. There were twicedaily checks of controlled mediation by staff.

• Patient records for medicine administration werecompleted appropriately.

• Operating department practitioner (ODP)staff, intheatre, informed us that medicines in the gynaecologytheatre were checked every morning by twoanaesthetics.

• Anaesthetic drugs were drawn up in syringes after theteam brief and before each individual patient arrived inthe anaesthetic room, according to national guidelines.

• In gynaecology theatre, drug fridge temperatures werechecked every evening and a log was maintained.Medicines cupboard was checked every morninghowever, there was no log to record the contents of thecupboard or record the daily check.

• The service did not undertake routine termination ofpregnancy, these were commissioned to an externallocal provider specialising in termination. However, thetrust did undertake termination of pregnancy for fetalanomalies and chromosomal problems, in line withRCOG guidelines. The termination of pregnancy (TOP)service had a system in place to ensure that two doctorscompleted a HSA1 form.

• There were no gynaecology specific patient groupdirections (PGDs) for nursing staff. PGDs allowhealthcare professionals to supply and administerspecifiedmedicinesto pre-defined groups of patients,without a prescription (NICE 2013).

Records

• Patient records consisted of a combination of paperrecords and electronic records.

• Patients’ records we reviewed were accurate, legibleand up to date.

• Records of patients attending the Early PregnancyAssessment Unit (EPAU) were stored on the trustselectronic system.

• Compliance of mandatory training for informationgovernance was 92.8%. (Trust target 85%).

• There were only four occasions when patient’s recordswere not available for clinics, in gynaecologyoutpatients department between January 2016 andDecember 2016.

• We reviewed four sets of patient record that had undergone a termination of pregnancy (TOP) at various weeksof pregnancy for different baby abnormalities. Specialistconsultants had reviewed all patients in a timelymanner. Management plans and postnataldocumentation was evident in all notes. Checklists wereall completed, which included information aboutblessings, cremation and burial and information for GPand community midwives. Bereavement support andinvolvement was documented in two of the sets ofnotes.




• Risk assessments for specific risks relating to the health,safety and welfare of patients such as venousthromboembolism(VTE) were available in their recordsand were up to date.

• The Child Health Record “Red book” was issued at birthand staff told patients about the purpose of the bookand how to maintain the record.

• Midwives conducting a patient’s antenatal bookingappointment completed the patient’s handheld notesduring the appointment. The handheld notes were thenphotocopied and the original given to the patient tokeep throughout her entire pregnancy. The midwifethen transferred the information from the photocopiednotes onto the IT booking system. Midwives said thiswas time consuming.

• On the combined antenatal and postnatal ward (C23),patient records were stored in an unlocked filing cabinetoutside each bay area. The medical and nursing notesfor each patient in that bay were accessible in thesecabinets at all times. These records containedconfidential information and were not stored securely.This did not meet with relevant guidance on the storageof confidential records and data protection. This wasalso a concern raised at the last CQC inspection.

Safeguarding

• Safeguarding (children) level three training compliancefor midwives was 88% and 91% for Health CareAssistants (HCA’s). This was above the trust target of85%.

• Between February 2016 and January 2017, safeguarding(children) Level 3 training was completed by 69% ofgynaecology nurses. Medical staff compliance rate was85%.

• Safeguarding (Children) Level 3 training was reviewedand updated annually by the service. Level 3 trainingwas produced in line with the intercollegiate document2014 and was guided by new legislation and guidance.

• In the last four years, the safeguarding training topicsfocused on female genital mutilation (FGM), child sexualexploitation (CSE), domestic abuse, mental health andsubstance misuse.

• A Level 3 Safeguarding Children Training programmehad been developed for 2017, which included childdeath process, substance misuse in young people, earlyhelp services and learning from serious case reviews.

• A 2018 safeguarding programme was under review andthe proposed topics included FGM, CSE, domestic abuseand unaccompanied asylum seekers.

• For the same period, safeguarding (children) Level 2training was completed by 53% of gynaecology nursesin the ward (C20) area. Compliance for gynaecologynurses in the clinic areas was 64%. Medical staffcompliance rate was 71%. The trust set a target of 85%for completion of safeguarding training.

• Between February 2016 and January 2017, safeguarding(adults) training was completed by 47% of gynaecologynurses in the ward (C20) area. Compliance forgynaecology nurses in the clinic areas was 57%. Medicalstaff compliance rate was 71%. This was below the trustset a target of 85%.

• However, information provided by the trust since theinspection, indicated an improvement in all areas ofsafeguarding training.

• The trust employed a safeguarding lead nurse matron.The women and children’s division also employed a parttime interim safeguarding lead midwife, who workedclosely with the lead nurse and led paediatricconsultant for safeguarding. There were also“champion” midwives for safeguarding in eachmaternity clinical area.

• The safeguarding lead midwife informed us that therewas a draft “Safeguarding Supervision” guideline underreview at the time of our inspection. One to Onesafeguarding supervision support for staff was also indevelopment stages.

• There were a team of seven safeguarding supervisorswho meet every four to six weeks to discuss anysafeguarding issues and concerns and we wereinformed that they were about to start monthly drop insessions for staff to discuss cases and concerns.

• Staff, we spoke with, were aware of their roles andresponsibilities in safeguarding and knew how to raisematters of concern appropriately.




• We reviewed records and attended a meeting regardinga patient with learning needs. All necessary steps weretaken to ensure patient mental capacity was assessedand that the patient understood her rights. There was agood trigger plan completed in the records and staff hadadhered to these.

• We observed no system in place in the gynaecologyhandheld records that alerted staff if a patient wasvulnerable or had a previous safeguarding concern.However, information provided by the trust since theinspection, stated that there was a flagging alertarrangement on their computer records system thatidentified vulnerable patients or those withsafeguarding concerns.

• Gynaecology staff told us that patients under 16 yearsold were seen in the gynaecology outpatientdepartment by paediatricians. This area was led byhealth-care assistants who chaperoned doctors duringconsultations. Health-care assistants in gynaecologyclinic had received safeguarding training level two butnot all staff had completed level three training. FromSeptember 2015 to March 2017, 313 under 16 year’s oldpatients attended appointments.

• Patients less than 16 years were seen in the EPAU. Staffwere trained to safeguarding level three. Any patientunder 16 years old requiring inpatient gynaecology carewas nursed on the paediatric ward with the support ofthe gynaecology team.

• Any patient between 16 years and 18 years generated anemail alert to all staff. At the time of inspection, a17-year-old patient had been admitted to Haltonhospital. The patient was nursed in a cubicle and theparent was resident.

Mandatory training

• The trust set a target of 85% for completion of allmandatory training.

• The maternity service employed a practicedevelopment midwife to oversee the staff mandatorytraining programme and preceptorship package for newstaff.

• The mandatory training programme included threeannual face-to-face mandatory training days ande-learning packages.

• Day one of mandatory training included obstetricemergencies, skills and drills, sepsis and thedeteriorating patient, antenatal screening, babyresuscitation, mental health and baby heart monitoring.

• Up to the end of February 2017, day one trainingcompliance for midwives were 94%, 87% for medicalstaff, 78% for anaesthetises and 78% for health careAssistants (HCA). This was an overall compliant rate of90%, which was above the trust target.

• Day two training consisted of bereavement, stopsmoking, promoting normal birth, reducing the risk ofstillbirth, adult resuscitation, medicines management,suturing and diabetes update.

• Up to the end of February 2017, adult resuscitationtraining compliance for midwives was 95%, 89% formedical staff, 86% for anaesthetises and 72% for HCA’s.This was an overall compliant rate of 92%, which wasabove the trust target.

• Day three training consisted of safeguarding level three,infection control, infant feeding, blood transfusion,manual handling and fire lecture.

• Up to the end of February 2017, day three trainingcompliance for midwives was 88% and 91% for HCA’s.The practice education midwife did not record the ratesfor the medical staff. However, a senior medical staffmember told us that they had not received any trainingin Female Genital Mutilation (FGM) and had completedsome safeguarding e-learning but did not know whatlevel training.

• From January 2016 to December 2016, breastfeedingtraining compliance rates was 84% for midwives, 75%for HCAs and 67% for neonatal staff.

• Staff informed us that there were plans in 2017 for allnew maternity staff to undertake the Acute IllnessManagement (AIM) course. AIM is a multi-professionalcourse to teach clinical staff a structured and prioritisedapproach in the assessment and management of theacutely ill patient. The aim was for midwives tocommence this training in April 2017 and for a third of allmidwives to have completed this training by the end of2017.

• Corporate induction training was completed by 100% ofgynaecology nurses. Women and Children’s Healthdivision medical staff compliance rate was 94%.




• Completion rates for dementia awareness training werebetween 64% and 67% for gynaecology nurses. Only18% of medical staff for the Women’s and Children’sHealth division had completed this training.

• Between February 2014 and January 2017, equality anddiversity training was completed by between 85% and95% of gynaecology nurses. The medical staffcompliance rate was 59%.

• Between February 2016 and January 2017, fire safetytraining was completed by 78% of gynaecology nurses.Information governance training was completed bybetween 67% and 85% of gynaecology nurses. Themedical staff compliance rate was 53%. Resuscitationtraining was completed by 59% of gynaecology nursesin the ward (C20) area. Compliance for gynaecologynurses in the clinic areas was 86%.

• Information provided by the trust, showed us that localinduction training was completed by less than onepercent of gynaecology nurses in the ward (C20) area.Compliance for gynaecology nurses in the outpatientclinic areas was 31%. The medical staff compliance ratewas 37%.

• Varied levels of some mandatory training complianceacross the different professions were also a concernraised at the last CQC inspection.

• There was some discrepancy between the clinicaldirector and the clinical medical staff we spoke too,about the availability of training for medical staff andease of attendance. Some staff told us it was difficult toattend training due to medical staffing levels andincreased capacity within the unit.

• Up to the end of January 2017, local induction wascompleted by 100% of agency staff for obstetrics andgynaecology. However, this included only one memberof staff. For the same period, local induction wascompleted by 100% of locum medical staff. However,again, this only included one member of staff.

• Medical staff informed us that the trust provided goodin-house weekly training sessions that they attended.They also informed us that a lot of their mandatorytraining was completed on line and mainly completed athome in their own time.


• There was no dedicated obstetric staff allocated to thedaily elective caesarean section list. The on call medicalteam covered the elective operative work as well ascovering the labour ward and gynaecologyemergencies. This stretched the service especially as themiddle tier medical cover was below national numbers.However, there was a national shortage of middle gradedoctors.

• The trust provided evidence, since the inspection,stating that middle grade doctor cover was now on therisk register, however, one long-term middle gradelocum cover had been appointed.

• Medical staff informed us that this caused delaysresulting in some patient’s procedures being cancelledor commencing elective work at 5pm when the on callstaff were starting their shifts. Staff informed us thishappened about once a month, which staff saidcompromised patient safety. This did not assure us thatthe trust were doing all that was reasonable to mitigaterisk for patient safety.

• Senior medical staff did assure us that consultant postswere covered by locum staff and a consultant wasalways available in Antenatal clinic (ANC) if required.

• There was no dedicated Triage area or Triage team inthe maternity unit. Antenatal day assessment unit(ANDU) saw some antenatal patients but did not haveofficial triage status, while the majority of patients wereseen on the labour ward. We were given an examplefrom medical staff about a patient who had phoned at2pm concerned about reduced baby movement’s .Aftercommunication between the doctor and labour wardteam, the patient was told that she could be seen at8:30pm that evening. This was not escalated at the timeto consultant level as we were told that the seniorlabour ward midwife “could not be by-passed and herword was law”. This did not assure us that the “SavingBabies Lives” pathway was being followed correctly andthat patient safety was a priority. It also suggested thatthere was still a culture, which was not very flexible inrecognising patient safety and needs.

• However, the trust provided evidence, since theinspection, which suggested they had madeimprovements to develop the ANDU and Triage serviceoffered to women. This needed to be embedded intopractice.




• Care pathways were in place that included details ofcare and treatment. Examples were guidance for themanagement of urinary incontinence, management ofacute pelvic inflammatory disease and guideline foroutpatient hysteroscopy clinic.

• A National Early Warning Score System (NEWS) was inplace to identify patients whose condition wasdeteriorating. We were told, by critical care staff that thegynaecology ward were the best department in thehospital for escalating a concern about a deterioratingpatient. However, the trust informed us that they did notundertake any audits or reviews of their NEWS systemand outcomes.

• A Neonatal Early Warning Score (NEWS) chart was inplace for newborn babies. These were used at shifthandover to identify any babies requiring increasedobservation or intervention.

• ‘Safety huddles’ occurred daily at 9.30am, 6pm and 8pmin the maternity unit. Senior staff from the gynaecologyward were hoping to join the 6pm huddles if capacityallowed.

• In the event of an emergency, at Halton, an escalationprocess was in place for a deteriorating patient. AResident Medical Officer (RMO) was present forreviewing patients. Over the previous 12 months, twogynaecology patients were transferred to Warrington asan emergency.

• A guideline for “the risk assessment in the antenatalperiod” was available to staff. This guideline outlinedthe process of clinical risk assessment during theantenatal period to ensure patients were offered achoice of place of birth, depending on all risk factors.

• The was a standard operating procedure (SOP) for allpatients who were 18 weeks pregnant and above, whoattend the Antenatal Day Unit (ANDU) with pregnancyrelated queries and complications and who requireassessment, treatment or admission. The SOPsupported staff to decide which admissions weresuitable for review in ANDU in order to provide aneffective, efficient and safe midwifery-led assessmentservice.

• There was a guideline for the care of patients attendingthe emergency department or admitted to othernon-maternity wards during pregnancy and the

postnatal period to help to ensure that they receive themost appropriate care. The guideline highlighted thatthe on call consultant obstetrician should be told aboutall sick pregnant patient in hospital whether they have amedical or an obstetric problem, which was aConfidential Enquiries into Maternal Deaths (CEMACH)recommendation.

• There were dedicated nursing and operatingdepartment practitioners (OPD) staff in both thematernity and gynaecology theatres.

• We observed operatives procedures in both theatresduring our inspection. All surgical WHO checklists werecompleted in full online. Pathways for dealing withanaesthetic emergencies were displayed on the theatrewalls.

• In the gynaecology theatre, ODP staff checked theanaesthetist equipment every morning.

• Weekly “Patient Care Indicators” reports werecompleted and displayed on ward C23 (combinedantenatal and postnatal ward). This includedsummaries and rates of infection, staffing levels,complaints, delays in induction of labour, early warningscores, documentation, Situation, Background,Assessment, Recommendation (SBAR) and Venousthromboembolism (VTE) assessments, third degreetears and postpartum haemorrhage (PPH).

• Between May and October 2016, completion of AMUantenatal risk assessment for place of birth was 35%and the intrapartum (labour) risk assessment for placeof birth 50%. These low rates had been included in theAMU action plan and were being reviewed on a monthlybasis by the consultant midwife. Since the inspection,the trust provided evidence indicating improvements inthe completion of risk assessments.

• If low risk patients on AMU needed transferring to labourward, AMU staff informed us that there were pathways inplace to assist in the transfer process.

• Data provided by the trust informed us that there hadbeen two transfers of patients from gynaecology serviceat Halton to the gynaecology service at Warrington dueto complications. Both were reported as incidents andreported as being appropriately managed.

• There was an escalation policy and standard operatingprocedure (SOP) for management of the deteriorating




patient at the Halton site, which was located on thetrust intranet HUB. There was also a SOP and policy fortransferring patients from the Halton site to theWarrington site. When assessing patients, staff used ascoring system called NEWS (National Early WarningScore).

• Midwives informed us that risk assessments werecompleted for the appropriate monitoring of baby’sheartbeat using a cardiotocography (CTG) machine forlow risk patients. This was in line with NICE and RCOGguidance. This was an improvement since the last CQCinspection, where most low risk patients were offeredcontinuous CTG monitoring.

• Guidelines relating to sepsis in labour had recently beenreviewed and updated due to the unnecessary increaseuse of antibiotics for patients and unexpected increasein admissions to the neonatal unit for babies. There wasnow a red laminated NICE red flag guideline to assiststaff in the appropriate treatment required forprolonged rupture of membranes. Previously, patientshas been incorrectly categorised and had receivedantibiotics unnecessarily.

• We observed reception and ward staff confirming theidentity of patients on arrival to the departments.

Midwifery staffing

• Staffing levels and skill mix remained a day-to-day issuewithin the service, especially on the combined antenataland postnatal ward (C23) and gynaecology ward (C20).However, midwifery staffing levels had improved andthe midwife/patient ratio had increased from 1:31 to1:29 since the last inspection. One to one care on labourward was not affected by reduced staffing levels, thiswas managed well my team leaders.

• The Maternity Service used the Birthrate Plus workforceplanning tool for calculating midwifery staffing levels,based on specific activity, case mix, demographics andskill mix.

• A combination of methods such as the Safer NursingCare Tool (SNCT): a systematic evidence basedapproach and exercising professional judgement) wasused by the trust to determine gynaecology staffinglevels.

• General staffing levels were last reviewed and revised inApril 2016, with the roll out of E-rostering (onlinemanagement of shift patterns), the implementation oflonger 12-hour working shifts and allocation of staffingto the Alongside Midwifery Led Unit (AMU).

• Noticeboards were displayed to show the number ofmidwifery and nursing staff expected and actual toshow a full compliment.

• We reviewed staff working rotas for Ward C20(gynaecology) for august 2016, Total planned nursehours required for day shifts was 1260 hours. The totalactual staff hours provided was 510 hours. Plannedstaffing hours for care staff was 835 hours. Actual hoursprovided was 682 hours. Nursing planned and actualhours for night duty were similar; however, there was noplanned or actual hours recorded for care staff on nightduty.

• We observed a reduction in midwifery planned andactual staffing hours for day shifts on ward C23 in August2016. However, labour ward and AMU were adequatelystaffed for day and night duty shifts.

• There was also a reduction of planned and actualstaffing hours for all staff on C20, C23, labour ward, AMUin November and December 2016. Reasons given for theshortage of staff included vacancies, maternity leavecover, sickness, escalation in times of bed pressures andstaff being moved around from different areas of theunit to cover acute activity. However, staff informed usthat managers worked clinically and communitymidwives were redeployed to cover peaks in activity, asper staffing escalation policy.

• In December 2016, the trust reported that the antenataland postnatal ward had 100% staffing levels formidwifery staff.

• From off duty records we observed, the Gynaecologyward at the Warrington site had a 34% shortfall innursing staffing levels in December 2016. Staff informedus that the trust had recruited staff from overseas with arequirement for these staff to work initially for the bankprior to permanent positions. Two of the band fivenurses had been recruited through this process. Staffalso informed us that staff worked additional hours,support was given from ward managers and the use ofbank staff was used to increase staffing hours to theplanned staffing requirement.




• A “People Measurement” tool used by the trust showedthat in January 2017, women and children’s divisionrecorded a sickness rate of 4.89%. This was above thetrust target of less than 4.2%.

• Divisional staff turnover was 6.72% (below trust target of10%) however; nursing and midwifery staff had aturnover rate of 8.83%. Return to work interviewcompliance was 58.76% (below the trust target of morethan 85%) and use of agency staff was 1.8% (below trusttarget of less than 3%). However, the trust providedevidence since the inspection to indicate an increase inthe return to work compliance rate.

• Nursing and midwifery vacancy rate was 5% (trust targetwas below 5% for the same period). Combined data forthe division was classified as “significant concerns” onthe measuring tool.

• At the time of inspection, both the band seven shiftco-ordinator and the matron in the gynaecology wardwere attending to patient needs.

• Bank staff were needed when the gynaecologyescalation bay was open. This bay was normally closedat weekends, however; during recent bed pressures, thebay has been open every day.

• Staff informed us that at times inexperienced staff couldbe left in charge of ward areas. Examples were givenwhere a junior midwife with two care assistants caredfor a full ward with babies requiring increasedobservation.

• Band 5 staff told us that they could be working a nightshift with another Band 6 midwife but the band 6midwife could also be asked to care of the patients inthe induction bay so the junior staff often felt vulnerableand unsupported.

• Changes to staffing were made at short notice to covershortages with no evidence of advanced planning orassessment of skill mix.

• We observed a nurse and midwifery handover thatincluded passing on all relevant current patientinformation as well as a safety brief. Nursing andmidwifery staff worked 12-hour shifts, thereforehandovers were completed twice daily formally.

Medical staffing

• There were eight combined Obstetrics/Gynaecologyconsultants and two specific gynaecology consultantswith middle grade doctors, juniors and trainees tosupport.

• Medical staff told us there were always gaps in the rotafor middle grade doctors. This was due to sickness, parttime staff and maternity leave. In house staff orlong-term locums that were known to the trust wereused to cover the gaps. Medical staff said this causedsome delays for patients due to doctors covering morethan one area. This gap in middle grade doctors wasalso an issue raised at the last CQC inspection. Seniormedical staff informed us that the problem was due tothe allocation of staff from the medical school deaneryand was a national concern.

• As of December 2016, the trust reported a medicalvacancy rate of 4% in Maternity and Gynaecology.Medical turnover rate was 25.9% and medical sicknessrate was 1.3%. However, information provided by thetrust since the inspection, stated that the medicalturnover rate had indicated a decline.

• Between April 2015 and March 2015, the trust reported amedical bank and locum usage rate of 5.2% in thewomen and children’s services.

• In October 2016, the proportion of consultant staffreported to be working at the trust was about the sameas the England average (38% to 39%) and theproportion of junior (foundation year 1-2) staff wasabout the same (4% to 6%). However, staff informed usthat there were a reduced number of junior and middlegrade doctors at present.

• Medical staff felt supported by the consultants andenjoyed working in the unit.

• Obstetric cover was provided 24 hours a day by staffemployed on dedicated on-call rotas. On-call specialisttrainees in obstetrics and gynaecology were resident onduty using a shift rota system 8:30am to 1pm, 1pm to5pm, 5pm to 8:30pm and night shift 8:30pm to 8:30am.

• A consultant obstetrician was available to provide24-hour cover through a combination of resident onduty and on call rota allocation. This had beenconsistent for at least the last 18 months and within thenational safer childbirth guidelines 2007.




• Consultant cover for obstetrics and gynaecology wasprovided in sessions; 8:00am to 1pm, 1pm to 5pm, 5pmto 7pm resident on call weekdays, 9:00am to 12.00 (3hours) Resident on Call Saturday, Sunday, BankHolidays, and then 7pm to 8:00am on call cover fromhome .

• At Halton, there was a senior house officer (SHO) on-siteuntil 5pm each weekday. A Resident Medical Officer(RMO) was present 24 hours a day.

• At Warrington, doctors were available throughout theday and on-call cover at night as well as access to nightnurse practitioners and associate practitioners.However, medical cover for gynaecology after 5:30pmwas by the labour ward on call team.

• There was a dedicated anaesthetist allocated to provide24-hour cover on the labour ward. This meant they wereavailable in the case of an emergency.

• On trainee medical staff member informed us that therewere usually three junior medical staff on call at any onetime during the day. However on the day we spoke tothe staff member, we were informed that due tosickness, there was only one medical staff member oncall who was covering the gynaecology ward, antenatalday assessment unit (ANDU) and the combinedantenatal and postnatal ward.

• Staff informed us that it was sometimes difficult to getpatients reviewed on the wards by senior registrars orconsultants, as they were usually busy on labour ward.


• The women and children’s health division had abusiness continuity plan in place. The frameworkincluded a range of actions and considerations requiredto ensure a continuation of services, such as failure ofspecialist equipment, or a surge in sickness due to aninfection outbreak.

• The trust informed us that within the CBU, there werethree staff that were part of the trust major incidentmanager on-call rota. All three completed on callinduction training, were invited to on-call review andupdate sessions and two staff had competed theadditional major incident training. All on-call managerswere required to keep up to date with the on call policyas part of their on call role. However, when we spoke to

staff on the maternity wards, they were not aware whothese three dedicated staff were and were not aware oftheir own role, within the wider hospital, should a majorincident occur. They had not taken part in any drills.

• Staff we spoke to provided recent examples respondingto incidents. These included evacuation following aflood from the toilets near the EPAU waiting area and afire evacuation from the gynaecology ward when apatient was smoking in the bathroom.

Are maternity and gynaecology serviceseffective?


We rated effective as requires improvement because:

At the previous inspection in January 2015, we ratedeffective as requires improvement mainly due to littleevidence shown that actions had been taken to improveaudits that showed poor performance, no goals set forsafety standards, midwifery staff were not up to date withannual appraisal and lack of multidisciplinary working. Wehave maintained this rating following this inspectionbecause:

• The maternity services did not have a current robustdata collection system, such as a maternity dashboard,to benchmark outcomes, review clinical and qualityperformance and implement clinical changes toimprove patient care.

• The Early Pregnancy Assessment Unit (EPAU) openedweekdays, there was no weekend clinic. Therefore,patients would need to access the scanning services viaaccident and emergency in the evenings or weekends.

• Breast feeding rates provided by the trust showed that58% of patients were breastfeeding after delivery and57% were breastfeeding at discharge from hospital. The2010 Infant feeding Survey states that the breastfeedinginitiation rate at birth in England was 83%, therefore thetrust was below the national average.

• The homebirth rate was 0.1%. In 2013, 2.3% of patientsgave birth at home in England and Wales (Office ofNational Statistics).




• The maternity service did not have an establishedenhanced recovery pathway.

• There was no data available on the current recordingsystem relating to the incidents of third and fourthdegree perineal tears and postpartum haemorrhage(PPH) that occurred on the labour ward. Thishighlighted that the service were not reviewingelements of care that other trusts locally and nationallywere reviewing.

• In 2016, the Neonatal Audit was below the nationalNeonatal Audit programme (NNAP) standards for all ofthe five standards. Three standards were just below thestandard benchmark grade. The remaining twostandards were significantly below the benchmark setnationally. However, these two standards were notdirectly linked with the maternity unit.

• There was little assurance from minutes of meetings tosuggest that midwives or gynaecology nurserepresentation was evidence at senior or local meetings.

• Mental Capacity Act training for staff was below the trusttarget

• Gynaecology nursing and junior medical staff informedus that due to the outlier patients on the gynaecologywards, which included trauma, orthopaedics andgeneral medicine patients, they did not always feelcompetent to care for all these specialties.

• The TOP service had not performed any audits tobenchmark their service.

• There were still occasions when cardiotocography (CTG)monitoring of the baby’s heartbeat was performedwithout a clinical indication. This was also a concernlighted in the last CQC inspection.

However:

• Policies and procedures were up to date and compliedwith relevant national guidance. However, policies werenot easy to find and access on the trust intranet system.

• The service undertook regular audits and used theoutcome data to review resources, safety and areas ofimprovement. However, monitoring performance andimproving practice was limited due to the currentsystem to collect and correlate the information, lack of arobust dashboard and issues with the new electronicpatient system.

• Midwives and medical staff said that teamwork andcommunication between them had improved since thelast CQC inspection.

• The new Head of Midwifery (HOM), in conjunction withthe consultant midwife, were focused on developing“normality” during labour based on current evidencebased information. We observed an increased emphasison caring for low risk women and midwifery led carewithin the maternity services.

• The trust provided evidence since the inspection, toindicate some improvements and initiatives hadcommenced to develop “normality”.

• Staff were up to date with their professionaldevelopment annual appraisal reviews. This was animprovement from the previous inspection.

• Multi-disciplinary working between medical andmidwifery staff had improved since the last CQCinspection.

• A surveillance system of CTG monitoring in labour bymeans of “Fresh Eyes” was used where a secondmember of staff reviewed the baby’s recorded heart rateregularly.

• Bespoke community midwifery skills and drills trainingtook place to ensure skills were adequate for the homebirth setting.

• Many staff were trained in complimentary therapies andprovided specialist clinics to low risk patients and wellas providing therapies during labour.

• A mental health specialist clinic ran weekly by a leadmental health obstetric consultant, mental healthmidwife and a mental health specialist nurse.

• Gynaecology employed nurse specialist in colposcopyand hysteroscopy.

• The maternity service was research active andpromoted evidence based practice.

• Many forms of paint relief, including somecomplimentary therapies were available to patients.

• We observed procedure specific consent forms forelective and emergency caesarean sections andgynaecology services.




• The gynaecology service provided laparoscopichysterectomies to patients within the hospital. Thisservice had been introduced since the last CQCinspection.

• Patients, on the gynaecology ward, were assessed usingthe Malnutrition Universal Screening Tool (MUST) tool.

• Gynaecology patient identified as needing assistancewith feeding were identified and a ‘red tray’ system wasin place and fluid balance charts were completed forpatients who needed nutrition or hydration monitoringto ensure adequate intake.


• Care and treatment was evidence-based and providedin line with best practice guidance including theNational Institute for Health and Care Excellence (NICE).Standard operating procedures (SOP’s) were also inplace to support staff.

• However a women’s and children’s health “NICEguidance compliance report” from January 2017,showed that out of six NICE regulation standards, theservice was compliant in two standards, partiallycompliant in two standards and not compliant in twostandards. Three standards were on the risk register.These included antenatal and postnatal mental health,preterm labour and birth and non-invasive prenataltesting to determine baby’s blood group status. Actionplans were in progress for the standards that were notcompliant.

• The maternity service employed a research midwife whowas research active and promoted evidence basedpractice.

• The trust was taking part in the NHS England “SavingBabies Lives-Reducing Stillbirths Care Bundle”programme. This included the assessment of smokingand carbon monoxide monitoring, detection of baby’sgrowth below their expected rate, the use of thereduced baby movement leaflets and checklist andbaby monitoring.

• The trust had used customised individual growth chartsand closer monitoring of reduced baby growth throughincreased number of scans. This was in line with RCOGGreen top guideline 2013.

• The trust was one of 16 maternity units across England,Scotland and Wales to take part in the Obstetric AnalSphincter Injury (OASI) Care Bundle (RCOG) to addresssome of the underlying causes and problems. Theintervention package included a guide,multidisciplinary skills development module for healthcare professionals and campaign materials (such asleaflets and newsletters designed to raise awareness).

• The trust took part in local and national audits. Thewomen’s health audit programme contained 17maternity, obstetrics and gynaecology audits up toJanuary 2017. At the time of our inspection, all 17 auditswere completed. Action plans were completed for sevenof these, 10 action plans were in progress but werewithin the timescale for completion.

• A retrospective audit took place from 1 October 2015 to30 September 2016 to monitor compliance withnational standards for the national Sickle cell andThalassemia programme. The Key PerformanceIndicators(a measurable value that demonstrates howeffectively the service is achieving key objectives) metthe acceptable national standard and compliance rates.However, it did highlight data collection and analysisissues due to the introduction of the trusts newelectronic patient IT system.

• The World Health Organisation (WHO), five steps to safersurgery checklist was in place for surgical interventions.This tool ensures safety ofsurgeryby reducing deathsand complications and improving communicationamong theatre staff.

• A WHO checklist audit took place in July 2016. Theobservation of the use of the WHO checklist wasperformed prior to each procedure and the teams werecompliant with the checklist. The care pathwaydemonstrated good compliance with the process. Thenew format of recording the information online wasworking well since it was introduced in November 2015.Data showed 100% compliance in 1251 patients acrossthree sites. Maternity cases had shown a significantimprovement in data completion since the introductionof the new IT System. An action plan was implementedand completed.

• Staff informed us that the maternity service did not havean established enhanced recovery pathway (ERP). ERPconsists of best evidence based practices delivered by a




multidisciplinary team with the intention of helpingpatients to recover faster after surgery. It involves stafftraining, reorganisation and procedure specific careplans. However, we were informed that they wereworking towards a new guideline.

• Information provided by the trust since the inspectionsuggested that improvements had been made but yet tobe embedded into practice.

• A surveillance system of CTG monitoring in labour bymeans of “Fresh Eyes” was used where a secondmember of staff reviewed the baby’s recorded heart rateregularly.

• A “Fresh Eyes” assessment audit took place in October2016. Fifty-one patient’s notes were reviewed. Findingsshowed that 98% of women had fresh eye assessmentin labour. Results reflected improvement in fresh eyedocumentation from the previous audit andimprovement in the hourly assessment rate. Presence ofa student midwife was associated with higher numberof full assessments and documentation of “Fresh Eyes”.The presence of a doctor to review a cardiotocograph(CTG) was not associated with full assessments anddocumentation of “Fresh Eyes”. There was no differencebetween daytime and nighttime admissions. The actionplan stated distribution of findings to midwives anddoctors and to re-audit in 12 months’ time.

• A weekly meeting to discuss CTG monitoring was inprogress however; there was poor midwifery attendanceat the meeting we attended. This was also highlighted inthe last CQC inspection.

• The Alongside Midwifery led Unit (AMU) six-monthinterim report between May and October 2016 waspublished by the trust in December 2016. One hundredand seventy one patients were admitted to the unit(12% of total births in the unit). The service anticipatedthat 25-30% of women would access the unit per yearbased on patient demographics and benchmarkingagainst other AMUs in the region.

• Audits, from the maternity service, demonstrated thatdespite the active promotion of the AMU, andintroduction of a robust risk assessment to determineappropriate place of birth, patients were still beingadmitted to the labour ward unnecessarily. Audit resultsidentified that a significant number of patients whowere admitted to the labour ward have not had the

intrapartum risk assessment completed and as a resulthave been treated as “high risk” and cared for on theobstetric unit. Recommendations were made in order toensure all patients were appropriately risk assessed onadmission and admitted to the appropriate place ofbirth. A key finding showed that all births that occurredon the AMU were appropriate and the majority oftransfers from the low risk to high-risk intrapartumpathway were appropriate.

• However, information provided by the trust, since theinspection indicated that the completion of riskassessments had improved.

• The trust reported that they did not undertake anyaudits for patients receiving pain-relief withinrecommended timescale of 30 minutes of request (SaferChildbirth 2007).

• The gynaecology service provided laparoscopichysterectomies to patients within the hospital. Thisservice had been introduced since the last CQCinspection.

• Since the recent recruitment of the new Head ofMidwifery (HOW), in conjunction with the consultantmidwife, there was an increased focus on developing“normality” during labour based on current evidencebased information. It was recognised within that trustthat this aspect of the service required someimprovement. This was also highlighted in the lastinspection.

• A management and referral pathway and guideline wasin place when a baby abnormality was detected. Thisincluded a timeline for when patients should be seen bya consultant, written information for parents andhospital contact details. However, there was littleinformation for patients when discharged for hospital.The guideline was due for review since February 2016.

• Staff informed us that the TOP service had notperformed any audits to evaluate practice or benchmarkthe service. The last audit undertaken was October2014, which was “Management of Intrauterine deathand late TOP”. The recommendations concluded are-audit. However, there was no evidence this wasundertaken.

• We reviewed the guideline for the management of a lateintrauterine death between 18 and 24 weeks of




pregnancy and a stillbirth less than 24 weeks ofpregnancy. This included a list of investigationsrequired, administrative and emotional supportchecklist. The review date was November 2017.

• Gynaecology undertook a national audit to assess theoutcomes for patients undergoing urogynaecologysurgery at Warrington Hospital over a four-year period2012 to 2015. The service met the 100% NICE clinicalguideline urinary incontinence target.

• A six-month retrospective audit from 1 April 2016 to 30September 2016 took place to monitor complianceagainst UK National Screening Committee standards forHIV, hepatitis B and syphilis screening in the antenatalperiod. The trust exceeded the achievable performancethreshold of greater than 99.0% for all three standards.Performance demonstrated that failsafe systems forbooking bloods were effective.

• The screening midwives undertook a 12-monthretrospective audit for the timely assessment of womenwith Hepatitis B from 1 January 2016 to 31 December2016. The Trust met the acceptable performancethreshold of greater than 70.0%.

• A Hepatitis B vaccination given to infants of Hepatitis BPositive Mothers audit took place between January2016 to December 2016 to demonstrate that the trustwas monitoring compliance with regional and nationalguidelines. Eight patients and 10 babies took part. All 10babies were vaccinated within 24 hours of birth, usuallywithin 6 hours, which met national standards.

• A Maternity Quality Indicators audit took place in May2016 to assess clinical practice and documentation inorder to assess practices in line with maternity local andnational guidelines. The audit used five randomlyselected sets of health records. The outcome scored100% in three areas. Five areas showed improvementfrom the previous audit. Four areas showeddeterioration, three areas produced exactly the samepercentage of compliance as previous audit. None ofthe twelve areas audited scored less than the minimumexpected compliance of 75%. An action plan wasimplemented but the version we received was notcompleted.

• Local Supervising Authority (LSA) audit report took placein September 2016. The report stated that thesupervisors of midwives (SoM) were a strong,

well-established and experienced team. All six standardswere met with some recommendations including:“ensure the SoM caseload is more equally distributed,existing supervisor folders for individual midwivesshould move to paperless system, the current strategyfor supervision needs to be reviewed and adapted toreflect the changes to supervision”.

• Some medical staff informed us that regular auditmeetings were held within the trust but due to workloadand clinical commitments, it was not easy to attendthem, as the time was not “protected time”.

Pain relief

• A choice of pain relief was available to patients, whoinformed us that they had been able to discuss thechoices available and where possible their wishes wererespected.

• Complimentary therapies, such as hypnotherapy,aromatherapy and acupuncture were available to assistwith pain relief and aid psychological wellbeing duringpregnancy and labour.

• A 24-hour epidural service was available with the trust.

• Community midwives offered Entonox and poolfacilities to labouring patients at home. They did notoffered pethidine as a form of pain relief in thecommunity setting.

• Pain relief was offered to all patients on admission for aTermination of pregnancy (TOP).


• Breast feeding rates provided by the trust showed that58% of patients were breastfeeding after delivery and57% were breastfeeding at discharge from hospital. The2010 Infant feeding Survey states that the breastfeedinginitiation rate at birth in England was 83%, therefore thetrust was below the national average.

• Staff informed us that they had achieved full Level three‘Baby Friendly Initiative’ (BFI) status and were due forreassessment next week. Staff informed us that theaccreditation certificate was displayed in the antenatalclinic (ANC). However, we did not see any certificate orBFI accreditation success in any of the clinical areas. BFI




is a recognised United Nations International Children’sEmergency Fund UK initiative which consists of threestages of assessment, including parents feedback, withregard to support for breastfeeding.

• Staff informed us that patients, with babies on neonatalunit, tended to express their breast milk and store theiron the neonatal unit, not on the postnatal ward.

• There were water coolers and drinks machines availablein the outpatient waiting areas.

• Patients, on the gynaecology ward, were assessed usingthe Malnutrition Universal Screening Tool (MUST) tool.The tool is a five-stepscreening toolto identify adults,who are at risk ofmalnutrition. It includes guidelinesthat can be used to develop care plans.

• Gynaecology patient identified as needing assistancewith feeding were identified and a ‘red tray’ system wasin place. The “Red Tray” system is a simple way ofalerting health care staff to the fact that a personrequires help with eating.

• Fluid balance charts were completed for gynaecologypatients who needed nutrition or hydration monitoringto ensure adequate intake.

• There was no area on the gynaecology ward for staff totake breaks resulting in using the ward office. Weobserved small break room in the ANC that alsodoubled up as an office for some specialist midwives.This did not assure us that the wellbeing of the staff wasmaintained or that the specialist midwives hadadequate and appropriate space for private andsensitive patient conversations via the phone.

Patient outcomes

• The maternity services did not have a current robustdata collection system, such as a maternity dashboard,to benchmark outcomes, review clinical and qualityperformance and implement clinical changes. This didnot provide assurance that patient safety issues wereidentified in advance so that timely and appropriateaction could be taken to ensure a patient-centred, highquality, safe maternity care service.

• We were informed that the service recognised the lackof a dashboard to effectively collect and correlatepatient outcomes and were waiting on the developmentof a regional dashboard across the Cheshire andMerseyside area.

• The service undertook regular audits and used theoutcome data to review resources, safety and areas ofimprovement. However, monitoring performance andimproving practice was limited due to the currentsystem to collect and correlate the information, lack of arobust dashboard and issues with the new electronicpatient system.

• A dedicated member of staff generated local statistics,by hand, from the birth register book andcross-referenced data with information collected fromthe new electronic patient IT system. Therefore, therewas reliance for full completion of the register book byall staff. Failure to do so, could affect the outcomefindings, policy and processes relating to implementingpractice changes. Staff reported this was labourintensive, time consuming and not a very efficient oreffective way to review the overall performance of theservice.

• Emergency caesarean section rate was below thenational rate of 15%, eight out of the 12-month periodbetween January and December 2016. However, thehighest rate was 20.56% in October 2016 and 19.57% inNovember 2016.

• For the same period, the elective section rate was abovethe national rate of 15%, seven of the 12 months. Thehighest rate was 18.87% in March 2016. Senior medicalstaff informed us that caesarean section rates werecontinuously reviewed and the main theme and trendsfor the increased rates were due to differentmanagement styles and management decisions forsenior medical staff.

• From January 2016 to December 2016, the induction oflabour rate was 40%. National induction of labour ratesis 18% (Hospital Episode Statistics: NHS MaternityStatistics – England, 2013-14).

• In response to the rising rates of induction of labour, aretrospective audit was undertaken in February 2017 bythe consultant midwife to identify the clinical indicationfor induction, determine whether any trends wereevident in the reasons for induction, and whether any




practice issues were identified. Despite the higher thannationally recommended rate of induction observed,the audit did not identified any trends or areas ofconcern. However, recommendations were made whichincluded to continuously monitor the induction rates.

• Between January 2016 and December 2016, the forcepsrate was 8.03%. This was below the national averagewas 6.8% (Maternity statistics for England 2014).

• The current homebirth rate was 0.1%. The nationalaverage is2.3% in England and Wales (Office of NationalStatistics). Senior staff informed us the rates were beingreviewed in order to try to increase the uptake ofhomebirths. This included a change of model of care,new community midwifery teams and rotation ofcommunity midwives into the AMU.

• During the inspection we were informed by staff thatthere was no data available relating to incidents of thirdand fourth degree perineal tears and postpartumhaemorrhage (PPH) on the labour ward. Thishighlighted that the service were not reviewingelements of care that other trusts locally and nationallywere reviewing.

• In 2016, the Neonatal Audit was below the nationalNeonatal Audit programme (NNAP) standards for all ofthe five standards. Three standards were just below thestandard benchmark grade. The remaining twostandards were significantly below the benchmark setnationally. However, these two standards were notdirectly linked with the maternity unit.

• Data from the trust showed that the stillbirth ratereported in 2015 was seven. In 2016, this was reduced tothree stillbirths. Up to 7 April 2017, there were nostillbirths recorded. These reduced numbers were animprovement since the last CQC inspection and withinnational rates.

• Admissions to the maternity High Dependency Unit(HDU) between February 2016 and February 2017 were28 patients. Fourteen patients were admitted forbleeding related issues and six patients were admittedwith high blood pressure.

• From January 2016 and December 2016, there wereeight patients admitted to the trust Intensive Care Unit(ICU). The main reasons for admission were infection,pneumonia and bleeding. The average stay was nomore than two days.

• Between March 2016 and November 2016, there was anincrease of unexpected admissions of babies toneonatal intensive care unit (NICU) with suspectedsepsis (infection). Staff informed us that the cause forthe increase was due to the rigid interpretation of theNICE guideline relating to the prolonged rupture ofmembranes and the subsequent use of antibiotics forpatients and babies. Identified risks were displayed onstaff notice boards and shared at staff safety briefmeetings. Education was provided to help staff interpretthe risk factors and complete a datix incident reportwhen appropriate.

• Ninety-six patient referrals were made to the stopsmoking midwife in 2015. Since the nationalintroduction of compulsory carbon monoxide testing(NHS 2010) in the antenatal period, referrals hadincreased to 276 patients in 2016.

• The stop smoking midwife informed us that the rate ofpatients smoking at booking was 10.4%. This was belowthe national average of 12% (hscic 2015). The trustswere unable to provide smoking rates at delivery due toIT data collection problems.

• Birth outcomes, from the interim performance report onthe Alongside Midwifery Led Unit (AMU), between May2016 and February 2017, showed that 84% of first timemothers and 95% of second time mothers gave birth onthe unit. Eleven percent of all patients were admitted tothe maternity service, were to AMU, however, the trustpredicted target was 25-30%.

• Seventy one percent of patients admitted to the AMUgave birth without any interventions. Forty sevenpercent of patients used water during labour as a formof pain relief, 45% gave birth in water.

• One hundred percent of patients on AMU were on theappropriate pathway.

• Sixty three percent of patients breast-fed followingdelivery on AMU. The 2010 Infant feeding Survey statesthat the breastfeeding rate at birth in England was 83%.




• The AMU interim performance report highlighted animprovement in the completion of risk assessments,patients on the appropriate pathways, an increase inphysiological delivery of the placenta (no drugs used)and a decrease in poor clinical outcomes. Areas forimprovement included improved documentation,increase the number of patients assessed on AMU,transferred to labour ward when baby’s heart rate is aconcern and number of patients discharged from AMU.

• For the same reporting period, the rate of postpartumbleeding (PPH – bleeding after birth) over 1500mls onAMU was 1.5%. There were three cases of shoulderdystocia (shouldersfail to deliver shortly after the baby’shead). All eligible babies received optimal (delayed)cord clamping and skin-to-skin contact (nationalrecommendations).

• Baby admission rates from AMU to the neonatal unit(NICU) were 3.1%. There were no babies born with Apgarscores (a score of ten that represents the best possiblecondition of a newborn baby) less than 4 at 5 minutes,and the rate of babies born with medical complicationsincluded one baby that required cooling ( a procedureto improve babies who have lacked oxygen at birth)(0.7%).

• However, information provided by the trust since theinspection, indicated that the neonatal admission ratefrom AMU to NICU had decreased.

• All cases on AMU of shoulder dystocia, PPH greater than1000mls, admissions to NICU, and adverse patient orbaby outcomes were subject to multidisciplinaryincident reviews and external reviews where indicated.

• The overall intrapartum transfer rate from AMU to thelabour ward between May and October 2016 was 25%,which was below the rate suggested in the birthplacestudy (2011).

• The majority of transfers from AMU were appropriateand there were no cases where patients should havebeen transferred to the high-risk pathway. Of the 42patients transferred from the low risk to high-riskintrapartum pathway, 57% physically changedgeographical location to the labour ward. The remaining43% patients remained on the AMU. The reason for not

transferring patients was often not documented in therecords. Of those transferred, 50% achieved a vaginalbirth, 29% assisted instrumental birth, 17% caesareansection, and 4% failed instrumental Caesarean section.

• In October 2016, a labour ward audit took place todetermine compliance with risk assessments for placeof birth. Only 7% of patients had completed anintrapartum risk assessment. Thirty two percent ofpatients were on an inappropriate high-risk pathway,35% of patients admitted to labour ward were suitablefor AMU. Thirty-five percent of patients had babymonitoring discussed and 32% had a CTG without aclinical indication. This did not assure us that all staffwere following the national and trust guidelines.

• However, information provided by the trust since theinspection, indicated an improvement in thecompletion of risk assessments and a reduction in thenumber of patients receiving CTG without clinicalindications.

Competent staff

• Up to February 2017, 93% of midwives and health careassistants (HCA) had completed an annual appraisal.This was above the trust target of 85%. An appraisalgives staff an opportunity to discuss their workprogression, professional and personal developmentand future aspirations, objections and goals. This wasan improvement from the last CQC inspection.

• Gynaecology staff were supported in their developmentusing the appraisal process, which was undertakenannually. There was 100% compliance for appraisals fornursing staff in the gynaecology department. This wasabove the trust target.

• A preceptorship and development programme (to guideand support all newly qualified practitioners to makethe transition from student to develop their practicefurther) was offered to all newly qualified staff. Thisenabled all new staff to work in all clinical areas to gainexperience and increase confidence. The programme foreach member of staff was between 18 months and twoyears.




• All new staff received a document to complete theircompetencies when achieved. It also containedinformation such as the role and responsibilities of thenew midwife, accountability, supervision, revalidation,reflection, training expectations and job description.

• Regular monthly preceptor meetings with held betweenthe practice education midwife and new staff on thepreceptor programme.

• Gynaecology staff informed us that they attendedtraining for immediate life support (ILS) training as partof mandatory training requirements with a complianceof 100%.

• Community midwives informed us about bespoke skillsand drills training that were held during the year,appropriate for the home setting. A flat on the hospitalsite was used for the training to make it realistic for thecommunity midwives and the midwives were trained insmall groups, again to make it realistic. The trainingincluded risk assessment for place of birth, recordkeeping, transfer into hospital, water use in labour,delivery of the placentas, suturing and contents reviewof new homebirth kit bags. Practical homebirthscenarios were also re-enacted.

• Newborn life support training (NLS) was providedexternal to the trust for band seven labour wardmidwives. All nine of the band seven midwives hadcompleted the training.

• Due to shortness of staff, we observed a staff member,from another speciality, scrubbed in theatre when theyhad not done so for a long period. We also observed aHCA from the ward being asked to scrub in theatre,however she declined as she had not done so for sometime and felt she was not safe to do so.

• At the time of our inspection, community midwives werenot part of the escalation process for staffing within thematernity unit nor did they rotate into the labour wardto maintain skills and competencies. Some communitymidwives told us they had not undertaken a homebirthor pool birth in many years and some midwivesinformed us that they had never undertaken a poolbirth. This was raised as a concern to the senior serviceleads during our inspection.

• However, in response to the concerns raised, the trustresponded promptly to address the community

midwifery skills and competencies. Information,provided by the trust since the inspection, indicatedthat training had been completed and competencieshad increased for community midwives.

• Community midwifery management staff, at the time ofthe inspection, informed us that they were confidentthat their community staff were competent and skilled,as they had undertaken a bespoke community midwifeskills and drills training day as well as attending thethree-day mandatory training programme.

• We were informed that two community midwivesworked bank shifts on labour ward and that two othermidwives highlighted themselves as benefiting fromworking on the AMU to keep upskilled and came intowork on the labour ward and AMU for a block period ofone month.

• We were also informed that from April 2017, communitymidwives were to start to rotate into the AMU to keep upto date, increase continuity of care and increase overallbirth rates.

• Maternity ward staff informed us that only recently hadthey been trained and supported to undertake astandard blood test from babies to monitor their bloodsugar levels. The paediatric doctor undertook otherstandard tests for babies such as a blood test (serumbilirubin or SBR) for measuring for jaundice levels. Allbabies who required phototherapy treatment forjaundice were cared for on the neonatal unit (NICU).Babies also attended NICU for intravenous (IV)antibiotics. This did not assure us that all staff weremaintaining their skills and working within their RCMtraining and competency levels.

• However, the trust provided evidence since theinspection, to indicate an improvement in theunnecessary admissions to the neonatal unit. Thisneeded to be embedded into practice and audited inthe future.

• The ratio of supervisors to midwives to midwives metwith the national recommendations of one to fifteen.The primary role of the SoM is to ensure the safety ofpatients and babies and in the provision of high qualitymidwifery care.

• A Supervisor of Midwives (SoM) was available 24 hours aday, 7 days a week in the maternity service.




• Specialist roles within the maternity service included:consultant midwife, governance manager, infant feedingcoordinator, practice development midwife, auditmidwife, teenage pregnancy midwife, substance misusemidwife, research midwife, antenatal screeningcoordinator, bereavement midwife, smoking cessationmidwife, practice education facilitator.

• One midwife was trained in acupuncture and two morewere undergoing the training. There was a weeklyacupuncture clinic in antenatal clinic (ANC) thatprovided relief for backache in pregnancy. Patientscould be referred from the community midwives,physiotherapist and consultant midwife.

• Six midwives were diploma trained in aromatherapyand reflexology complimentary therapies. They in turnhad cascaded their training and knowledge intodeveloping their own in house package where 98% ofmidwives have been completed the trained. Once aweek a “post-dates” aromatherapy clinic takes place, inANC where patients who were past their due date wereoffered a membrane sweep (an internal examination tohelp start labour) and aromatherapy oils plus a routineantennal check. All patients have risk assessmentscompleted and guidelines are in place for staff to follow.

• Complimentary therapies were also offered to low riskpatients who had previously experienced a caesareansection and would like a normal delivery. Staff informedus that these therapies also reduced the likelihood ofbeing induced to start labour contractions. Riskassessments were completed to access suitability.

• Five midwives were trained to deliver hypnobirthing (aform of self-hypnosis for labour and natural childbirth).

• Staff informed us that unannounced, multidisciplinaryskills and drills scenarios took place in maternityservices to simulate obstetric emergencies such asshoulder dystocia, cord prolapse, and post-partumhaemorrhage.

• Gynaecology had specialist-trained nurses incolposcopy and the rapid access clinics.

• Gynaecology staff informed us that due to the outlierson the gynaecology wards, which included trauma,orthopaedics and general medicine patients, they didnot always feel competent to care of these specialties.

• Junior medical staff informed us that while they enjoyedthe work on the labour ward because they receivedgood support and were not asked to do anythingbeyond their capabilities, this was not always the casewhen they worked on the gynaecology wards.


• Midwives and medical staff said that teamwork andcommunication between them had improved since thelast CQC inspection. They informed us that they nowattended multi-disciplinary meetings together and felthappy discussing patient care and serviceimprovement, which included challenging practicearound evidence, based information.

• All staff we spoke with told us that departments workedwell together and supported each other acrossdepartments. There were processes in place to refer tophysiotherapy, for example if there were patients fromthe trauma and orthopaedic speciality.

• However, we attended a cardiotocography (CTG)meeting, which lacked midwifery involvement andattendance. This meeting was informal between theoutgoing and incoming on call medical team, which wasmore like a patient handover meeting rather than aneducational meeting. There were no opportunities toask questions. No formal notes were taken. There wasno formal timetable or schedule for these meeting.

• We reviewing MDT perinatal morbidity and mortalitymeeting minutes, where we observed a lack ofmidwifery involvement and attendance. Midwivesinformed us that it was not always easy to attendmeetings due to the clinical demands on the unit.

• We requested minutes from the last three maternityconsultant and medical meeting minutes. The trustprovided us with minutes from the multidisciplinaryteam meeting held in December 2016. No attendeeswere listed on the minutes.

• We were provided with minutes from two women’sbusiness health meetings held in December 2016 andJanuary 2017. Ten people attended the meeting inDecember 2016; there was no midwifery or gynaecologyrepresentation at the meeting. Fifteen people attended




the meeting in January 2017, only one midwiferyrepresentative attended. There was little assurance tosuggest that midwives or gynaecology nurserepresentation was evidence at senior or local meetings.

• Staff informed us that all baby abnormalities andmanagement were discussed at MDT meetings heldevery three months. Staff that attended includedspecialist consultants, sonographer, paediatricians,bereavement midwife, screening midwife, and antenatalassessment day unit (ANDU) midwives.

• There was an example of when a patient had beendischarged and had not received the required follow upby community midwives from another provider. Thisshowed a breakdown in communication between thehospital staff and community midwives in the local area.However, we saw evidence to suggest that this concernwas raised and discussed between the two providerssteps were being taken to improve dischargecommunication.

• There was a midwife with a lead role for supportingpatients with mental health issues. They could assistpatients to get access to specialist services and theinpatient mental health services could be used ifrequired. A mental health specialist clinic ran weekly bya lead mental health obstetric consultant, mental healthmidwife and a mental health specialist nurse.

• Antenatal clinic staff had access to a phlebotomist totake patients’ blood samples every morning. However,this service was not available in the afternoons.

• For patients who attended for diagnostic colposcopyand hysteroscopy, the nurse specialist liaised with aneighbouring trust where treatment took place. Stafftold us that this system worked well.

Seven-day services

• The Antenatal Day Assessment Unit (ANDU) was openedseven days a week from 8am to 6pm. Out of hour’spatients went directly to the labour ward.

• Antenatal clinic opened Monday to Friday, 8am to 5pm;however, some evening booking appointments wereoffered to accommodate patients who could not easilyattend during the day. There was consultant and seniorregistrar cover in ANC every day.

• Women could self-refer to ANDU or be referred by thecommunity midwife, labour ward, emergencydepartment, GP, or other referral agencies. The directline phone number was provided in the patient’s handheld notes.

• The antenatal day unit provided a seven-day servicebetween 9am and 6pm, offering some lateappointments in the evenings.

• The Alongside Maternity Led Unit (AMU) was openedseven days a week, 24 hours a day.

• The EPAU was open Monday and Friday 9am until 5pm.On Tuesdays, Wednesdays and Thursdays, EPAU clinicswere in the morning only. There were no clinics atweekends. This meant that patients would need toaccess the scanning services via accident andemergency in the evenings or weekends.

• The scanning room was available 24 hours a day. Thesonographer was available when the EPAU was open;otherwise, medical staff with ultrasound skillscompleted any out of hour’s scans.

• Patients in the Halton area were able to access day casesurgery services at Halton hospital but needed to meetcriteria of the American Society of Anaesthesiologists(ASA) guidelines. In addition, the day-case ward wasopen Monday to Friday only from 7:30am until 7:30pm. Ifa patient needed to stay overnight, they weretransferred to the neighbouring ward.

• We were told that pharmacy services were available atHalton between 9am and 5pm and between 9am and7pm at Warrington Monday to Friday. Saturdays andbank holidays services operated from 10am and onSundays from 11am until work was finished (generallybetween 3pm and 5pm).


• Staff accessed information from the trusts electronicsystems, intranet and paper records that were readilyavailable.

• Policies and procedures were available on the trustsextranet where the most current versions were stored.

• Patient discharge letters included information websiteand helpline details.




• Information leaflets and posters were available andaccessible for patients.

• There were leaflets in other languages other thanEnglish available on the trust intranet “hub”.

• A translation service was available either face-to-face oraccessed via the telephone. Staff informed us that theydid not rely on family members for interpretation.

• There was specific information in an easy read format,such as pictures for patients with learning disabilities.However, not all staff was aware where the informationwas kept on the maternity ward.

• Community midwives informed us that they used twodifferent IT systems, which did not interlink with eachother; therefore, it was time consuming to use bothsystems. They also provided examples of incorrectsensitive patient information being incorrect transferredfrom one IT system to another that had to be escalatedto their manager.

• Midwives were all allocated electronical devices toaccess information within and outside the hospitalpremises.


• Mental Capacity Act training compliance rates over thelast 12 months for doctors was 53%, midwives 59% andnursing staff 58%. The trust target for all training was85%. This did assure us that staff were up to date andadequately skilled to feel confident in their roles andresponsibilities in identifying and protecting patients atrisk and follow best practice when providing care.

• However, staff informed us that they had received somemental health training on their annual mandatorytraining days and had a non-judgemental attitudetowards women with mental health issues, learningdisabilities or substance misuse.

• We were informed that staff worked closely with socialservices that were happy to visit the wards to provideMDT support.

• Maternity services had a specialist mental healthmidwife, a dedicated obstetrician for mental health andmental health nurse, who all facilitated a weekly mentalhealth clinic. They also provided support to staff on thewards.

• We reviewed records and attended a multidisciplinarymeeting regarding a patient with special needs. Allnecessary steps were taken to ensure the patients’mental capacity was assessed and that the patientunderstood her rights. There was a good trigger plancompleted in the records and staff had adhered tothese. We observed good input from the safeguardinglead.

• There were picture booklets that staff could use withpatients with learning difficulties.

• We observed procedure specific consent forms forelective and emergency caesarean sections andgynaecology services. This was an improvement fromthe previous CQC inspection.

• All consent forms we reviewed in theatres werecompleted appropriately.

• For TOP procedures, we saw evidence that two doctorsreviewed the documentation and signed the HSA1 form,if they agreed that the reason for the termination ofpregnancy met one or more grounds of the Abortion Act1967. Legislation requires that for an abortion to belegal, two doctors must each independently reach anopinion in good faith as to whether one or more of thelegal grounds for a termination is met.

• A quality of consent and documentation audit tookplace in December 2016. It looked at the consentprocess and consent forms for elective procedures andtreatments at the obstetrics and gynecologydepartments at Warrington and Halton Hospitals. A totalof 21 patient notes and consent forms were reviewed.Compliant rate was meet however documentationshowed that patient information leaflets about theprocedure was provided to only 76% of patients, 38% ofpatients was referred for anesthetic opinion prior to theprocedure taking place. The action plan was to re-auditin December 2017.

• A consent form audit took place in January 2017 by thetheatre team. The audit focussed on the two-stageconsent process. Twelve patient case records werereviewed. Recommendations included re-emphasisewithin the division that patients should be given theyellow copy of the consent form or clearly state ifpatients do not want the copy and illegible writing to beimproved. The procedure for consent was not identified




on four consent forms. This was discussed with theatrestaff at safety briefing meetings. A re-audit with a largersample size was planned for February 2017 with thereport completed for 31st March 2017.

• For a patient with a hearing impairment, the Deaf Centrewas contacted to access a signing expert. Fornon–English speaking patients, the trust interpreterservice was accessed for consent.

• In February 2017, an email, with a link, was sent to allstaff in the Women’s and Children’s Division to remindthem about the Court of Protection (COP) advice aboutnot delaying in applying to the court in obstetric caseswhere mothers lack capacity and are refusing carebelieved to be in her best interests.

Are maternity and gynaecology servicescaring?

Good –––


At the previous inspection in January 2015, we rated caringas good mainly due to staff treating patients with dignityand respect, kind and polite interactions observed,patient’s involvement with birth plans and recognition byall staff to increase normality of labour. We havemaintained this rating following this inspection because:

• The majority of staff were kind and polite in theirinteractions with patients and families.

• Patients said they were involved in their birthing plansand their choices were listened to and respected.

• Patients we spoke to informed us that they were happywith the care they had received and spoke positivelyabout the staff that were caring for them.

• Gynaecology staff informed us about a wedding theyhad arranged on the ward for an unwell patient and hadsubsequently won “Team of the Year” within the trust forthis

• The bereavement team had been successful in theNational Butterfly Awards.

• The Friends and Family Test results were similar tonational averages.

• Gynaecology staff told us about fund raising events theyheld in order to buying personnel toiletries and suppliesfor patients who were without on the wards.

• A visitor arrived on the gynaecology ward to say thankyou and show their appreciation to staff during our visit.

Compassionate care

• Patients we spoke to said staff were kind and caring.They said they had been treated with patience andrespect.

• Patients said staff introduced themselves, were friendlyand included them in their care. Patients were verypositive about the care they received from all staff.

• Thank you cards, received from patients, were displayedin office areas.

• We observed two phone calls between staff andpatients that were compassionate, empathic and caring.

• We observed that patients were treated with respectand promptly in all areas. Privacy and dignity of patientswas maintained during consultations. In the outpatientareas, consultations took place in individual closedrooms with chaperones present and notices to ‘knockbefore entering’.

• On the ward, consultations took place either in a closedtreatment room or behind privacy curtains aroundpatient beds, however; curtains were not sound proof.

• We observed that during busy times, doors to bays orcorridors were open, however staff attempted to keepthem shut where possible.

• During the inspection, a hospital volunteer completed a‘privacy and dignity’ survey as we had observed someaspects of care where privacy was not alwaysmaintained, especially on the gynaecology ward. Thiswas highlighted at the time of our inspection.

• The week prior to inspection, the gynaecology ward hadreceived a hospital award for “Team of the Year inExcellence in Patient Care 2017”. They were nominatedfollowing a wedding that was held on the ward for apalliative care patient. Staff decorated the ward andstayed over their shift times to create a special day forthe patient.

• We were told that the ward staff had carried outfund-raising activities in order to raise funds to purchase




items on the ward. These have included toiletries andnightwear for patients who dot have any with them aswell as small food hampers, such as juice, and a wardhairdryer.

• At the time of inspection, a former patient visited thegynaecology ward to thank all the staff for their excellentcare during her stay. In addition, she requested detailsof senior management in order to contact them andpass on her gratitude about the ward.

• From November 2015 to November 2016, antenatalFriends and Family Test (FFT) was generally similar tothe England average. In November 2016, theperformance for antenatal clinic was 97.7% comparedto a national average of 96%.

• For the same reporting period, FFT for birth wasgenerally similar to the England average. In November2016, the performance for birth was 97.3% compared toa national average of 96.6%.

• For the same reporting period, postnatal FFTperformance was generally similar to the Englandaverage. In November 2016, the performance was 93.6%compared to a national average of 93.7%.

• For the same reporting period, postnatal communityFFT was generally better than the England average. InNovember 2016, the performance for postnatalcommunity was 100% compared to a national averageof 97.5%.

• The current FFT (a survey which asks patients whetherthey would recommend the NHS service to friends andfamily who need similar treatment or care results)results were displayed outside the gynaecology wardshowing that 96.2% would recommend the service.

• The trust performed about the same as other trusts for15 out of 16 questions in the CQC Maternity survey 2015.The only indicator they performed worse than othertrusts on was “If you raised a concern during labour andbirth, did you feel that it was taken seriously?”

• The trust reported no Local Patient Surveys had beenundertaken


• Patients could be reviewed by staff, with those close tothem if preferred as well as a chaperone.

• Colposcopy advocated a ‘vocal local’ approach with anurse carer present to talk to the patient during theprocedure as well as the trained nurses.

• Varieties of leaflets were available in all areas containinginformation specific to certain conditions or treatments.

• Community midwives and staff on the AMU informed usthat they involved patients as much as possible in theirbirth choices and plan.

• The consultant midwife, midwifery lead for AMU and theHead of Midwifery informed us that they were keen topromote a “normal birth”which involved and includedpatients to make informed decisions about how theywould like to give birth.

• Maternity patients said they had been included in theirown care and been able to discuss and choose themode of delivery. Where possible their choices had beenrespected and when they had not, discussions with thepatient had taken place and explanations had beenclear.

• Partners could be present on the AMU, labour ward andbereavement room. However, there were no facilities forpartners on the ward or induction bay area.

Emotional support

• There were two nurse practitioners for colposcopy, oneof which was also the nurse specialist cancer rapidaccess. These staff provided wellbeing support as wellas providing clinical care. A local charity organisationwas also accessed if needed to provide support.

• Any patient, following a miscarriage or stillbirth wasreferred to the bereavement midwife for clinical,practical and emotional support. The bereavementmidwife allocated time to comfort and advise parentsthrough sensitive issues such a memory items such asphotos, pictures, cuddling their baby as well as provingsupport and advise around burial.

• Staff were supportive to parents and those close tothem following the loss of a baby, and offered emotionalsupport to provide comfort and reassurance. The trustprovided memorial services for newborn babies and thefamilies.

• The bereavement service had won the “Bestbereavement birth professional” in the NationalButterfly Awards 2016.




• All patients following a termination of pregnancy (TOP),for baby abnormality, were offered counselling and ablessing from the hospital chaplain, involvement fromthe local or family church if requested.

• The consultant midwife offered “Birth Choice” one toone appointments and monthly workshops to discussand support families who had experienced a traumaticbirth, are experiencing fear of childbirth, or to discussvaginal delivery following a pervious caesarean section.We attended one of these small group sessions in theevening. It was delivered in a sensitive, practical andprofessional manner, allowing plenty of time for familiesto discuss their concerns.

• Gynaecology staff caring for patients, who hadexperienced a TOP, had developed a checklist to ensureconsistent care was provided when different staff werelooking after the patient.

• A designated screening midwife offered support andcounselling to patients who had received bad newsfollowing diagnostic screening. They also directedpatients to additional external support.

Are maternity and gynaecology servicesresponsive?


We rated responsive as requires improvement because:

At the previous inspection in January 2015, we ratedresponsive as require improvement mainly due to staffingand capacity issues, multiple closures of the maternity unit,long waiting period for patients, outlier patients on thegynaecology ward and lack of transitional care facilities onthe maternity ward. Following this inspection we havemaintained this rating following this inspection because;

• Bed occupancy on the gynaecology ward was above100% in January 2017 and February 2017. It was 98.66%in December 2016.

• Gynaecology beds were used on a daily basis, includingweekends, for patients with other medical, surgical ororthopaedic conditions. This resulted in access and flowissues and some cancellations of procedure. These

patients often remained longer on the gynaecologyward than expected, therefore, effecting capacity ofbeds for gynaecology patients. This was a concernhighlighted in the last CQC inspection.

• We observed elective surgery patients being telephonedby staff and their procedures cancelled on the same dayit was due.

• We observed examples of patients telephoning thematernity service to be told of significant delays to theirexpected admission.

• Staff informed us of delayed doctor reviews for patientsdue to the workload capacity within the unit. This couldoften lead to delays in treatment or discharge home.

• Full transitional care facilities were not available on thematernity ward, which meant babies who requiredtreatment such as phototherapy, or intravenousantibiotics were transferred to the neonatal unit. Thiswas not in line with best practice as it meant the motherand babies were separated. This was a concernhighlighted in the last CQC inspection.

• The design of the some of the waiting areas in theantenatal clinic meant that gynaecology and maternitypatients could wait together in the same area, whichwas not in the best interest for their emotional needs.

• We observed privacy and dignity concerns in both theobstetric theatre and gynaecology wards, which did notmeet the individual patient’s needs.

• Due to bed demands, staff informed us that sometimesantenatal and postnatal patients shared the samerooms on the maternity ward.

• Staff informed us of delays of patients on the inductionof labour bay due to staffing issues and increasedworkload on the labour ward.

• Patients complained about staff not answering thetelephone on the Early Pregnancy Unit (EPAU) whenthey tried to phone the unit from home.

• The maternity service did not audit delays in transferfrom the antenatal ward, triage or induction bay tolabour ward.

• The maternity service did not audit waiting times in theantenatal assessment day unit (ANDU).




• There was no dedicated triage area in the maternityservice.

• Information notice board was displayed in staff andpublic areas. However, data collected on some of thepublic facing boards were difficult to understand asinformation was represented by coloured dots ratherthan written information.

However

• In May 2016, the service introduced n AlongsideMidwifery Led unit (AMU) beside the labour ward topromote midwifery led care and promote “normality” inlabour. A dedicated band seven midwife managed thisservice.

• Maternity services ran specialist clinics to provide carefor individual needs and concerns and facilitatedworkshops for couple with specific worries such as fearin childbirth and previous poor obstetric history.

• From December 2016 and 8 March 2017, there were nomaternity unit closures.

• Leaflets were available in different languages on thetrust intranet system. The gynaecology wards also hadresources in braille and large font.

• Staff were aware how to arrange interpreter services.

• Midwifery staff were trained to provide complimentarytherapies to patients and facilitated workshops foraromatherapy, hypnotherapy and acupuncture.

• Smoking cessation advice and carbon monoxidemonitoring being offered to patients in the antenatalclinic.

• The maternity service was recently successful inachieving a large financial award. The service plannedto develop the training and development programme.

• The maternity labour ward had a large private dedicatedbereavement room for patients to delivery in and forpartners to stay overnight. This was decorated in asensitive homely way.

• Antenatal booking appointments in antenatal clinicwere offered in the evening to accommodate patientswho were at work or busy during the day.

• Twenty-two midwives had completed the Newborn andInfant Physical Examination(NIPE) programme. Thisoffered parents of newborn babies the opportunity tohave their child examined shortly after delivery.

• Community midwives also offered appointments at GPpractice close to the patients home.

• EPAU staff at the Warrington site tried to arrangeprocedures for Halton patients at the Halton site forpatient ease and convenience.

• Medical termination of pregnancy (TOP) service wasavailable at Warrington for baby abnormalities. Patientsthat requested a TOP for ‘social’ reasons weresignposted to independent health providers locally.

• Patients with dementia were identified using the “ForgetMe Not” flower symbol on the electronic patientinformation system.

• Gynaecology service provided a “rapid access” clinic forpatients with cancer.

• Gynaecological cancer services achieved the nationaltwo-week wait for all patients where gynaecologicalcancer was suspected. The service also met the 31-daynational standard. However, the 62-day national targetwas not achieved.

• Written information was readily available in a variety oflanguages. This was also an improvement from the lastCQC inspection.


• We observed smoking cessation advice and carbonmonoxide monitoring being offered to patients in theantenatal clinic (ANC). Staff were aware how to referpatients to the local stop smoking service for furtheradvice and treatment.

• Antenatal booking appointments in antenatal clinicwere offered in the evening to accommodate patientswho were at work or busy during the day. Communitymidwives also offered appointments at GP practiceclose to the patient’s home.

• Gynaecology services included many nurse led clinicsand consultant clinics such as, colposcopy clinics,histoscopy clinics, and pre-operative clinics.




• Patients from the Halton area, could accessgynaecology day surgery at the Halton hospital site.

• Community midwives told us about providing care invarious geographical areas to help patient’s accessservices easily.

• Full transitional care facilities were not available on thewards, which meant babies who required treatmentsuch as phototherapy, or intravenous antibiotics weretransferred to the neonatal unit. This was not in line withbest practice as it meant the mother and babies wereseparated.

• However, since the inspection, the trust had providedevidence, which suggested improvements to enablemothers to care for their babies, who needed extra care,with support from staff. This needed to be embeddedinto practice and audited to access the impact.

Access and flow

• Bed occupancy, including beds used for escalation forother speciality patients; on the gynaecology ward forDecember 2016 was 98.66%. January 2017 was 110.48%and February 2017 was 109.52%.

• Bed occupancy levels for maternity were generally lowerthan the England average, with the trust having 59.2%occupancy, compared to the England average of 61.1%.

• Between March 2015 and December 2016 the maternityunit closed on seven occasions. There were no furtherclosures up to the 8 March 2017. The last time it closedwas June 2016. Lengths of closures were between 4hours and 14 hours. On three occasions, the length ofclosure was not recorded. The trust informed us that themain reason for the closures was the lack of availablebeds. No patients delivered in other trusts during theperiods of closure.

• There was a hospital divert policy in place. This waswithin the midwifery escalation policy.

• Information provided by trust about outpatients waitingtimes was difficult to understand. Data was collectedfrom April to March but the year was not stated. For thisperiod overall obstetric waiting times was recorded as11%, gynaecology 14.49% and midwifery 6.80%.However, these figures were not explained orrepresented against a trust or national target.

• Gynaecology 18 weeksreferral to treatment(RTT)trusttarget was met between April 2016 and January 2017.

• Between April 2016 and December 2016, gynaecologicalcancer services achieved the national two-week waitseven of the nine months, for all patients wheregynaecological cancer was suspected. The service alsomet the 31-day wait from diagnosis to first treatment forall months. The 62-day national target was not achievedfive of the nine months however; November andDecember 2016 achieved 100%. The trust reported thatthey were in the process of fully implementing SomersetCancer register by the end of March 2017 to helpimprove the 62-day target. Staff also told us that the62-day target was due to lack of radiographer supportand a risk mitigation plan was in place.

• Data provided by the trust relating to delayeddischarges showed that between August 2016 andJanuary 2017, 165 patients experienced delay discharge.The trust stated that the delays were attributable toboth the NHS and Social Care. Reasons includednon-completion of risk assessments, funding, carehome placements and community equipment andadaptions.

• We requested any audits, outcomes and action plans ofdelays in transfer from the antenatal ward, triage orinduction bay to labour ward. The trust informed us thatthere are no audits performed to monitor this. This didnot assure us that the trust were monitoring assess andflow and delays in transfers to the labour ward,therefore unable to implement any changes to improvethe patient experience and monitor safety of patientand baby

• We requested the patient waiting times audits for triage.The trust provided us with an audit of the patientjourney through ANDU from October 2015. This did notassure us that the trust were regularly monitoring assessand flow and waiting times in order to implement anychanges to improve the patient experience and monitorsafety of patient and baby.

• Between July 2015 and December 2016, there were 294attendances for gynaecology at Warrington and 1, 581gynaecology attendances at Halton, for the sameperiod.




• From April 2016 to March 2017, 584 gynaecology daysurgery cases went undertaken at the Halton Day CaseUnit. We were informed that 600 cases were projectedfor full 12-month period ending 31 March 17.

• The gynaecology ward included two six bedded baysand two cubicles for gynaecology and breast surgerypatients. There was also an additional bay for dayattenders, however; due to bed pressures in thehospital, this additional bay was being utilised as anescalation bay.

• The gynaecology ward was used for medical andsurgical patients on a regular basis. There were fivemedical outliers and four surgical outliers on one day ofthe inspection. Staff told us that this was usual. Staffsaid this affected their ability to accommodategynaecology patients and operations could becancelled as a result. However, information provided bythe trust showed that over the last 12 months, therewere only five patient outliers on the gynaecology ward.

• We also observed a patient fasting for over 36 hours inthe gynaecology ward while waiting for a sensitiveprocedure. The patient was upset and anxious due tothe nature of her condition. Staff informed us that thiswas due to the busy workload and the medical teambeing too busy. This was highlighted to the CQCinspection Lead and highlighted to senior managementas a concern during our inspection.

• For elective surgery, patients were contacted by phoneto update about the availability of beds. At the time ofinspection, two patients were admitted in the morning,however; the three patients expected in the afternoonwere cancelled and rearranged.

• There was some uncertainly among midwifery staffregarding where the designated triage area wassituated. The antenatal day unit (ANDU) acted as atriage for some patients with any pregnancy relatedissues, including abdominal pain, vaginal bleeding,close and regular blood pressure monitoring andrupture of membranes (sac of water that surrounds thebaby in the womb). Staff reported that the unit couldbecome very busy with patients waiting for longperiods. There was a senior house officer (SHO)assigned to work on the unit every day. Registrar and

consultant cover was available until 7pm. This did notprovide a timely response to patients who hadpresented with concerns. This was also a concern raisedat the last CQC inspection.

• A triage service was also available on the labour ward.Having two types of triage areas did not assure us thatall patients knew where to phone into or attend whenseeking advice and review.

• A junior doctor was responsible for the antenatal clinicand ANDU, with the second on call doctor (the registrar)who was responsible for the labour ward. This meantany patients who needed to see a doctor had to wait forone to become available. Staff said when the unit wasdue to close at 5pm they could have patients stillwaiting to see a doctor. This meant there were delays inpatients being admitted to the labour ward or beingdischarged from this unit. This was also a concern raisedat the last CQC inspection.

• Due to the workload and staffing level on the labourward, we observed examples of advice given to patientsvia the telephone which highlighted an access and flowsue. A patient rang at 8pm with a history of reducedbaby movements and was told by staff to come into theward at 21:30pm, a patient rang at 3:40pm and was toldto come in at 7pm, a patient rang at 6:10pm and wadinformed to come in at 8pm. This did not assure us thatpatient concerns safety was actioned immediately.

• Some midwives informed us that due to lack of accessto medical staff on the post-natal ward, patients werenot always reviewed or discharged home in a timelyway. This was also a concern raised at the last CQCinspection.

• Maternity staff informed us that they currently did notactively promote 6-hour discharges from hospital butthis would commence on AMU in the future.

• Twenty-two midwives had completed the Newborn andInfant Physical Examination(NIPE) programme. Thisoffered parents of newborn babies the opportunity tohave their child examined shortly after delivery andhelps with discharges from the postnatal ward in atimely way. Four more midwives were currentlyundertaking the training.





• We observed a patient undergoing a sensitive medicallyenhanced emotive procedure, sharing a six-beddedroom on the gynaecology ward during our inspection.This did not assure us that privacy and dignity wasmaintained.

• We observed a patient fasting for over 36 hours in thegynaecology ward while she waited for an emergencysensitive procedure. This was highlighted to the CQCinspection Lead and highlighted to senior managementas a concern during our inspection.

• The Early Pregnancy Assessment Unit (EPAU) was onlyopen during weekdays, although patients were givenopen access to the gynaecology ward out of hours. Wewere given examples from patients about the difficultyin ringing the EPAU and having to choose an alternativedepartment to be seen in due to their health and anxietyconcerns.

• Clinics were accessible for patients with reducedmobility, however; there was no raised seating seen.

• Staff told us that there was no hearing loop ingynaecology, however; staff could contact a local deafcentre to access signing services if needed.

• There was no system in place to identify gynaecologypatients with a learning disability, although, onceidentified patients were able to visit the wards prior tosurgery and be accompanied by carers during their stay.

• There was a counselling room, in the EPAU, however; itwas very plain. The ward sister explained that she wouldlike to change the décor of the room. In addition,change one of the side rooms to be suitable for patientsrequiring sensitive surroundings.

• There was no ‘one stop clinic’ for colposcopy andhysteroscopy. Patients attended a consultation andscan appointment, via a rapid access system. The trustprovided a diagnostic service; any treatment neededtook place at a neighbouring NHS trust.

• There was a designated bereavement suite, whichincluded a separate delivery room, for parents who hadlost a baby. This included a large homely designed roomaway from the main ward with facilities for parents toremain with their baby should they wish. It was asensitive environment and the decoration had beenchosen and provided by a bereaved parents’ charity.

• The community midwives ran parent education classes.A four week programme was based on the national“Pregnancy Birth and Beyond” programme. Venues werein the community setting and hospital. Day and eveningclasses were available to accommodate all parents. Aprogramme included the health visitor attending, basicnewborn resuscitation awareness training and a tour ofthe maternity unit.

• The consultant midwife cared for and supportedpatients who would like to try for a normal vaginal birthfollowing a previous caesarean section in the past.

• The maternity service was involved with the “BosomBuddy” volunteer’s programme that provided extrasupport to breast feeding mothers. They workedvoluntarily within the trust and in the Children's Centresin the community.

• Patients in the Halton area were able to access day casesurgery services at the Halton hospital but needed tomeet criteria of the American Society ofAnaesthesiologists (ASA) guidelines. In addition, theday-case ward was only open Monday to Friday from7:30am until 7:30pm. The day case unit closed duringquieter times in the year, such as Christmas andsummer holidays.

• Medical termination of pregnancy (TOP) service wasavailable at Warrington for baby abnormalities. Patientsthat requested a TOP for ‘social’ reasons weresignposted to independent health providers locally. Thisservice involved MDT from the baby medicineconsultants, bereavement midwife, paediatricians.

• Patients admitted for TOP that were more than 18weeks pregnant, were cared for in a dedicated ButterflyRoom on labour ward. Patients that were less than 18weeks pregnant were cared for on the gynaecologywards. However, staff informed us that there was notenough space on the gynaecology wards to provideprivacy to patients, especially those experiencing amiscarriage or TOP. A single side room was not alwaysavailable which could lead to a delay in procedures.

• The trust had a “Fetal Remains” policy that included aflowchart for handling and storing remains, postmortem consent form, specific roles and responsibilitiesfor staff such as the mortuary, ward staff, bereavementteam, chaplaincy and crematorium.




• Staff informed us that they followed the fetal remainstrust policy when caring for patients who had lost ababy. The policy included duties and responsibilities ofstaff and departments, sources and references andassociated documents.

• For non–English speaking patients, the trust accessedan interpreter service to provide face to face ortelephone interpretation as well as a translation service.

• There was a range of information leaflets available thatwere all in English. Staff told us that leaflets, inlanguages other than English, could be accessedthrough the trust electronic systems. This includedinformation in either larger font or Braille for visuallyimpaired patients.

• Gynaecology patients with dementia were identifiedusing the “Forget Me Not” flower symbol on theelectronic patient information system.

• We observed a hospital chaplain visiting a patient onthe ward providing support to a patient.

• There was a prayer room close to the gynaecology andmaternity departments at Warrington. This includedwashing facilities for Muslim patients and visitors.

• There were a number of noticeboards, on thegynaecology ward including palliative care, studentboard, fire information, staff information and ‘how arewe doing?’

• Equipment in colposcopy was suitable for bariatricpatients. Patients with reduced mobility could be seenin the main scan area where hoisting was possible ifneeded.

• Patients who attended EPAU or patients withhyperemesis (excessive nausea and vomiting inpregnancy) were given open access to the gynaecologyward. Some initially presented at Halton Hospital.Patients could be transferred to Warrington if needed forfurther care and treatment.

• For the EPAU, any patient that experienced amiscarriage was referred to the bereavement midwifefor support and counselling.

• On the gynaecology and maternity wards, the dailysafety briefing record included any patients with specificneeds and required additional support.


• All complaints were reviewed by the patient experiencemanager who liaised with the ward managers andmatrons depending on the seriousness level of theconcern. A multidisciplinary 72-hour rapid review wascarried out to deter the cause for complaint andimplement further view and an action plan if required. Alead member of staff was appointed to oversee thecomplaint and a timeline was established by thegovernance lead.

• Complaints from complaints were discussed at thedivisional integrated governance group whererecommendations, education were discussed andlessons learnt disseminated to staff via newsletters,email, multi-disciplinary meetings and safety briefmeetings.

• Staff informed us that if a single learning point messagecame from a complaint a “Quality Headline” memowere sent to staff.

• Between January 2016 and December 2016 there were10 complaints about maternity and gynaecology. Thetrust took an average of 134 days to investigate andclose complaints, this was in line with their complaintspolicy, which states complaints should be closed withinsix months . There were four complaints open, for anaverage of 203 days, which is not in line with the trust’stimeframe. Staff told us that there had been about sixcomplaints in the past 12 months with a timelyresponse for all these complaints.

• There was information displayed, throughout thegynaecology department to inform patients how tomake a complaint via the Patient Advice and LiaisonService (PALS) system.

Are maternity and gynaecology serviceswell-led?



At the previous inspection in January 2015, we rated wellled as requires improvement mainly due to the division




between medical and midwifery staff, lack of a teamapproach to improve the service, reactive approach fromleadership and a risk averse culture among staff. We havemaintained this rating following this inspection because:

• Through the trust’s Clinical Business Unit (CBU),Women’s and Children’s Health was one of fourspecialities that was within the “Surgery and Women’sand Children’s Health” structure. Surgery and Women’sand Children’s Health was managed by the Chief ofService, Associate Director of Operations and AssociateDirector of Nursing.

• Women’s and Children’s Health consisted of breastsurgery, maternity, obstetrics and gynaecology andpaediatrics and neonatology.

• Women’s and Children’s Health management structureconsisted of a Clinical Director, CBU Manager,Paediatrics matron, Midwife Matron, Head of Midwiferyand Speciality Lead.

• The Clinical Business Unit (CBU) team was reviewing thelack of a specific maternity dashboard to collect activitydata and benchmark outcomes to implement changes.However, we were not assured that the current datacollection system was adequate to review the quality ofcare, monitor services or support improvements.

• The risk register had seven maternity, obstetrics andgynaecology risks listed. Five risks remained static, onerisk had increased in severity and only one risk hadreduced in severity. This did not assure us that controlswere working and that action to mitigate risk waseffective.

• Senior staff were aware and concerned about theannual reduction in the birth rate at the trust. However,we were informed about plans to increase this rate.

• Not all staff were aware of the vision and strategy for thefuture of the maternity service; however, they wereaware of the short terms plans to develop the service.

• The ward managers and band seven midwives said theydid not always have the time to carry out theirmanagerial roles as they were often providing hands oncare to patients and were not supernumery on the dutyrota.

• Staff informed us there was open culture throughout theservice however, we were given examples were staff hadspoken up and raised concerns and there was littleevidence to suggest the concerns were taken seriouslyand managed well.

• Staff reported that it was not always possible to attendnecessary meetings due to clinical and staffingdemands, therefore difficult to relate information backto their staff.

• Staff informed us that the trust executive team did notvisit the maternity ward areas frequently.

However:

• Medical and midwifery staff informed us that the riskaverse and reactive culture that was present at the lastCQC inspection had improved but there was room forfurther improvements.

• The service had recently relaunched the MaternityServices Liaison Committee (MSLC) with a newlyappointed chair.

• We observed and staff informed us that the workingrelationship and communication between medical staffand midwifery staff had improved since the last CQCinspection.

• Midwifery staff told us that they could articulate theiropinions and views and work within a more teamfocused approach. There was evidence of sharededucation, shared practice and shared learning.

• Maternity staff told us it was a happier place to work andthe culture had improved.

• Midwives informed us that a recently appointed HoMwas visible, proactive and they now felt they had arepresentative “voice” up to the executive board. Shewas well respected by all the staff and staff felt thatmaternity would now be high on the trusts agenda.

• Information was disseminated regularly through dailyemails and a closed Facebook page, which includedvideo information.

• For TOP procedures, national legislation was followed inthe completion of the HSA1 form.




• The maternity service had been award a large sum ofmoney from the Maternity Safety Training Catalogue –Health Education England. The plans were to developthe training and education programme.

• The Midwifery service won the RCM 2017 “Team of theYear” during our inspection. The acupuncture midwifewas also “highly recommended” at these nationalawards.

• The trust chief executive officer (CEO) was a panelmember on the National Maternity Review (NHSEngland majorreviewof maternityservices as part of theNHS Five Year Forward View).


• The Clinical Business Unit (CBU) had seven mainobjectives set out for 2016 to 2107, which included thetrust mission, vision and core values. The objectiveswere set out under the CQC core values of safe, effective,caring, responsive and well led. Measurements forobjectives included monthly governance dashboard, upto date risk register with appropriate risk classificationsand shared lessons learned by cascading theinformation to all specialties.

• There was a Midwifery Strategy 2017-2021 Making BirthsBetter, with clear priorities to deliver good quality care.The strategy was based on evidence andrecommendations in the Intrapartum Care Guideline forWomen with uncomplicated pregnancies (NICE 2014)and Better Births: A five Year Forward View for MaternityCare (NHS England 2016), staff feedback from the focusgroups and workshops and the Maternity ServiceLiaison Committee (MSLC) meetings. Senior staff werekeen for midwives to be the integral component of thisstrategy.

• An updated Women and Children’s Strategy, 2016 - 2018,was also in place. This included plans that would beeasily adapted to fit any around the new regionalstrategy within the new care models for the future. Thestrategy included objective and action plans, somealready in progress.

• We were also provided with a midwifery strategy for2015-2018. This was a list of expectations, duties andresponsibilities of all midwives employed by the trust.

• The vision for the AMU was to establish a culture wherenormality is valued and part of mainstream service

delivery. This included increasing Maternal choice inplace of birth, awareness of Midwife led care in the AMU,increase the number of births on the AMU and providingsafe and effective care, ensuring all transfers areclinically indicated, timely and appropriate.

• Even though midwives were keen and enthusiasticabout the appointment of the new Head of Midwifery(HoM) and the establishment of the AMU, there was alack of clarity for clinical staff about the future of thematernity service. Staff informed us that they were keento establish midwifery led care and the “normal birth”care model however; they were not sure how this wouldfit into the plans across the region and worried aboutthe financial and environmental constraints within thetrust.


• Since the implementation of the new electronic patientsystem computer system in November 2015, Women’sand Children’s Health had been unable to collectmaternity statistics and data for reports required bylocal, regional and national organisations such as PublicHealth England, UK National Screening Committee,Department of Health and Clinical CommissioningGroup. There was no facility enabled on the newelectronic patient IT system to generate these reports.The inability to monitor quality of care and provideassurance reports to local, regional and national bodieswas on the risk register.

• However, since the inspection, the trust have providedevidence which suggested they had madeimprovements to collect maternity data.

• CBU senior staff informed us that they recognised theneed for a detailed robust data collection system andthat senior staff had been reviewing the issue since May2016.

• During our inspection, we were shown a draft regionalmaternity dashboard from February 2017, where fullimplementation was to discussed at the next CBUwomen’s health governance board meeting on the 16March 2017.

• Once agreement was given by the trust to implementthe new regional maternity dashboard, CBU staffinformed us that they would continue to use their old




data collecting system as well as slowly introducing thenew system, until the Failure Mode Effective Assessment(FMEA) tool was completed. This was to provideassurance that the new data collection system waseffective and could be used to change practice.

• At the time of our inspection, the data collectionmidwife collated data from the Birth Register book onlabour ward on a monthly basis, by hand. This coveredonly some elements of labour and delivery outcomesand did not cover all the data collection needed;therefore, this was only a partial control measure. Wewere also informed that data collected in this way wasvery reliant of completion of all clinical data by theclinical midwives, which proved challenging at times.Therefore, we were not assured that the current datacollection system was adequate, sufficient and robust toreview the quality of care, monitor services or supportimprovements.

• A Strategic Clinical Network North West Coast Maternitytrial dashboard had been in circulation across the area,however, CBU staff informed us that the trust decidednot to use it until the format finalised. Staff informed usthat they were behind other regional trusts in the localnetwork, as they could not join the pilot schedule for thenew reginal dashboard, as the trust did not have thedata to input onto the system due to theimplementation of the new electronic patient IT system.

• The risk management lead midwife carried out riskassessment audits and led on the progress of actionplans from these audits. The results from these auditswere feedback to team leaders, governance lead,governance board, and the practice developmentmidwife for training needs analysis.

• All maternity risks were managed and monitored by theclinical governance lead and reviewed at the monthlywomen’s health governance meetings.

• These meetings were well attended however; wereviewed minutes from the October, November andDecember 2016 meetings and observed that the head ofmidwife (HoM) and bereavement midwife had onlyattended one of these meeting. The safeguarding andaudit midwives had not attended any of these meetings.No other midwifery representation was evident.

• All new significant and high risks were approved throughthe directorate processes before being placed on therisk register.

• The trust provided a risk register for the period up to 9March 2017. There were seven maternity, obstetrics andgynaecology risks listed.

• Six risks were rated as “high”. This included poor dataquality compliance due to the trust wide issues with thenew electronic patient IT system. This was identified onthe risk register in January 2016 and the initial risk scorewas eight. After the last review in January 2017, this hadincreased to a rating of 12. A risk mitigation action planwas in progress. However, due to the increase in rating,the action plan did not assure us that actions tomitigate risk were adequate.

• One risk identified in October 2015 involved CTGmachines. The risk rating of nine was static since firstbeing identified. Another risk identified in June 2016regarding non-compliance with NICE guidelines formental health also had a static rating score of nine. Bothrisks had action plans in place. However, the staticratings did not assure us that actions to mitigate riskwere adequate.

• Two other risks were identified in December 2016 andone in January 2017. All were identified as high risk butagain all had static rating scores after review.

• There was one risk identified in December 2016 for thenon-compliance of cancer waiting times. This wasinitially rated as “extreme” with a risk score of 20.Following review and a risk mitigation action plan, therisk had reduced to “high” with a rating score of nine.This provided some assurance that the action plan washaving a positive effect to mitigate risk.

• Minutes from the Patient Safety and ClinicalEffectiveness Sub Committee meetings provided fromthe trust included discussions and actions for topicssuch as serious incident review updates, lessons learntfrom incidents updates, safety alerts, high-level briefingand risk register. The minutes documented leads for anyactions and review dates. Attendees included the trustexecutive board and senior heads of services. Wereviewed five different meeting minutes and observedthat direct midwifery representation only occurred intwo of these meetings.




• Monthly Colposcopy MDT meetings took place. Theagenda included comments from informationdocuments submitted to Women’s Health Risk groupand operational issues. Minutes and action plans weredocumented with a named lead.

• Monthly Guideline Review meetings took place toapprove new guidelines and discuss current guideline.This provided assurance that guidelines were reviewedregularly according to evidence based practice.

• For TOP procedures, national legislation was followed inthe completion of the HSA1 form.


• Through the trust’s Clinical Business Unit (CBU),Women’s and Children’s Health was one of fourspecialities that was within the “Surgery and Women’sand Children’s Health” structure. Surgery and Women’sand Children’s Health was managed by the Chief ofService, Associate Director of Operations and AssociateDirector of Nursing.

• Women’s and Children’s Health consisted of breastsurgery, maternity, obstetrics and gynaecology andpaediatrics and neonatology.

• Women’s and Children’s Health management structureconsisted of a Clinical Director, CBU Manager,Paediatrics matron, Midwife Matron, Head of Midwiferyand Speciality Lead.

• Some staff felt this new CBU structure was positive andsaid it would help to improve the focus on quality formaternity services and strengthen the structure,leadership and management of the service. However,other staff told us that maternity and gynaecology was“overshadowed by surgery”.

• There were clear local management structures in placethat identified lines of accountability.

• There were clearly defined and visible local leadershipin place in all gynaecology and maternity areas.

• Staff felt generally well supported by their localmanagers who were visible, approachable and willing todiscuss any concerns.

• The consultant midwife was the clinical lead for low riskcare within the trust and provided guidance, leadershipand professional direction of the service.

• The ward managers and band seven midwives said theydid not always have the time to carry out theirmanagerial roles as they were often providing hands oncare to patients and were not supernumery on the dutyrota. This affected their ability to leave the clinical areasto attend management and MDT meetings.

• Maternity staff informed us that there was poor visibilityof the executive board in the clinical areas. However,they did feel that the new HoM had a “voice” at boardlevel and they felt confident the HoM would representthe service in a proactive and positive way. This was animprovement from the last CQC inspection, where stafffelt management worked in a reactive way.

• However, some senior midwifery, nursing and medicalstaff informed us that the trust board still had a reactiveapproach and went above and beyond protecting staffand patients following some incidents by changing andstopping practice to avoid similar issues reoccurring.

• Senior staff also felt that there was an over amount ofstandard operating procedures (SOPs) and guidelinesfor standard practice, which inhibited staff from carryingout routine basic clinical procedures. Examples weregiven of maternity staff not carrying out blood sugartests for babies or testing babies for jaundice. However,these are standard procedures covered under the NMCcode of practice and midwifery training.


• Most staff we spoke with felt supported by theirdepartmental managers. They felt supported to learnand develop professionally through their annualappraisals.

• Most staff felt there was an open culture and told usthey were supported across departments and all staffwe spoke to liked working at the hospitals.

• However, we were given three examples from differentstaff about concerns being raised but nothinghappening as a result. There was a perception fromsome staff that if concerns were raised higher than theirimmediate manager, nothing would happen. This hasled to some frustration with the staff and a feeling thatescalating concerns was sometimes pointless. A similarconcern was raised at the last CQC inspection.




• Senior staff informed us that there was a working partyset up to support the “It’s OK to Question” project. Thiswas to provide support staff, especially more junior staff,when productively and professionally questioningchallenging clinical decisions by other members of staff.

• Most staff were very positive and spoke enthusiasticallyabout their own departments, with good teamwork andmany having worked at both hospitals for several years.Midwives told us that two years ago they “walked withtheir heads down” but now “walk with their heads heldhigh”.

• The head of midwifery had an open door policy andmatrons visited all areas daily to address concerns andissues.

• The working relationship between medical staff andmidwives had improved since our last CQC inspection.Both professions told us that they now worked closelytogether into a productive and supportive way.

Equalities and Diversity – including Workforce RaceEquality Standard (to be used by exception only –main section is in the Provider report)

• Information provided from the trust showed that 44% ofthe doctors in the women’s health department were ofwhite ethnic origin and 56% were from black, Asian,minority ethnic (BAME) group. We found that in thehealthcare assistant (HCA) group of staff there were 95%white HCAs and 5% from the BAME group. There were93% midwives from a white background and 7% fromthe BAME group. There were 94% white staff nurses and6% from the BAME group. This indicated that apart fromthe medical doctors, there was a sufficient difference inboth groups.

Public engagement

• The service had recently relaunched the MaternityServices Liaison Committee (MSLC) with a newlyappointed chair. This forum enables maternity serviceusers, providers and commissioners of maternityservices to come together to design services that meetthe needs of local patients, parents and families.

• The gynaecology department participated in the NHSFriends and Family Test (FFT) and information abouthow patients and those close to them could providefeedback was displayed in corridors.

Staff engagement

• Ward managers had an ‘open-door policy’ and activelyencouraged staff to discuss any concerns.

• Staff told us that staff engagement and communicationwas mainly through team meetings, memos, newslettersor by emails.

• The HoM sent staff regular updates via her closed socialnetworking blog page. Staff spoke very positively aboutthis form of communication.

• All staff received a Friday email message from the ChiefExecutive.

• Senior staff told us that it was not always possible toattend management and divisional meetings, thereforedifficult to relate information back to their staff.

• Junior midwives told us they would like to be invited tomanagerial and senior meetings to gain a greaterunderstanding of what was discussed and the rationalebehind decisions made. This would also make them feelmore part of the wider team. Currently, some junior stafftold us that only the senior staff were invited to suchmeetings and they were never asked to deputise ifsenior staff were unable to attend.


• We were informed that the current traditional way ofworking for the community midwifery team was aboutto change. Community midwives were soon to rotateinto the AMU to increase continuity of care and increasehospital and homebirth rates.

• The women and children’s health clinical business unithad a business plan set out for 2017 to 2018. Highlightedwere concerns about senior clinical and nursing staffretiring, which is a nationally recognised problem.

• The CBU was committed to supporting new initiativesand delivering national standards in conjunction with anumber of new papers and guidance such as NationalMaternity Review 2016.

• There was some uncertainty among staff about thefuture of the maternity service especially within the localVanguard (leading the way in new developments or




ideas) New Care Model programme within the region.Staff were aware of the plans within the unit for changesbut there was some uncertainty and insecurity aboutfuture plans within the wider geographical area.

• The maternity service had been award a very large sumof money from the Maternity Safety Training Catalogue –Health Education England. The plans for the fundingincluded: PROMPT (Practical Obstetric MultiProfessional Training), AIMS training, RCOG labour wardleads, RCM leadership training, CTG masterclasstraining, human factors training, breech birth training,conferences and midwifery led environment.

• The Health Education England funding was also goingtowards two initiatives: “Whose Shoes?” This is avalues-led, bespoke approach to change management,in the form of an engaging board game. The scenarioshave been co-produced using the real voices of peopleusing maternity services, clinicians, policy makers,commissioners, independent providers and othersassociated with pregnancy, childbirth and earlyparenthood.

• The second initiative is purchasing the Baby Buddy app.This app will guide parents through pregnancy and thefirst six months of their baby’s life. It has been designedto help and support health and wellbeing and isavailable 24 hours a day.

• During our inspection, the midwifery service won theRCM Team of the Year 2016 for Excellence in MaternityCare. The acupuncture midwife was also “highlyrecommended” at these national awards.

• Other awards achieved within the service included:Maternity Service – Health Service Journal (HSJ) Finalist2016 for Patient Safety - Learning and Improvement.

• The trust chief executive officer (CEO) was a panelmember on the National Maternity Review (NHSEngland major reviewof maternity services as part of theNHS Five Year Forward View).

• Gynaecology Innovations included a dedicated fertilityclinic, Urogynaecologist lead on all complex vaginalgynaecology surgery, specialist nurse colposcopists, anda gynaecology rapid access clinic.




Safe Good –––






Information about the serviceWarrington and Halton Hospitals NHS Foundation Trustprovides a range of paediatric and neonatal services.Neonatal services are located on the first floor andpaediatric services are located on the ground floor of themain hospital building in Warrington. In addition, somepaediatric outpatient appointments are offered at HaltonGeneral Hospital.

The neonatal unit has 18 cots and provides intensive care,high dependency care and special care for newborn babies.The children’s unit consists of 37 beds, which include a 10bedded cubicle area incorporating one high dependencybed, a seven bed paediatric day surgery area a six beddedassessment area and a 14 bedded bay area. A dedicatedpaediatric outpatient clinic is located next to the children’sunit and a paediatric accident and emergency area issituated next to the main accident and emergencydepartment. A paediatric acute response team (PART)deliver care in conjunction with a local community providerat a Health and Wellbeing centre in Warrington towncentre.

Hospital episode statistics data (HES) showed there were5435 children and young people seen between 1 December2015 and 30 November 2016. Of these 93.1% wereemergency admissions, 5.4% were day case admissionsand 1.5% were elective admissions.

We visited Warrington and Halton Hospitals between the 7and 10 March 2017 and performed an unannounced visiton the 23 March 2017. We inspected a range of paediatric

services including the children’s unit, the neonatal unit,surgical theatres and the paediatric outpatientsdepartment and we visited the Paediatric Acute ResponseTeam (PART) at Bath Street Health and Wellbeing Centre.

We spoke with 16 patients and/or carers, observed careand treatment and inspected 17 sets of records and 16prescription charts. We also spoke with 48 staff of differentgrades including nurses, doctors, consultants, wardmanagers, specialist nurses, housekeepers andadministrative staff. We received comments from peoplewho contacted us to tell us about their experiences and wereviewed performance information about the trust.

Servicesforchildrenandyoungpeople

Services for children and young people


Summary of findingsWe rated services for children and young people asGood because:

• Staff could demonstrate the process to reportincidents and received feedback both individuallyand in staff meetings. Lessons learnt were shared instaff meetings and through the Safety Brief and trustwide email.

• The wards and clinical areas were visibly clean. Staffwere aware of and adhered to current infectionprevention and control guidelines such as the ‘barebelow the elbow’ policy. Personal protectiveequipment such as aprons and gloves were readilyavailable throughout the neonatal and children’sunit.

• Staff were aware of their safeguarding roles andresponsibilities and knew how to raise matters ofconcern appropriately.

• All staff groups exceeded the trust target forcompliance with mandatory safeguarding training.

• Age dependant pain assessment tools were in use inthe children’s unit and analgesia and topicalanaesthetics were available to children who requiredthem.

• Between October 2015 and September 2016, thetrust performed better than the England average forthe percentage of patients aged 1-17 years who hadmultiple emergency admissions for asthma.

• 18 staff out of 33 on the children’s unit hadcompleted the high dependency course.

• In the neonatal unit 28 out of 34 eligible staff wereQualified in Speciality (QIS). This is a standard level ofknowledge and skills for nurses within neonatal care.

• Staff described the principles of Gillick competencyused to assess whether a child had the maturity tomake their own decisions.

• Parents told us they felt involved in the decisionsregarding their child’s care and confident aboutleaving their baby in the neonatal unit.

• A CAMHS worker was present in the paediatricemergency department between 5pm and 11pmseven days per week to ensure timely assessment ofchildren and young people.

However,

• Cleaning checklists were observed but at the time ofthe inspection, these were not consistentlycompleted within all departments.

• Safety testing for equipment was in place however,we noted that a number of items in the paediatricoutpatient clinic were out of date for example aurinalysis machine that had been due for review inApril 2015 and two ophthalmoscopes due in January2016 and February 2016.

• Six staff within the children’s unit had completedAdvanced Paediatric Life Support (APLS) traininghowever, managers told us there was not always anurse on duty with APLS.

• Staffing within the children’s unit did not follow RoyalCollege of Nursing (RCN) standards (August 2013)and neonatal nurse staffing did not meet standardsof staffing recommended by the British Associationof Perinatal Medicine (BAPM).




Are services for children and youngpeople safe?

Good –––

We rated safe as 'Good' because:

• Staff could demonstrate the process to report incidentsand received feedback both individually and in staffmeetings. Lessons learnt were shared in staff meetingsand through the Safety Brief and trust wide email.

• Joint obstetric and neonatal mortality and morbiditymeetings were held monthly. Mortality reviews forpaediatric deaths were completed by the paediatricteam in conjunction with the safeguarding team and keymessages and learning points were fed back to staff.

• The wards and clinical areas were visibly clean. Staffwere aware of and adhered to current infectionprevention and control guidelines such as the ‘barebelow the elbow’ policy. Personal protective equipmentsuch as aprons and gloves were readily availablethroughout the neonatal and children’s unit.

• Hand hygiene audits completed between 01October and 31 December 2016 showed the neonatalunit achieved 100% compliance in all areas, results onthe children’s ward B11 ranged from 89% to 100%.

• Emergency resuscitation equipment was in place in thechildren’s unit and neonatal unit and records indicatedthis was consistently checked.

• All medicines in the neonatal and children’s unit werefound to be in date and stored securely in a lockedcupboard as appropriate, and in line with legislation.Controlled drugs were stored securely and accuraterecords maintained in accordance with trust policy.


• All staff groups exceeded the trust target for compliancewith mandatory safeguarding training. Newborn LifeSupport training was completed by staff in the neonatalunit, 88% of staff had received this training and therewas always at least one staff member with NLS on everyshift.

However:

• The children’s unit and neonatal unit had controlledaccess however, even with a raised handle, access couldbe obtained to the dirty utility room in paediatricoutpatient clinic despite being designated a staff onlyarea.

• Safety testing for equipment was in place however, wenoted that a number of items in the paediatricoutpatient clinic were out of date for example aurinalysis machine that had been due for review in April2015 and two ophthalmoscopes due in January 2016and February 2016.

• There was no dedicated paediatric pharmacist for thechildren’s unit which is not in line with accepted bestpractice. Since the CQC visit the team has submitted abusiness case that approved and trust has confirmthat a specialist paediatric pharmacist has beenappointed.

• Six staff within the children’s unit had completedAdvanced Paediatric Life Support (APLS) traininghowever, managers told us there was not always a nurseon duty with APLS.

• Staffing within the children’s unit did not follow RoyalCollege of Nursing (RCN) standards (August 2013) andneonatal nurse staffing did not meet standards ofstaffing recommended by the British Association ofPerinatal Medicine (BAPM).

However,

• Staff could demonstrate the process to report incidentsand received feedback both individually and in staffmeetings. Lessons learnt were shared in staff meetingsand through the Safety Brief and trust wide email.

• Joint obstetric and neonatal mortality and morbiditymeetings were held monthly. Mortality reviews forpaediatric deaths were completed by the paediatricteam in conjunction with the safeguarding team and keymessages and learning points were fedback to staff.





• Hand hygiene audits completed between 01/10/2016and 31/12/2016 showed the neonatal unit achieved100% compliance in all areas, results on the children’sward B11 ranged from 88.9% to 100%.


• All medicines in the neonatal and children’s unit werefound to be in date and stored securely in a lockedcupboard as appropriate, and in line with legislation.Controlled drugs were stored securely and accuraterecords maintained in accordance with trust policy.


• All staff groups exceeded the trust target for compliancewith mandatory safeguarding training. Newborn LifeSupport training was completed by staff in the neonatalunit, 88% of staff had received this training and therewas always at least one staff member with NLS on everyshift.

Incidents

• Incidents were reported using an electronic reportingsystem. Staff could demonstrate the process andreceived feedback both individually and in staffmeetings.

• Lessons learnt were shared in staff meetings andthrough the Safety Brief and trust wide email. Staffcould describe examples of changes in practicefollowing incidents such as a change in the brand oftopical anaesthetic cream used and the introduction oftimers to monitor length of application.

• There were no never events or serious incidentsreported by the trust within children’s services betweenJanuary 2016 and December 2016. Never events areserious patient safety incidents that should not happenif healthcare providers follow national guidance on howto prevent them. Each never event type has thepotential to cause serious patient harm or death butneither need have happened for an incident to be anever event.

• Between January 2016 and December 2016 520incidents were recorded by children’s services. Of these,

517 were reported as low or no harm. This showed thetrust were actively reporting and recording incidents toensure the quality of the service was maintained. Of theincidents classified as low or no harm 33 related to themanagement and administration of medicines and 54related to staffing. We reviewed details relating to fourincidents, all documented the outcome of the incidentand highlighted actions to improve service delivery.

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson. Some staff we spoke to were unfamiliar with theterm ‘Duty of Candour’ however all could describe theprinciple and the circumstances in which it was used.

• Joint obstetric and neonatal mortality and morbiditymeetings were held monthly. These are meetings toreview deaths and adverse incidents to enable lessonsto be learnt and highlight areas for improvement.Mortality reviews for paediatric deaths were completedby the paediatric team in conjunction with thesafeguarding team and key messages and learningpoints were fedback to staff.

• Managers told us all child deaths were reviewed by adesignated lead paediatrician from the Child DeathOverview Panel (CDOP).



• Hand washing facilities, including hand gel were readilyavailable in prominent positions in each clinical area forthe use of staff, visitors and patients.

• There were arrangements in place for the handling,storage and disposal of clinical waste, including sharps.

• Hand hygiene audits completed between 01/10/2016and 31/12/2016 showed the neonatal unit achieved100% compliance in all areas, results on the children’sward B11 ranged from 88.9% to 100%.




• Cleaning checklists were observed however these werenot consistently completed within all departments. Thiswas highlighted to trust staff at the time of ourinspection, who took action to address this concern.The trust have submitted additional information tosupport these changes. A schedule was in place forcleaning and changing curtains within clinical areas.

• Stickers were placed on equipment to inform staff at aglance that equipment had been cleaned and we sawevidence of this being used in the children’s unit and theneonatal unit.

• In the CQC children’s survey 2014 the trust scored thesame as other trusts for the question “How clean do youthink the hospital room or ward was that your child wasin?”.

• Parents in the children’s unit told us they observed staffwashing their hands before delivering care and parentsin the neonatal unit told us they were provided withinformation regarding infection control.


• The children’s unit was decorated with an underwatertheme. Pictures of fish and underwater scenes were alsopositioned on the main corridor and were designed as adistraction for children on the way to theatre.

• The entrance to the neonatal unit had a photographicdisplay of previous patients with their birthweight,entitled “Look at us now”. This indicated how thechildren had grown and developed since discharge fromthe unit and demonstrated positive outcomes forcurrent and future parents.

• The children’s unit and neonatal unit had controlledaccess however, even with a raised handle, access couldbe obtained to the dirty utility room in paediatricoutpatient clinic despite being designated a staff onlyarea. This meant visitors to the department includingpatients and siblings, could access a potentiallydangerous area containing medical equipment andused for testing clinical specimens. Following theinspection the trust provided evidence that anadditional high level lock had been fitted.

• Bay two in the neonatal unit was designated for 10special care cots. Four cots did not have wall mountedoxygen and suction, however portable oxygen andsuction was available. This was added to the neonatalunit risk register following our inspection.


• Supplementary emergency equipment and a transferbag used when accompanying sedated children forMagnetic Resonance Imaging (MRI) was observed inpaediatric outpatient clinic however, records indicatedbetween 3/1/17 and the time of our inspection thisequipment had not had daily checks on a number ofoccasions. This was brought to the attention of staffduring our inspection.

• Safety testing for equipment was in place however wenoted that a number of items in the paediatricoutpatient clinic were out of date for example aurinalysis machine that had been due for review in April2015 and two ophthalmoscopes due in January 2016and February 2016. This was brought to the attention ofstaff during our inspection.

• We reviewed equipment again in paediatric outpatientclinic during our unannounced visit and observed someof the non-compliant items of equipment had beentested since our announced visit to the trust.

• The recording of the temperature of the fridge on theneonatal unit used for the storage of breastmilk was notconsistently completed. Between 1/1/17 and the time ofour inspection temperature recordings were missed on27 occasions. This had also been noted in an infectioncontrol audit completed by the trust in January 2017.

• A Suicide Prevention Policy was in place, which detailedhow the paediatric environment should be risk assessedprior to the admission of a child or young person withmental health issues.

• In the CQC children’s survey 2014 the trust scored thesame as other trusts for the question “Did the wardwhere your child stayed have appropriate equipment oradaptations for your child?”.

Medicines




• All medicines in the neonatal and children’s unit werefound to be in date and stored securely in a lockedcupboard as appropriate, and in line with legislation.

• Controlled drugs were stored securely and accuraterecords maintained in accordance with trust policy.Controlled drugs that had expired were included intwice daily checks but separated from stock that was indate until removed by pharmacy, however staff advisedthat this could take several weeks.

• Medicines fridges were secured however daily fridgetemperatures were not consistently recorded. Thetemperature of a medicine fridge should be monitoreddaily to ensure the contents are stored under conditionsto ensure quality and effectiveness is maintained.

• There was no dedicated paediatric pharmacist for thechildren’s unit which is not in line with accepted bestpractice however pharmacy support was available froma pharmacist within the clinical business unit. Lack ofpaediatric pharmacy support had been recorded on thedepartmental risk register since July 2015 and an actionplan was in place to mitigate risk. The BritishAssociation of Perinatal Medicine (BAPM) details therequirements for pharmacy support to neonatal servicesin their service standards for hospitals providingneonatal care.

• Prior to our unannounced inspection a StandardOperating Procedure for pharmacy visits to paediatricshad been developed and daily pharmacy visits hadcommenced. A business case was also drafted toidentify pharmacy support going forward..

• The trust employed a medicines safety nurse whomonitored drug errors as part of their role. Records wereviewed confirmed that following a drug error thepractice of the individual would be reviewed andsupport provided to reflect on the incident.

• We reviewed 16 prescription charts during ourinspection. Of those reviewed, all had the weight andage or date of birth of the child, 15 were legible, signedand dated and 14 had allergies documented.

• A stock of take home medicines were stored on the wardto give to patients discharged outside of the pharmacy’sopening hours. Processes were in place to ensure thesafe issue of medicines at the point of a patientsdischarge.

• In the paediatric outpatients department doctorsprescribed medicines for patients to take home on anoutpatient prescription form, medication was thendispensed by pharmacy.

• Nurses in the paediatric acute response team (PART)used Patient Group Directives (PGDs) to dispensemedication such as paracetamol. A patient groupdirection allows some registered health professionals(such as nurses) to give specified medicines (such aspainkillers) to a pre-defined group of patients withoutthem having to see a doctor.

Records

• The trust were in the process of moving to a paperlesssystem. Patient records on the children’s unit consistedof paper records at the bedside including observationand prescription charts while demographic informationand medical and nursing records were electronic. Allpaper records were in use on the neonatal unit.

• Documentation audits were completed weekly in thechildren’s unit and results were presented monthly aspart of the Quality Report. This included audit ofobservation charts, name bands, discharge paperworkand presence of up to date care plans.

• Results between October 2016 and December 2016showed 100% for completion of observation charts,presence of name bands and care plans howevercompletion of discharge paperwork ranged from 62.6%in October 2016 to 70% in December 2016.

• We reviewed 17 sets of records across the neonatal andchildren’s unit, which were generally completed to agood standard. All had a diagnosis and managementplan documented, 16 of the 17 had all entries signedand dated and all had evidence of a daily ward roundincluding review with senior clinicians.

• Any child where there was social or child protectionneed had a separate information sharing form in theirrecords to inform staff at a glance. We observed a formcompleted appropriately in a patients records.

Safeguarding

• Safeguarding policies and procedures were in placeacross the trust and these were available electronically




for staff to refer to. The Safeguarding Children Policyincluded information regarding child sexual exploitation(CSE), female genital mutilation (FGM), domesticviolence and the counter-terrorism strategy Prevent.

• In discussion with us, it was clear that staff were awareof their roles and responsibilities and knew how to raisematters of concern appropriately.

• Staff we spoke with were aware of the safeguardingteam and how to access support and advice.

• Safeguarding training formed part of the trustsmandatory training programme and the trust target was85%. Compliance rates for nursing staff within thechildren’s unit at the time of our inspection were 99%for Safeguarding Adults Level 1 and 97% forSafeguarding Adults Level 2, 100% for SafeguardingChildren Level 1 and 2 and 95% for SafeguardingChildren Level 3.

• Compliance rates for neonatal nursing staff at the timeof our inspection were 100% for Safeguarding AdultsLevel 1 and 97% for Safeguarding Adults Level 2, 100%for Safeguarding Children Level 1 and 2 and 90% forSafeguarding Children Level 3.

• Compliance rates for medical and dental staff withinservices for children and young people were 100% in allmodules.

• The trust safeguarding team structure included a leaddoctor and lead nurse for safeguarding children,supported by a specialist nurse and a named midwife.

• A pathway was in place in the paediatric outpatientsdepartment for children who were not brought forappointments and formed part of the SafeguardingChildren Policy.

• An audit of the trust wide use of the Did Not Attend(DNA) pathway reported in September 2016 that thetrust was non-compliant with the safeguarding childrenDNA process. An action plan in response to the findingsincluded a review of the DNA process within thesafeguarding children policy, circulation of informationregarding neglect and the impact of DNAs and repeat ofthe audit annually.

• A paediatric liaison health visitor visited the children’sunit daily and details of primary care professionals wereobtained as part of the admission process. This ensured

communication with community health professionalswho were involved with the child, enabled informationregarding current safeguarding concerns to be sharedand ensured continuity of care between hospital andcommunity.

• Following the inspection and at the factual accuracystage the trust provided evidence that the SafeguardingChildren Supervision policy was ratified and went live inMay 2017. Midwives and paediatric nurses who casehold patients have all been allocated a supervisor andare expected to attend supervision ever six to eightweeks. All identified safeguarding children supervisorswill also be provided with one-to-one supervision fromthe Named Nurse Safeguarding Children.

Mandatory training

• Staff received training in areas such as fire safety,infection control, information governance andresuscitation. Training was delivered online as well asface to face.

• Managers and staff we spoke to told us that nursing staffwere allocated mandatory training sessions and thiswas incorporated into the off duty rota.

• The trust target for mandatory training was 85%.Compliance rates for nursing staff within the children’sunit at the time of our inspection ranged from 92% forresuscitation to 100% for Health and Safety.

• Compliance rates for neonatal nursing staff ranged from75% to 98% with compliance rates for Infection Controland Information Governance falling below the trusttarget.

• Compliance rates for mandatory training for medicaland dental staff within services for children and youngpeople ranged from 60% to 90% with Fire Safety, Healthand Safety and Infection Control falling below the trusttarget.


• The trust used Paediatric Early Warning Scores (PEWS)which is a tool is designed to identify children who areat risk of deterioration. (PEWS) were used to monitor thecondition of a child on the children’s unit and NewbornEarly Warning Scores (NEWS) on the neonatal unit.




Records we reviewed showed that patient observationswere recorded in all cases and action taken ontriggering PEWS/NEWS scores occurred in five out ofseven cases were it was appropriate.

• Monthly audit of Paediatric Early Warning Scores [PEWS]was completed on the children’s unit as part of theQuality Report and results for October 2016 toDecember 2016 showed 100% compliance.

• The Royal College of Nursing documentDefining-staffing levels for children and young people’sservices identifies as a core standard to be applied inservices providing health care for children and youngpeople at least one nurse per shift in each clinical area(ward/department) to be trained in APLS/EPLSdepending on the service need.

• Six staff within the children’s unit had completedAdvanced Paediatric Life Support (APLS) traininghowever, managers told us there was not always a nurseon duty with APLS. Risk was mitigated as all paediatricstaff had completed Paediatric Immediate Life Support(PILS) training and support was provided by onsitemedical staff. Between 1 January 2017 and 28 February2017 48 shifts out of 118 had an APLS trained nurse onduty. Following the inspection the trust providedevidence that the number of APLS trained staff hadincreased to 11 and the remaining 12 staff are tocomplete training by December 2107.

• Newborn Life Support training was completed by staff inthe neonatal unit, 88% of staff had received this trainingand there was always at least one staff member withNLS on every shift.

• Guidelines were in place for the management ofpaediatric sepsis and staff told us they had receivedinformation sessions when these were introduced.

• Transfers of infants between hospitals was completedby the Cheshire and Merseyside Neonatal NetworkTransport service.

• Children and young people who required child andadolescent mental health services (CAMHS) werereviewed in the paediatric emergency department by aCAMHS worker who was present between 5pm and11pm seven days a week. If admission to the children’sunit was required a risk assessment was completed.

Nursing staffing

• The expected and actual staffing levels were displayedwithin the neonatal and children’s unit. This informedpatients and visitors of the current staffing levels.

• At the time of our inspection staff from the children’sunit nursing establishment covered the paediatricaccident and emergency department however a reviewof paediatric urgent care was in progress.

• Staffing within the children’s unit did not follow RoyalCollege of Nursing (RCN) standards (August 2013) whichrecommends a staff ratio of 1:3 for children under twoyears of age and 1:4 for children above 2 years of age.The minimum staffing ratio adhered to was 1:5 withinthe children’s unit. Staff and managers told us this wasmaintained with the use of bank or agency staff ifrequired and rotas we reviewed supported this.

• Managers told us staff and beds were also flexedbetween the ward and assessment area to allow forredeployment of staff according to patient need.

• A staffing review had been completed in September2016 which identified the need for additional staff dueto service pressures and an increase in the acuity ofpatients being cared for on the children’s unit.Recruitment had taken place and was continuing duringour inspection. Following the inspection the trustprovided evidence to show a paediatric acuity tool hadbeen introduced to monitor staffing levels.

• The average fill rate for registered nurses in thechildren’s wards for January 2017 and February 2017 forthe day shift was 94.4% and 106.9% respectively and86.8% and 125.7% for night shifts.

• The average fill rate for care staff in the children’s wardsfor January 2017 and February 2017 for day shift was93.2% and 96.4% respectively and 100% for night shifts.

• The average fill rate for registered nurses and care staffin paediatric emergency department was 100% for bothJanuary 2017 and February 2017 day and night.

• Between January 2016 and December 2016 fiveincidents were recorded relating to staffing on thechildren’s unit. An escalation policy was in place tomaintain safe staffing and a flowchart was displayed in aprominent position in the unit.

• Staffing within the neonatal unit did not meet standardsof staffing recommended by the British Association of




Perinatal Medicine (BAPM). We reviewed staff rotas onthe neonatal unit between 1 January 2017 and 9 March2017 and found that BAPM standards were met on 86shifts from 136, a rate of 61.8%.

• Between January 2016 and December 2016, 48incidents were recorded relating to staffing on theneonatal unit. In the six months prior to our inspectionthe neonatal unit reduced cot capacity on 22 occasionsdue to staffing levels.

• A similar review of nurse staffing was conducted in theneonatal unit in September 2016 which identified anincrease in staff was required to be compliant withBAPM standards.

• Managers told us that bank staff were used to cover forstaff shortages in the neonatal unit and that shifts weremainly covered by existing staff members who werefamiliar with the unit.

• Following the inspection a further paper was preparedrelating to neonatal staffing and an acuity toolintroduced to monitor levels of BAPM compliance.

• We observed a nursing handover, which provided name,age, diagnosis, observations, medications andtreatment plan of patients on the ward. Socialinformation was also provided such as if parents wereresident or if there was any ongoing social careinvolvement.

Medical staffing

• Consultant paediatric and neonatal cover was provided24 hours per day. In December 2016, the proportion ofconsultant staff working at the trust was lower than theEngland average as was the proportion of junior staff,however a further consultant had come into post priorto our inspection.

• In December 2016 the trust reported a vacancy rate of15.9% and a turnover rate of 18.2% in children’s services.

• The trust had nine whole time equivalent consultants(WTE), of whom seven took part in ‘paediatrician of theweek’ rota. At our last inspection British Association ofPerinatal Medicine recommendations for Local NeonatalUnit out-of-hours Tier 1 medical cover was not adhered

to. We reviewed medical rotas between January 2017and March 2017 and while the rota was covered, therewas little extra capacity should there be any additionaldemand on the service.

• Medical staffing was recorded on the risk register andthe trust had employed Advanced Paediatric NursePractitioners (APNP ) in the paediatric emergencydepartment and the neonatal to support the medicalrota. A further APNP post was being recruited to for theneonatal unit at the time of our inspection.

• Paediatric consultants who took part in a “Consultant ofthe week” rota were present in the hospital during timesof peak activity and available on call at other times. Thisensured senior clinical decision could be made in atimely manner.

• We attended a clinical handover on the children’s unit.This was attended by the consultant of the week and alljunior doctors and was observed to be efficient andthorough.


• The trust had a business continuity plan for theWomen’s and Children’s Health Clinical Business Unitwhich listed key risks that could affect the delivery ofservices.

• Staff were aware of the major incident policy anddescribed how information was sent by email from theCommunications department during a recent episodeof bad weather.

• The trust set a target of 85% for completion of majorincident training. Compliance for major incident trainingcourses between January 2016 and December 2016 was57 registered nurses and midwives against a target of 62,14 healthcare assistants against a target of 16 and fivemedical staff against a target of nine.

• Managers told us a separate winter management planwas no longer in place in the children’s unit as demandwas high throughout the whole year however thepaediatric team sat on the Winter Planning groups inthe autumn.

Are services for children and youngpeople effective?




Good –––

We rated effective as Good because:

• The service used National Institute for Health and CareExcellence (NICE) guidelines to determine care andtreatment provided and records we reviewed confirmedthere were a number of evidence-based pathways inplace.

• Paediatric Early Warning Score (PEWS) audits werecompleted monthly as part of a Quality Report andbetween October 2016 and December 2016 compliancewas 100%.

• Age dependant pain assessment tools were in use in thechildren’s unit and analgesia and topical anaestheticswere available to children who required them. In theCQC children’s survey 2014 the trust performed betterthan others for the question ‘Do you think the hospitalstaff did everything they could to help ease your child’spain?’.

• The National Paediatric Diabetes Audit 2014/15 showedthat Warrington hospital performed better than theEngland average for the number of individuals who hadcontrolled diabetes.

• Between October 2015 and September 2016 the trustperformed better than the England average for thepercentage of patients aged 1-17 years who hadmultiple emergency admissions for asthma.

• Staff identified their learning needs through the trustsappraisal process and the trust target was 85%. Trustdata showed that at the time of our inspection 95% ofnursing staff on the children’s unit had received anappraisal, 88% of nursing staff on the neonatal unit and100% of medical staff.

• Eighteen staff out of 33 on the children’s unit hadcompleted the high dependency course This meantthere was at least one nurse on each shift to care forhigh dependency patients.


• Meetings were held with social care and communityprofessionals as required, for example in cases involvingsafeguarding or for patients who required dischargeplanning such as infants receiving oxygen.

• The paediatrician on call was available on a designatedtelephone number three hours per day for GP’s whorequired advice.

• Staff described the principles of Gillick competencyused to assess whether a child had the maturity to maketheir own decisions and how support would beobtained from specialist colleagues and thesafeguarding team when dealing with parents who maylack capacity.


• The service used National Institute for Health and CareExcellence (NICE) guidelines to determine care andtreatment provided for example for neonatal jaundiceand intravenous fluid therapy in children and youngpeople in hospital.

• There were a number of evidence-based pathways inplace for conditions such sepsis and asthma and thePaediatric Acute Response Team (PART) used pathwaysfor conditions such as bronchiolitis and diarrhoea andvomiting.

• The neonatal unit had achieved Level 3 Baby Friendlyaccreditation. The Baby Friendly Initiative supportsbreastfeeding and parent infant relationships and toachieve accreditation the provider is required todemonstrate they have met a set of evidence basedstandards.

• Policies and procedures were in place and could beaccessed via the trust’s intranet and staff we spoke withwere aware of how to access them.

• Paediatric Early Warning Score audits were completedmonthly as part of a Quality Report and betweenOctober 2016 and December 2016 compliance was100%.

• A Children’s Health Audit Programme was in place andincluded topics such as Neonatal Cooling Therapy,Croup and an annual meningitis audit.

Pain relief




• The children’s unit used age dependant painassessment tools. For younger children a faces painrating scale was used and for older children pain wasassessed using a number scoring system.

• The neonatal unit used visual observation to assesspain and anticipatory prescribing of sucrose prior toprocedures taking place.

• Analgesia and topical anaesthetics were available tochildren who required them in the children’s unit.

• The monthly quality report included pain assessment aspart of the record keeping audit. Between October 2016and December 2016 the percentage of records showinga documented pain assessment ranged from 74.9% to90%.

• Managers told us the Pain Specialist Nurse wouldcomplete ward rounds with the surgical team on thechildren’s unit and we observed a discussion with achild and parent during a pre-operative appointmentthat included a discussion regarding pain relief duringthe procedure.

• Patients we spoke with told us that pain relief was given“whenever I needed it”, the staff “always come to ask if Ineed any pain relief” and “I can always ask for more if Ineed it”.

• In the CQC national children’s survey 2014 out of 137acute NHS trusts, the trust performed better than othersfor the question ‘Do you think the hospital staff dideverything they could to help ease your child’s pain?’.


• A range of menus were available on the children’s unit.Patients told us there were “plenty of options”, there was“quite a lot of fruit and a wide choice” and the food “wasbetter than school”.

• Staff told us that feeding advice on the neonatal unitwas consultant led however, the dietician would cometo the unit if there were any specific requirements.

• Infants on the neonatal unit were weighed three timesper week and fluid balance was monitored.

• A designated breast milk fridge was kept on theneonatal unit and mother's were encouraged to expressbreastmilk.

• Breastfeeding training was part of the trust’s mandatorytraining programme for staff within the neonatal unit toensure advice given was consistent and evidence-basedand junior doctors received information regardingbreastfeeding during their induction.

• A private room was available to mothers on theneonatal unit if they wished to express and a referralcould be made to a breastfeeding co-ordinator foradditional support if required.

• Breakfast was offered to all parents and all meals wereoffered to mothers who were breastfeeding.

Patient outcomes

• The trust provided data for the National Neonatal AuditProject. The latest published report was 2016 using 2015data and showed there was a documented consultationwith 89% of parents and/or carers within 24 hours ofadmission; this ensures that parents have a timelyexplanation of their baby’s condition and treatment.Thirty-six per cent of eligible babies were dischargedfeeding only mother’s milk and 20% taking somemother's milk. Results also showed 100% of eligiblechildren were screened for Retinopathy of Prematurity(ROP). ROP is an eye condition that can affect babiesborn weighing under 1501g or 32 weeks gestation.

• An action plan was developed to address areas ofimprovement such as improving awareness of thebenefits of breastfeeding by use of posters andrestarting the lunch provision for breastfeeding motherson the neonatal unit however, no review date wasdocumented.

• The National Paediatric Diabetes Audit 2014/15 showedthat Warrington hospital performed better than theEngland average for the number of individuals who hadcontrolled diabetes.

• Between September 2015 and August 2016 there was alower percentage of children aged under one yearreadmitted following an emergency admissioncompared to the England average.

• The speciality of Trauma and Orthopaedics had areadmission rate of 3.2% compared to the Englandaverage of 1.1% for patients aged between one and




seventeen years. We discussed this with managers whoadvised that patients admitted with a trauma injurywere often sent home overnight and would return thenext day for treatment, for example surgery.

• Between October 2015 and September 2016 the trustperformed better than the England average for thepercentage of patients aged 1-17 years who hadmultiple emergency admissions for asthma.

Competent staff

• Staff identified their learning needs through the trustsappraisal process and the trust target was 85%. Trustdata showed that at the time of our inspection 95% ofnursing staff on the children’s unit had received anappraisal, 88% of nursing staff on the neonatal unit and100% of medical staff.

• Induction processes were in place for new staff andstudents. Preceptorship was in place for newly qualifiedstaff and included demonstration of competencies withequipment.

• Competency assessments were in place for healthcareassistants and student nurses for procedures such asthe application of topical local anaesthetic andrecording of patient observations such as heart rate andrespiratory rate.

• Band 5 staff nurses on the children’s unit had anidentified band 6 buddy who they could approach withany concerns however staff told us this was notrestrictive and they could approach any senior memberof staff if needed.

• Junior medical staff reported Consultants were helpfuland supportive.

• In the event of a drug error an appointment would bearranged with the medicines safety nurse to reviewpractice and reflect on the incident.

• Eighteen staff out of a total of 33 on the children’s unithad completed the high dependency course.



• Good multidisciplinary (MDT) working was noted inareas we visited. Clinical staff told us there were goodworking relationships between medical and nursingstaff.

• Records we reviewed indicated multi-disciplinary (MDT)working as appropriate however, there was nodedicated paediatric pharmacist or daily pharmacysupport provided to the children’s unit.

• A child and adolescent mental health (CAMHS) workerwas present in the paediatric emergency departmentbetween 5pm and 11pm seven days a week. If childrenand young people presented outside of this time theywere usually seen the next day. Staff told us that theCAMHS workers telephoned the unit daily to enquire ifany inpatients required a review.

• Paediatric physiotherapy support commissioned by alocal community trust was provided for children withCystic Fibrosis and adult physiotherapists with specialinterest in paediatrics delivered care for children withother respiratory conditions or who were under thespeciality of trauma and orthopaedics.

• Records we reviewed confirmed that meetings wereheld with social care and community professionals asrequired. For example in cases involving safeguarding orfor patients who required discharge planning such asinfants receiving oxygen.

• Two play specialists were available within the childrenand young people’s service, one based on the children’sunit and one in the paediatric emergency department.Play specialists worked a shift system and worked withchildren and young people to prepare them for theatre.

• Paediatric Health Visitor liaison informed communityprofessionals when a baby was admitted to theneonatal unit and when children and young people hadattended the accident and emergency department.

• Health Visitors were advised by telephone when a babywas discharged from the neonatal unit and summaryletters were sent electronically to a patients’ GPfollowing discharge from children’s services.

• Specialist nurses were in post to support young peopletransitioning to adult services and joint clinics tookplace for young people with respiratory conditions such




as Cystic Fibrosis, Epilepsy and Diabetes from 14 yearsof age. Children with complex needs transitioned toadult services on an individual basis in conjunction withparent’s preferences.

• The Paediatric Acute Response Team (PART) team wereco-located with the GP out of hour’s service anddescribed examples where multi-disciplinary workinghad prevented the need for attendance at hospital.

• In the CQC national children’s survey 2014 out of 137acute NHS trusts, the trust scored the same as others forthe question, ‘ Did the members of staff caring for yourchild work well together?’.

Seven-day services

• Seven-day services were provided on the children’s unitincluding the assessment unit as well as the neonatalunit, X-ray and A& E. The PART service was available sixdays a week however, appointments in the paediatricoutpatient department were only scheduled Monday toFriday.

• Child and adolescent mental health services (CAMHS)were available seven days per week between 5pm and11pm in the paediatric emergency department andchildren referred to CAMHS were usually seen the nextday if admitted outside of these hours.

• The two play specialists for the children’s unit worked ashift system that covered seven days.

• Consultant on-call cover was provided out of hours. Theconsultant of the week was present in the hospitalduring times of peak activity and available on call atother times.


• Policies and procedures were kept on the trusts intranetand staff we spoke with confirmed they were familiarwith how to access them.

• Parent Health Child Health Records (PHCR) werecompleted by staff in the neonatal unit at parent’srequest.

• Care Summaries were sent to GP’s following dischargefrom the children’s unit to ensure continuity of care inthe community and a copy was provided to parents.

• Discharge summaries were provided to GPs whenbabies were discharged from the neonatal unit.

• The paediatrician on call was available on a designatedtelephone number three hours per day for GP’s whorequired advice.


• The trust’s Consent to Examination, Treatment orAutopsy Policy included specific information regardingobtaining consent to treat young children. Guidancewas also included for children who understood fullywhat was involved in the proposed procedure (Gillick orFraser competent) and were able to give valid consentfor treatment.

• Staff could describe the principles of Gillick competencyused to assess whether a child had the maturity to maketheir own decisions and how decisions were made withthe involvement of parents.

• Staff described how they worked on the principle ofverbal consent for some procedures such as takingobservations of temperature and pulse.

• We observed a discussion about obtaining writtenconsent for a Looked After child going to theatre, duringa pre-admission appointment.

• Staff described how support would be obtained fromspecialist colleagues and the safeguarding team whendealing with parents who may lack capacity.

• Data from the trust showed that between January 2014and December 2016 89% of medical staff and 95% ofnursing staff in the children and young people’s servicehad completed Mental Capacity Act training.

Are services for children and youngpeople caring?

Good –––

We rated caring as Good because:

• Care was provided by committed, compassionate staffwho were enthusiastic about their role.

• Staff were observed treating patients and their relativeswith kindness and respect both in person and on thetelephone.




• Staff described how they had supported a family fromabroad who experienced a sudden illness andbereavement. Staff provided practical, emotional,spiritual and psychological care for the family who werealone a great distance away from home and went overand above what could be normally expected to facilitatethe family’s return home as easily as possible.

• Parents told us they felt involved in the decisionsregarding their child’s care and one parent stated theyfelt able to ‘say what I want’ and another stated theycould ‘disagree too’.

• Parents encouraged to stay with their child on thechildren’s unit and fold out beds were available at eachbedside however, newly delivered mothers wereprovided with a regular bed.

• Parents felt confident about leaving their baby in theneonatal unit, one parent said the baby was "definitelyin safe hands when I am not around".

• Children scheduled for surgery would be cared for bythe same nursing staff during their pre-operativeoutpatient appointment, inpatient admission forsurgery and recovery period to ensure they had afamiliar face and continuity of care.

• Cold cots were available in the neonatal unit to enablebereaved parents to spend time with their infant afterthey had passed away and a bereavement midwife wasin post to support families who had lost a child in theneonatal or children’s unit.

Compassionate care

• Care was provided by committed, compassionate staffwho were enthusiastic about their role.

• The children’s unit presented as a calm environmentduring our inspection and call bells were observed to beanswered in a timely fashion.

• Staff were observed treating patients and their relativeswith kindness and respect both in person and on thetelephone. We observed a staff member speaking with aparent in a polite and helpful manner.

• Results of the CQC national children’s survey 2014showed that out of 137 acute NHS trusts, the trustperformed better than others for the question ‘Do youfeel your child was well looked after by the hospitalstaff?’.

• Parents told us that staff ‘had been fantastic every time Icome’, that nurses had been reassuring and supportive,that staff were easy to talk to and ‘they don’t just lookafter the babies, they look after the parents’.

• Staff described how they had supported a family fromabroad who experienced a sudden illness andbereavement. Staff provided practical, emotional,spiritual and psychological care for the family who werealone a great distance away from home and went overand above what could be normally expected to facilitatethe family’s return home as easily as possible.

• Results of the NHS Friends and Family Test for thechildren’s unit 1 December to 31 December 2016showed that from 24 reviews in this period 21respondents were "likely" or "extremely likely" torecommend the service.

• Friends and Family data was not collected on theneonatal unit, however there was a suggestions box onthe unit for parents to leave comments or ideas andparents could submit feedback on a neonatal socialmedia page.


• Parents told us they felt involved in the decisionsregarding their child’s care and staff are happy to answerany questions. One parent commented they felt able to‘say what I want’ and another stated they could‘disagree too’.

• Information booklets were provided for parents onadmission to the children’s unit and the neonatal unitand included details of visiting times, parent’s facilitiesand car parking.

• Patients discharged from the neonatal unit were givenan information pack and blanket.

• Parents were encouraged to stay with their child on thechildren’s unit and fold out beds were available at eachbedside however, newly delivered mothers wereprovided with a regular bed.

Emotional support

• Parents felt confident about leaving their baby in thechildren’s unit and neonatal unit, one parent told ustheir baby was ’definitely in safe hands when I am notaround’.




• Children scheduled for surgery would be cared for bythe same nursing staff during their pre-operativeoutpatient appointment, inpatient admission forsurgery and recovery period to ensure they had afamiliar face and continuity of care.

• A play specialist supported children to prepare fortheatre. Play specialists and healthcare assistants useddistraction therapy to help children cope with painful ordifficult procedures.

• Parents were provided with the contact number for theneonatal unit on admission this allowed them totelephone for advice following discharge if they had anyproblems.

• Children and young people with complex needs andlong term conditions had open access to the children’sunit. This meant that parents or carers could contact thechildren’s unit at any time if they had concernsregarding their child’s health.

• Psychological support was available for children withdiabetes and long term conditions. Counselling wasavailable following referral to child and adolescentmental health services (CAMHS).

• Cold cots were available in the neonatal unit to enablebereaved parents to spend time with their infant afterthey had passed away.

• A bereavement midwife was in post to support familieswhose child passed away in the neonatal unit orchildren’s unit.

• Bereavement support and counselling for parents andsiblings was accessed locally in a tertiary centre.

Are services for children and youngpeople responsive?

Good –––

We rated responsive as Good because:

• The environment on the children’s unit includingpaediatric outpatients and the paediatric emergencydepartment was colourful and child friendly and aseparate adolescent waiting area was available in thepaediatric outpatient department.

• Parents were encouraged to stay with their child on thechildren’s unit and facilities were available to supportthis.

• Facilities to stay were available for parents with infantsin the neonatal unit if the baby was unwell or parent’slived a distance from the hospital. The rooms could alsobe used by parents to gain confidence caring for theirbaby prior to discharge.

• Breakfast and drinks were provided for all parents onboth the neonatal and children’s unit and lunch anddinner was provided for breastfeeding mothers.

• Open visiting was available to parents with infants onthe neonatal and children’s units and support wasavailable with parking charges when children had beenon the units for more than a week.

• Specialist nurses were in post in a range of specialitiesincluding Epilepsy and Diabetes and provided supportto young people transitioning to adult services.

• A CAMHS worker was present in the paediatricemergency department between 5pm and 11pm sevendays per week to ensure timely assessment of childrenand young people.

• Young people between the ages of 16 and 18 years whorequired admission to hospital were offered the choiceof a bed on an adult or paediatric ward.

• The Paediatric Acute Response Team (PART) workedwith a local community trust to reduce the need forchildren and their families to attend hospital.

• The children’s community respiratory team (CREST)provided a service to support parents and avoidadmission to hospital if possible.

• Data from the trust showed at the time of our inspectionthe 90.5% of patients referred to paediatric serviceswere seen within the 18 week standard.

• The consultant of the week triaged all referrals to ensurechildren and young people were seen appropriately, thiscould be in outpatient clinic, the paediatric assessmentunit or by the PART team.




• Parents we spoke with told us they felt able to raiseconcerns or complain if necessary. Staff were aware ofthe complaints process and complaints were discussedwith staff at monthly ward meetings and through thesafety brief.

However,

• Adult areas were children were seen with the exceptionof ophthalmic clinic, lacked any child friendlydecoration or activities.

• There was a separate paediatric section in the theatrerecovery area however, this was not child friendly andhad no decoration to distinguish it from other recoveryareas.

• Two play specialists were available within the childrenand young people’s service however seven out of nineparents asked, were unaware of a play therapist withinthe ward environment.


• The environment on the children’s unit includingpaediatric outpatients and the paediatric emergencydepartment was colourful and child friendly and aseparate adolescent waiting area was available in thepaediatric outpatient department. However, adult areaswere children were seen with the exception ofophthalmic clinic, lacked any child friendly decorationor activities.

• The children’s unit was decorated with an underwatertheme and this continued on the ‘walk to theatre’ with acorresponding activity book which was used as adistraction.

• A play room and an adolescent recreation room wereavailable however staff told us the adolescent room wasnot used and had become a meeting area. During ourinspection we noted surplus equipment placed in thisroom.

• Every bed in the children’s unit had an overheadtelevision which was free to use until 7.30pm and agames console and range of DVDs were available.

• Children attending for day case surgery could beaccompanied by their parents into the anaesthetic

room. There was a separate paediatric section in therecovery area however, this was not child friendly andhad no decoration to distinguish it from other recoveryareas.

• Parents were encouraged to stay with their child on thechildren’s unit. A sitting area was available with arefrigerator and tea and coffee making facilities awayfrom the patients’ bedside but within the unit. Parentswere able to make hot drinks that could be taken on tothe ward in lidded cups.

• The environment in the neonatal unit was welcomingand had designated ‘breastfeeding corners’ withscreens. A private room was also available next to theunit for mothers who wished to express breast milk in amore private environment.

• Parent’s facilities for the neonatal unit were situated in a‘flat’ just outside the unit. This contained twobedrooms, shower facilities and a kitchen and loungearea with a refrigerator, microwave oven and tea andcoffee making facilities.

• Facilities to stay were available for parents with infantsin the neonatal unit if the baby was unwell or parent’slived a distance from the hospital. The rooms could alsobe used by parents to gain confidence caring for theirbaby prior to discharge.

• Breakfast and drinks were provided for all parents onboth the neonatal and children’s unit and lunch anddinner was provided for breastfeeding mothers.

• Open visiting was available to parents with infants onthe neonatal and children’s units and support wasavailable with parking charges when children had beenon the units for more than a week.

• Parents we spoke with in paediatric outpatients told usfinding a parking space was difficult when attending forappointments however, based on the clinicalrequirements, individual parking arrangements could bemade.


• A national charity for premature and sick babiesprovided leaflets in a variety of languages to theneonatal unit.




• Interpreting services could be arranged to supportfamilies whose first language was not English and staffconfirmed they knew how to access these however, wedid not see this in use during our inspection.

• Records we reviewed confirmed that a pre-operativeassessment was completed by nurses who would carefor the child and family during their admission to ensurecontinuity of care.

• Two play specialists were available within the childrenand young people’s service however seven out of nineparents asked were unaware of a play therapist withinthe ward environment.

• Staff told us children were prioritised in x-ray anddiagnostic scanning areas and on adult theatre lists.

• Paediatric outpatient appointments for children withcomplex needs were arranged on the same day toprevent patients attending on more than one occasion.

• Specialist nurses were in post in a range of specialitiesincluding Epilepsy and Diabetes and provided supportto young people transitioning to adult services.

• A CAMHS worker was present in the paediatricemergency department between 5pm and 11pm sevendays per week to ensure timely assessment of childrenand young people. Children and young peoplepresenting at other times were assessed within 24 hoursand if admission to the children’s unit was required aSuicide Prevention Policy was in place to promotepatient safety.

• All parents with a child admitted to the neonatal unitless than 34 weeks gestation received an ‘Emily’s Star’box. This included toiletries for mother and baby as wellas items such as nappies, a vest and a muslin cloth.

• Following discharge from the neonatal unit infants whomet the criteria were visited by the neonatal communitynurse specialist. Eligibility criteria included infants bornless than 2.3kg or below 36 weeks gestation or anyfamily that may require additional support.

• Leaflets were available for parents on the children’s unitcovering a variety of topics including minor head injuriesand fever.

• Young people between the ages of 16 and 18 years whorequired admission to hospital were offered the choiceof a bed on an adult or paediatric ward.

• Managers told us children and young peopleapproaching end of life were cared for at home by alocal community trust, in a hospice or a tertiary centre.

Access and flow

• Admission to the children’s unit was either via A & E, GPor Paediatric Acute Response Team (PART) referral to theassessment unit however patients with knownconditions had direct ward access with a patientpassport.

• The PART service was located in a health and wellbeingcentre in Warrington town centre and was a joint servicewith a local community trust. Services providedincluded wound checks, intravenous antibioticadministration and review of jaundice in infants. Referralcould be initiated by a range of communityprofessionals as well as hospital staff and reduced theneed for children and their families to attend hospital.

• Between January 2016 and December 2016, 1,535children and young people were referred to the PARTservice. In this period 2,968 face to face contacts tookplace and 1,446 telephone contacts.

• The children’s community respiratory team (CREST)provided a service to support parents and avoidadmission to hospital if possible. The service sawchildren and young people with non-acute respiratorywheeze or asthma and provided an individualisedasthma care pathway, supported inhaler technique andprovided education for parents.

• At the time of our inspection a paediatric eczema anddermatology service (PED) was commencing. This was apartnership between a local GP with a special interestand a dermatology specialist nurse from the hospital.

• The observation and assessment unit was open sevendays a week between 7am and 8.30pm Patients whorequired care after this time were transferred to aninpatient bed.

• Babies admitted to the neonatal unit that requiredintensive care for longer than 48 hours were transferredto a specialist unit.

• Pre-operative assessments were completed on the wardand day surgery took place four days per week.

• Data from the trust showed at the time of our inspectionthe 90.5% of patients referred to paediatric services




were seen within the 18 week standard. This variedaccording to speciality with trauma and orthopaedicsachieving 83.6% and general medicine, cardiology,respiratory medicine and rheumatology achieving100%.

• Bed occupancy rates on the neonatal unit for 2016 were66.9%. This was broken down to 33.5% for intensivecare, 34% for high dependency care and 83.4% forspecial care. Following external advice arecommendation had been made to reduce cotcapacity with a planned completion date of 30 April2017.

• Between January 2016 and December 2016 bedoccupancy rates on the children’s unit were 5.7% for thepaediatric assessment unit, 63.2% for the paediatricbays and 64.5% for paediatric cubicles.

• The consultant of the week triaged all referrals to ensurechildren and young people were seen appropriately, thiscould be in outpatient clinic, the paediatric assessmentunit or by the PART team.

• There were no rapid access clinics however children andyoung people who required an immediate review wereseen on the children’s unit the following day.

• Children and young people who attended for medicaloutpatient appointments were seen in the paediatricoutpatient department. Appointments for otherspecialities such as general surgery or ophthalmologywere held in general adult clinics.

• Between January 2016 and December 2016 6,220paediatric medical outpatient attendances wererecorded at the Warrington site and 567 attendances atthe Halton site.

• Between September 2016 and December 2016 ninepaediatric outpatient clinics cancelled were within 6weeks.

• Between January and December 2016 there were 14,814attendances at the accident and emergencydepartment by patients aged 0-18 years, 55.5% of whichwere discharged without follow up. Of those patientsadmitted, 33% were patients under 1 year of age.

• When calculating length of stay a one day admissionwould be over midnight. Between January 2016 andDecember 2016 of the 3675 emergency admissions ofchildren and young people to the hospital, 50% wereless than a day.

• Children and young people referred to child andadolescent mental health services (CAMHS) were seenthe next day if not reviewed by the CAMHS worker whowas present in the paediatric emergency departmentbetween 5pm and 11pm seven days a week.


• Parents we spoke with told us they felt able to raiseconcerns or complain if necessary.

• Information leaflets were available within the areas wevisited advising patients and families about the PatientAdvice and Liaison Service (PALS) if they wished to makea complaint.

• Staff were aware of the complaints process. Staff told usthey would try and resolve issues immediately and ifthis was unsuccessful would direct the patient andfamily to the ward manager or Matron and PALS.

• Between January and December 2016 12 complaintswere received relating to paediatrics. The three mainthemes identified were regarding treatment, care andstaff attitude.

• Following a review of complaints learning points wereidentified for both individual staff members and teams.

• Complaints were discussed with staff at monthly wardmeetings and through the safety brief and staff coulddescribe changes in practice following a complaint.

Are services for children and youngpeople well-led?

Good –––

We rated well-led as Good because:

• Staff we spoke to were aware of the trusts vision andpaediatric strategy and could describe plans to developservices.

• The development of community services such as thePaediatric Acute Response Team (PART) and the




children’s community respiratory team (CREST) incollaboration with a local community trust was part ofthe trusts paediatric strategy to develop outreachservices.

• Quality and performance were monitored throughdivisional dashboards and the Child Health GovernanceGroup reviewed risks, incidents and complaints and newclinical guidance.

• Corporate and divisional risk registers were in place,managers knew the risks and mitigating actions withintheir departments.

• Monthly team meetings took place on the children’s unitto ensure staff received information and feedbackregarding incidents and complaints and were keptinformed of developments within the trust.

• Staff reported effective team working and felt they wereable to raise concerns or ideas for service improvement.

• The PART team had been shortlisted in the Primary Carecategory of The BMJ Awards 2017.

However,

• There were seven risks on the divisional risk registerrelating to paediatrics and neonatology at the time ofour inspection. All had action plans to mitigate risk andreview dates however three risks had been on the riskregister for more than two years.


• The children and young people’s service was active withthe Merseyside & Cheshire Women’s and Children’sVanguard. This aims to develop a network of servicesacross the region to improve quality and ensure futureservice delivery.

• Staff we spoke to were aware of the trusts vision andpaediatric strategy and could describe plans to developservices.

• The development of community services such as thePaediatric Acute Response Team (PART) and thechildren’s community respiratory team (CREST) incollaboration with a local community trust was part ofthe trusts paediatric strategy to develop outreachservices. Staff were proud of the services and theimpact on patients.


• Quality and performance were monitored throughdivisional dashboards and included patient access toinvestigations and treatment, patient experienceincluding complaints, workforce recruitment andattendance at essential training.

• The Child Health Governance Group met monthly andwas attended by senior staff including the divisionalgovernance lead, consultants, matron and wardmanagers. This forum was used to review risks,incidents and complaints and discuss the introductionof new clinical guidance. Meeting minutes could beaccessed by all staff on the trust intranet.

• Quality reports for the paediatric unit were submittedmonthly and detailed activity at ward level such ascompliance with controlled drug and resuscitationequipment checks as well as audits of documentationand paediatric early warning scores.

• We observed corporate and divisional risk registers inplace, managers knew the risks and mitigating actionswithin their departments.

• There were seven risks on the divisional risk registerrelating to paediatrics and neonatology at the time ofour inspection. All had action plans to mitigate risk andreview dates however three risks had been on the riskregister for more than two years.

• There was a named executive at board level who led onservices for children and young people.


• Services for children and young people were led by amatron supported by a band 7 manager within thechildren’s unit and the neonatal unit.

• Nursing staff told us managers were visible andapproachable.

• Doctors told us that consultants were supportive andhelpful.

• Monthly team meetings took place on the children’s unitto ensure staff received information and feedbackregarding incidents and complaints and were keptinformed of developments within the trust.




• There were no regular team meetings on the neonatalunit however a safety brief was circulated daily toprovide essential information such as lessons learnedfrom incidents.

• Staff we spoke with told us that the clinical businessmanager and members of the trust board were visible.


• Staff we spoke with were passionate about their workand were committed to providing high quality care.

• There was an open and honest culture in the service.Staff we spoke to were candid about the challenges theyfaced within the service and were proud of what workedwell.

• Staff told us morale could vary however they feltcolleagues were very supportive of each other.

• Staff reported effective team working and felt they wereable to raise concerns or ideas for service improvement.

• Managers spoke highly of the hard work andcommitment shown by their staff.

Public engagement

• The views of patients were actively sought within thechildren’s unit using the NHS Friends and Family Test.

• Parents on the neonatal unit could submit comments orideas via a suggestion box on the unit and feedbackcould be submitted on a neonatal social media page.

• We observed noticeboards on the corridor approachingthe main ward area on the children’s unit whichprovided examples of comments received from parentsand suggestions for improvements such as thefrequency drinks were offered.

• Managers told us parental engagement took place witha core group of parents whose children had complexneeds.

• Children’s eye clinic obtained feedback from patientsregarding the reception and waiting area, contact withstaff and overall experience.

Staff engagement

• Results of the 2016 NHS Staff Survey showed the trustscored better than the national average for acute trustsfor support from immediate managers and recognitionand value of staff by managers and the organisation.However the trust scored worse than the nationalaverage for acute trusts for staff recommendation of theorganisation as a place to work or receive treatment.

• Physical and psychological support services wereavailable to staff and staff we spoke with were aware ofhow to access them.

• Team meetings took place monthly in the children’sward and weekly trust wide emails were sent by thecommunications team to inform staff about events andnews within the trust.


• The trust was working with local partners to develop afully integrated community paediatric pathway. Thisincluded the existing PART and CREST teams and alsothe development of a paediatric eczema anddermatology service (PED) which had commenced priorto our inspection.

• The trust was working with a local specialist children’strust to increase the number of paediatric surgicalpatients treated at Warrington hospital.

• Recruitment was in progress for a second AdvancedPaediatric Nurse Practitioner (APNP) to work in theneonatal unit.

• Thee children’s unit was fundraising to develop anoutside play area next to the inpatient playroom.

• The PART team had been shortlisted in the Primary Carecategory of The BMJ Awards 2017.




Safe Good –––






Information about the serviceEnd of life care services were part of the hospital acute caredivision. Warrington Hospital’s specialist palliative careteam offered a service; from Monday to Friday with corehours of 8.30am to 4.30pm. The team covered bothWarrington Hospital and Halton General Hospital andcovered Bank Holidays.

Patients with palliative/end of life needs wereaccommodated on the general wards in the hospital. Thetrust provided a consultant led hospital specialist palliativecare (HSPC) team. The HSPC team is a resource available toall clinical areas within the hospital providing specialistpalliative care, advice and support for adult inpatients thatare affected by cancer and other life limiting illnesses. TheHSPC team provides an advisory and supportive servicewhilst the medical and nursing management of the patientremains the responsibility of the ward teams.

We visited nine wards where end of life care was beingprovided at the time of our inspection. We also visited thechapel/multi-faith room, the hospital mortuary, viewingroom and the bereavement offices.

During the inspection, we spoke with two patients and theirrelatives on the wards. We spoke with 36 staff across arange of staff including: nurses, doctors, consultants, wardmanagers, anatomical pathology technicians andmembers of the senior management team. Additionally wespoke with members of the hospital palliative care team,including the clinical lead and matron for palliative care

We observed care and treatment and we looked at 33paper care records and 32 electronic records. We looked atappropriate policies and procedures related to end of lifecare.

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End of life care


Summary of findingsWe inspected Warrington and Halton hospital in 2015and gave end of life services an overall rating of good.Following this inspection we have maintained theoverall rating because:

• There were systems for reporting actual andnear-miss incidents across the hospital which meantthe service was able to monitor any risks and learnfrom incidents to improve the quality of servicedelivery.

• There were sufficient numbers of trained clinical,nursing and support staff with an appropriate skillmix to ensure that patients receiving end of life carewere well cared for in all the settings we visited.

• Medicines were prescribed, stored and administeredsafely. Access to medicines for people needingcontinuous pain relief was available to ensurepatient’s pain was managed.

• The HSPC team had received mandatory trainingsuch as safety and safeguarding in order to maintainthe safety of patients.

• To meet patients’ needs the HSPC team haddeveloped a training programme for specialistpalliative care across the trust with end of life linknurses for each ward to support, advise and educateother ward staff in relation to end of life care.

• The HSPC team was adequately staffed, well trainedand received regular appraisals.

• A care management approach “amber care bundle”was in place when doctors were uncertain whether apatient may recover and were concerned that theymay only have a few months left to live. This is anapproach to care management used in hospitalswhen doctors are uncertain whether a patient mayrecover and are concerned that they may only have afew months left to live. The trust had appointed adesignated member of staff who worked within thepalliative care team to facilitate implementationacross the trust.

• The trust participated in the “End of life care Audit:Dying in Hospital 2016”, which replaced the NCDAH.

The audit results showed an improvement in end oflife care at the trust. Out of 17 clinical andorganisational indicators the trust had performedeither better than or in line with national average inthe majority of the indicators. The trust performedbetter than the England average for three of the fiveclinically related indicators. The trust scoredparticularly well for having documented evidencethat the needs of person(s) important to the patientwere asked about, scoring 73% compared to thescore of 56%.

• All the feedback we received was overwhelminglypositive showed a committed and passionateworkforce relating to the provision of end of life carein the trust.

• We found several examples of staff on the wards andthe mortuary consistently providing a service topatients at the end of their lives that went beyondwhat could reasonably be expected of them and theyregarded that as their everyday job.

• Services were planned and delivered to meet theneeds of local people. There were systems in place tosupport patients with particular needs.

• The trust worked with other services that providedend of life care in the Warrington area to carry out ajoint self-assessment identifying areas fordevelopment to promote excellence in end of lifecare.

• The trust had fully implemented an individual end oflife care plan of care (IPOC) when patients wereidentified as approaching end of life. This was astand-alone document which had been based on theprinciples and essential elements of excellent end oflife care as outlined in the “One chance to get itright.”

• The trust had a clear mission and vision statement.This was to provide high quality, safe healthcare “Weare Warrington and Halton hospital and together wewill work as one”. Staff we spoke to were able todescribe the vision and strategy and they felt thatthey were part of the trust.

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End of life care


• Since our last inspection the hospital specialistspalliative care team (HSPCT) had reviewed thestrategy for end of life care and had undertaken aself-assessment structured around the six nationalambitions for palliative and end of life care.

• We reviewed the trust self-assessment and actionplan for ensuring the implementation of the“Ambitions for Palliative and End of Life Care” toimprove the provision of better care for patients atend of life. Actions included the development ofmore leaflets for relatives to improve communicationand active engagement in regional audits to ensurethe HSPCT is complying with best local and nationalbest practice.

However:

• At our last inspection we found there was no accessto specialist palliative care medical support out ofhours. At this inspection we found this was still thecase with no access to out of hour’s specialistpalliative care medical support. Senior managerstold us that they had improved access to supportand advice through the hospital intranet and the lackof specialist palliative medical support had beenidentified on the trust risk register.

• The trust had commissioned an external audit of theuse of the DNACPR policy as well as its own internalaudit. Results showed there were a number ofoccasions, where documentation in relation toDNACPR forms has not been in line with Trust Policy.Engaging in difficult conversations with patients,family or carers was not always fully recorded withinthe case notes. Patient’s wishes were notappropriately discussed and recorded, and as aresult, they are not treated appropriately Wereviewed the action plan which had been put inplace to ensure the staff training and monitoring ofthe DNACPR policy was strengthened.to ensure thatthe DNACPR’s are completed accurately with themedical rationale for not attempting resuscitationand discussions with patients and family beingrecorded appropriately. The lack of a clear mentalcapacity assessment meant that the service could

not be clear how much the patient understood thecare they were receiving and it may not have accessto reasonable adjustments such as access tospecialist support.

• We found that patients at the end of their lives couldnot always be assured of a single room to ensureprivacy.

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End of life care


Are end of life care services safe?

Good –––

At the previous inspection in January 2015 we rated safe asgood. Following this inspection we have maintained theoverall rating because:

• There were systems for reporting actual and near missincidents across the hospital. Staff were able to explainthe process of using an electronic reporting system anddescribe the types of incidents that would be reported.This meant that the service was able to monitor anyrisks and learn from incidents to improve the quality ofservice delivery.

• Medicines were prescribed, stored and administeredsafely.

• We looked at 33 paper care records and 32 electronicpatient’s care and treatment records and found theywere accurate and clinical notes were completed to agood standard in order to inform care and treatment.

• Patients were transferred to an end of life care plan iftheir condition required this so they could receiveappropriate and timely care. The plan enabled staff toidentify care requirements through risk assessment ofthe patients’ needs such as symptom and pain relief,skin care, hydration and care of those people close tothe patient.

• There were sufficient numbers of trained clinical,nursing and support staff with an appropriate skill mixto ensure that patients receiving end of life care werewell cared for.

• Data provided by the trust showed that the hospitalSpecialist palliative care (HSPC) team completion ofmandatory training, including safeguarding training wasabove the trust target of 85%.

However:

• Staff were aware of their responsibilities in relation toduty of candour (DoC) and the need to be open andhonest with patients or their representatives. Werequested and did not see any examples of evidencethat the systems were in place to capture DoC within theEnd of Life (EOL) service.

• Some medical staff told us they had not had training onhow to complete the individual plan of caredocumentation which may impact on the ability of theservice to provide appropriate management of end oflife care.

Incidents

• There were systems for reporting actual and near missincidents across the hospital using an electronicincident reporting system. Staff were able to explain theprocess of using an electronic reporting system anddescribe the types of incidents that would be reported.This meant that the service was able to monitor anyrisks and learn from incidents to improve the quality ofservice delivery.

• Incidents reported relating to EOL care were very lowcompared with the rest of the trust. The seniormanagement team reviewed any incidents related toEOL across the trust to ensure that any actions requiredwere carried out.

• Staff were encouraged and supported to report anyissues in relation to patient care or any adverseincidents that occurred. We reviewed minutes of teammeetings and saw evidence of learning and reflection.

• Staff we spoke with described action that had been putin place immediately after an incident in the mortuaryto improve checking patient identification. The servicewas carrying out a root cause analysis to implement anyfurther learning across the mortuary service to improvepatient care.

• Staff were aware of their responsibilities in relation toduty of candour and the need to be open and honestwith patients or their representatives. The DOC is aregulatory duty that relates to openness andtransparency and requires providers of health and socialcare services to notify patients (or other relevantpersons) of certain “notifiable safety incidents andprovide reasonable support to that person. However, werequested and did not see any examples of evidencethat the systems were in place to capture DOC withinthe EOL service.

Equipment

• We saw that the Trust had actioned therecommendations from Medicines Healthcare ProductsRegulatory Agency (MHRA) safety alert with regards to

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End of life care


equipment (syringe drivers) used for pain relief. We sawthat syringe drivers were maintained in order to makesure they correctly worked and assisted in managingpatients

• We were told by mortuary staff and records showed,that the mortuary equipment; such as fridges andtrolleys were serviced within the manufacturer’srecommendations.

• The mortuary access was kept secure to preventinadvertent or inappropriate admission to the area.

• The security personnel used a covered body trolley totransport deceased patients from the ward to themortuary in order to maintain their privacy and dignity.The trolley was cleaned between use.

Medicines

• There was clear, accessible guidance for staff regardingthe prescribing of medicines to be given via a syringedriver or as the patients required including the use ofbooklets and specially printed mouse mats freelyavailable on the ward for staff to access. Policies andprocedures were also accessible to staff on the hospitalintranet and staff were aware of the procedures tofollow.

• We looked at six records for medicines (prescriptioncharts) and saw that patients were receiving theirmedicines safely and according to their needs.

• Medicines, including those requiring cool storage, werestored safely and at the correct temperature. We sawcontrolled drugs were stored and managed safely.

• Anticipatory end of life medicines were prescribedappropriately. The EOL team told us that requests forend of life medicines for patients going home on rapiddischarge could be provided with a quick turnaround.Which we observed during our unannounced inspectionwhen staff were arranging a rapid discharge for apatient. A number of members of the HSPC team weretrained to be non-medical prescribers with extendedprescription rights. Their role was to provide advice,training and support to clinicians and nursing staffwhere needed. The team confirmed the plans toincrease the number of non-medical prescribers in theteam.

Records

• The HSPC team utilised the trust electronic patientrecords, which were accurate and completed to aprofessional standard. Information relating to tests andinvestigations was also stored on the electronic system.In total we reviewed 32 electronic records and 33 paperrecords and 12 individual plans of care. We found theywere accurate and clinical notes were completed to agood standard in order to inform care and treatment.

• Following the introduction of electronic patient recordsystem some records were held in paper format. Theuse of these may impact on the consistency of accessingrelevant patient data and results.

• On the wards we found a hybrid approach todocumentation with nursing notes kept by the bed sideas well as other nursing notes on the electronic system.For people identified at end of life the trust hadintroduced a paper version of an individualised plan ofcare in response to the removal of the original Liverpoolcare pathway for end of life care. Patients would receivean individual plan of care when there was anticipationthat the patient may die within hours or days. We foundthat wards were using the new individual care plan andthere was evidence that the HSPC team reviewed thenotes in a timely manner. Staff told us and recordsconfirmed that there was clear documentation andcompletion of the plans which were signed and datedby the reviewing professionals which showed the careplans for the patients was reviewed and updated tomeet their needs.

• Staff we spoke with confirmed that the HSPC team wereaccessible as and when required to provide support andguidance on the documentation. However somemedical staff told us the documentation was easy to usebut they had not had formal training on how tocomplete the documentation. We were shown plansthat were in place for further rollout of training on thedocument.

• Effective systems were in place in the mortuary toensure that people were correctly admitted and safelystored. Release forms were signed before a deceasedperson was released to the undertaker.

Safeguarding

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End of life care


• Trust-wide policies and procedures were in place, whichwere accessible to staff electronically for safeguardingvulnerable adults and children to give them skills andknowledge to support and manage vulnerable patients.

• Staff we spoke with were aware of the process forreferring a safeguarding concern, advice and supportwas accessible 24 hours a day, seven days per weekshould staff require support.

• Safeguarding training formed part of the trust’smandatory training programme. At our last inspectionwe found 67% of the HSPC team had completed therelevant safeguarding training. At this inspection wefound 100% of the HSPC team had completed theirsafeguarding mandatory training and had the skills andknowledge to support vulnerable patients.

• HSPC staff we spoke with were knowledgeable abouttheir role and responsibilities regarding thesafeguarding of vulnerable adults. Additionally, theywere aware of the process for reporting safeguardingconcerns. Staff told us they felt confident to raiseconcerns and make safeguarding referrals, and felt wellsupported to do this.

Mandatory training

• At our last inspection we found staff did have access totraining but had not met the trust standard forcompleting the mandatory training due to pressure ofwork. At this inspection we found 100% of staff hadcompleted their mandatory training. Staff receivedannual mandatory training, which included key topicssuch as infection control, information governance,equality and diversity, fire safety, health and safety,safeguarding children and vulnerable adults, manualhandling and conflict resolution. Mandatory trainingwas delivered on a rolling programme and monitoredon a monthly basis.

• Basic life support (BLS) training was provided by thetrust as part of mandatory training. Data provided by thetrust showed that 100 % of staff across end of lifeservices had completed the training at the time of theinspection. Staff were able to support patients who mayrequire immediate resuscitation.


• The trust used the National Early Warning Score (NEWS)to recognise if a patients’ condition was deteriorating.

The NEWS score is a simple scoring system in which ascore is allocated. It uses six physiological parameters toform the basis of the scoring system, these include,respiratory rate, oxygen saturation, temperature, systolicblood pressure, pulse rate and level of consciousness.Records showed that this was used appropriately on thewards.

• A care management approach “amber care bundle” wasin place when doctors were uncertain whether a patientmay recover and were concerned that they may onlyhave a few months left to live. Patients would betransferred to an individual plan of care when they wereidentified as approaching end of life and there wasrecognition the patient was expected to die within hoursor days. The plan enabled staff to identify carerequirements through risk assessment of the patients’needs and provide appropriate care to meet theirindividual needs such as symptom and pain relief, skincare, hydration, and care of those close to the patient.Care was based on ensuring the person remained ascomfortable as possible at all times.

• Anticipatory care plans were put in place to ensure thatall staff were aware of the best ways to managesymptoms relating confirmed the team respondedpromptly when needs. We observed the team providingreassurance to a member of staff on how they weremanaging an individual patient’s needs.

Nursing staffing

• At our last inspection we found the increase in referralrates year on year presented a challenge for the serviceand the provider should ensure that the specialistpalliative care team has the appropriate staffing levelsand skill mix to meet the demands on the service. At thisinspection we found that a full skill mix review had beenundertaken of the HSPC team and managers confirmedthe service had now filled all vacant posts to assist inproviding care to safely meet patient’s needs.

• The HSPC team consisted of one clinical matron post,three whole time equivalent clinical nurse specialistsand part time administrative support. Senior managerstold us that the matrons role had included clinical workwhich they believed had limited their ability to take an

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active management role. They had reviewed this andsupported the matron to have a stronger managementpresence in order to have an overview of the safe careand treatment of patient.

• Providing end of life care was the responsibility of allstaff and was not restricted to the HSPC team. The roleof the HSPC team was to provide specialist support toall staff in order to achieve the best care and support forpatients to ensure that patients at the end of lifereceived sufficient care and treatment.

• The trust had at least one end of life link nurse per ward.The link nurses were part of the ward team whose roleincluded working with the specialist staff to provideconsistent safe care and treatment whose role includedraising awareness of end of life processes and cascadingeducation to the rest of the nursing team to provideconsistent safe care and treatment

• Nursing handovers took place at the start of each shifton all the medical wards. Staffing for the shift wasdiscussed as well as any high-risk patients or patients atend of life to ensure the appropriate staffing levels werein place. Handovers were detailed and staff on dutywere familiar with the needs of patients in their care.

• The HSPC team also held a comprehensive handovermeeting each morning to ensure staff were aware ofrisks and prioritise patients requiring urgent reviews toensure timely care and treatment. We observed thehandover and found that staff liaised closely with wardstaff and the community.

• The HSPC team also provided telephone support andface to face reviews for the sister hospital patients whenrequired.

Medical staffing

• The Association for Palliative Medicine of Great Britainand Ireland, and the National Council for Palliative careguidance states there should be a minimum of onewhole time equivalent (WTE) consultant per 250 beds.This trust had 649 beds this equates to a minimum ofthree WTE consultants. The trust employed 0.6 WTEconsultants. This was mitigated by the additional inputof ward medical staff with additional training andsupport given by the lead consultant.

• For patients with palliative/end of life needs, medicalsupport was provided on the general wards in thehospital. Medical nursing management of the patientremained the responsibility of the ward teams.

• Junior and trainee doctors told us they knew where toget support for information and management ofpalliative care and symptom control in order to providesafe care and treatment to patients in their care.


• There was a robust policy in place of action to take if thehospital was involved in a major incident. The policylisted the key risks that could affect the provision of careand treatment.

• The mortuary staff were able to describe how to initiateescalation plans for increased capacity in the event of amajor incident involving mass casualties by utilisingfacilities at the sister hospital site.

• Staff we spoke with were able to describe the actionsthey would take in the event of a fire and receivedtraining in fire and health and safety.

Are end of life care services effective?

Good –––

At the previous inspection in January 2015 we ratedeffective as good. Following this inspection we havemaintained the overall rating because:

• The palliative care team based the care it provided onthe National Institute for Health and Care Excellence(NICE) Quality Standard for End of Life Care for Adults(2013). They also followed the National Institute forHealth and Care Excellence (NICE), care of dying adultsin the last day’s life published in December 2015. TheTrust had previously contributed to the National Care ofthe Dying Audit (NCDAH).

• The trust participated in the “End of life care Audit:Dying in Hospital 2016”, which replaced the NCDAH. Therecent audit results showed an improvement in end oflife care at the trust. Out of 17 clinical and organisationalindicators the trust had performed either better than orin line with national average in the majority of theindicators. The trust performed better than the England

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End of life care


average for three of the five clinically related indicators.The trust scored particularly well for havingdocumented evidence that the needs of the person(s)important to the patient were asked about, scoring 73%compared to the national result of 56%.

• Patient’s level of pain was reviewed often foreffectiveness and changes were made as appropriate tomeet the needs of individual patients. Pain relief wasavailable for patients as they needed it. Anticipatoryprescribing took place to ensure that patients’ pain andother symptoms were managed in a timely manner.

• The trust had a comprehensive education and trainingprogramme in end of life care and a formal programmeof study days which was co-ordinated by the HSPCteam. Training in end of life care was provided within thehospital and collaboratively with other providers in thearea.

• There was a weekly integrated MDT meeting with videoconferencing across Warrington hospital, the localhospice and community services .Patients whoselocation of care was changing or who had complexneeds were discussed at this meeting.

• There was also a weekly discussion with the palliativemedicine consultant at another local hospice andpatients transferring care settings were discussed at thismeeting.

• Access to medicines and infusion pumps (syringedrivers) for people needing continuous pain relief wasavailable to ensure patient’s pain was managed. Syringepumps were maintained and used in accordance withprofessional recommendations.

However:

• At our last inspection we found there was no access tospecialist palliative care medical support out of hours.At this inspection, we found that this was still the caseSenior managers told us that they had improved accessto support and advice through the hospital intranet andthe lack of specialist palliative medical support hadbeen identified on the trust risk register.

• The trust had commissioned an external audit of theuse of the Do Not Attempt Cardio PulmonaryResuscitation (DNACPR) policy as well as its owninternal audit. Results showed there were a number ofoccasions, where documentation in relation to DNACPR

forms has not been in line with Trust Policy. Engaging indifficult conversations with patients, family or carers isnot always fully recorded within the case notes. Patient’swishes were not appropriately discussed and recorded,and as a result they are not treated appropriately. Wereviewed the action plan which had been put in place toensure the staff training and monitoring of the policywas strengthened to ensure that the DNACPR’s arecompleted accurately with the medical rationale for notattempting resuscitation and discussions with patientsand family being recorded appropriately.


• The trust had introduced in line with national guidancean individual plan of care and support for patients whohad been identified as at end of life to replace theprevious Liverpool care pathway. At our last inspectionthis had been introduced a few weeks prior to theinspection. The newly developed individual plans werein the process of being reviewed and evaluated in orderto make sure that they met patient’s needs. At thisinspection we found that this process had been fullyimplemented across the trust.

• The palliative care team based the care it provided onthe National Institute for Health and Care Excellence(NICE) Quality Standard for End of Life Care for Adults(2013). They also followed the National Institute forHealth and Care Excellence (NICE), care of dying adultsin the last days of life document published in December2015. The trust had previously contributed to theNational Care of the Dying Audit (NCDA). Following theprevious audit results the trust had put in place anaction plan to address the issues raised. We also sawevidence of and reviewed the end of life serviceprogramme in place in order to identify and address anyshort falls in clinical practice for end of life care.

• Policies and procedures were accessible on the trustintranet and staff were aware of how to access them.

• At our last inspection we found the palliative care teamhad reviewed the Department of Health’s National Endof Life Strategy recommendations, which identified theneed to introduce the “amber care bundle”. At thisinspection we found that the use of amber care bundleshad now been embedded across the trust.

Pain relief

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• Patient’s level of pain was reviewed often foreffectiveness and changes were made as appropriate tomeet the needs of individual patients. Pain relief wasavailable for patients as they needed it. Anticipatoryprescribing took place to ensure that patients’ pain andother symptoms were managed in a timely manner.

• The HSPC team provided advice and guidance withregards to pain management. Staff told us and recordsshowed they were able to access clear guidance on theprescribing of medicines to be given ‘as required’ (PRN)for symptoms that may occur at end of life, such as painand nausea. This meant that patients had timely accessto the most appropriate pain and symptom relief.

• Access to continuous pain relief for patients whoneeded this was readily available. There were systems inplace for checks to be carried out in relation to the useof syringe drivers. The use of syringe drivers formanaging patients’ pain was supported by the HospitalSpecialist Palliative Care team (HSPC). The HSPC wasavailable to support staff on a daily basis includingweekends. Staff reported no issues in obtaining syringedrivers for individual patients as needed.

• The National End of Life Care Audit: Dying in hospitalMarch 2016 showed the clinical protocols for theprescription of PRN medicines for the five key symptomswhich may develop at the end of life were adhered to ata better rate (68%) than the national average (65%) forEngland.


• Patients were screened using the malnutrition universalscreening tool (MUST) to identify any nutritionally risk.Staff were aware of patients who required additionalsupport with eating and drinking. Patients who requiredsupport and assistance with eating and drinking werediscreetly identified using a coloured jug system andsupported by staff accordingly.

• The ward staff supported patients to eat and drinknormally for as long as possible. Patients had access todrinks and food suitable to their needs. This wasidentified and monitored through their individual plansof care.

• Staff told us and records showed us they were able tosupport people’s religious and cultural needs regardingmeals and dietary requirements such as helping toobserve fasting or food prepared accruing to culturalbeliefs.

• All wards had access to specialist advice from dieticiansif required. Records we reviewed showed evidence ofappropriate discussion with dieticians.

• The National End of Life Care Audit: Dying in hospitalMarch 2016 showed that the clinical protocols for thereview of the patient’s nutritional requirements andreview of the patients hydration requirements wereachieved at a better rate (83%) than the nationalaverages (60% and 61%) for England. This included themonitoring and use of prescribed supplements andadditional nutritional support.

Patient outcomes

• In the period April 2015 and March 2016, 731 referralswere made to the Specialist Hospital Palliative careteam (HSPC), of these referrals 475 were cancer relatedand 256 were non cancer related. This was a similarbreakdown to the previous year. The trust had 221deaths in the same period.

• The trust participated in the “End of life care Audit:Dying in Hospital 2016”, which replaced the NCDAH. Therecent audit results showed an improvement in end oflife care at the trust. Out of 17 clinical and organisationalindicators the trust had performed either better than orin line with national average in the majority of theindicators. The trust performed better than the Englandaverage for three of the five clinically related indicators.The trust scored particularly well for havingdocumented evidence that the needs of the person(s)important to the patient were asked about, scoring 73%compared to the national result of 56%. It also scoredbetter than the national average “multi-disciplinaryrecognition that the patient is dying”.

• The trust answered yes to three of the eightorganisational indicators. However we found the trusthad answered no to question 8C compared to 71% oftrusts nationally which answered yes. This questionasked whether formal in house training was providedcovering communication skills for care in the last hoursor days of life for registered nursing staff. At the time of

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our inspection we found that the trust had alreadyresponded to the audit resulted and had appointed apalliative care educator to improve access to stafftraining in palliative care.

• The trust had developed an action plan in response tothe end of life care audit to address the issues raised.Key actions included the development of formal inhouse training for both nursing and medical staff whichhad been implemented.

• The service had completed the End of Life Care QualityAssessment Tool self-assessment. The latestassessment showed that the trust was compliant in 80%of the key areas with the rest partially compliant. Theservice had identified actions to achieve full compliancewithin set timescales; progress against the timescaleswas regularly monitored.

• The HSPC team aimed to see at least 90 % of patientswithin 24 hours. Data showed that the team exceededthis in the last three months prior to our inspectionachieving 95% of patients seen within 24 hours.

• From September 2016 to February 2017 all patients hada plan of care or advice from the HSPC.

• Referrals to the HSPC team from the hospital werereceived either electronically, by telephone, bleep, or viaface to face contact with staff on the ward. Followingreferral the patients’ needs were assessed and advicewould be discussed with the clinical staff responsible forthe patients care. All patients were discussed in detail atthe HSPC handover to ensure that the patient’smanagement was as effective as possible and anyrelevant communication required with team memberswas in a timely manner.

Competent staff

• Newly appointed staff had an induction including end oflife care and their competency was assessed beforeworking unsupervised. Agency and locum staff also hadinductions before starting work.

• A full Preceptorship programme was offed to all newlyregistered nurses.

• The trust had a comprehensive education and trainingprogramme in end of life care and a formal programme

of study days which was co-ordinated by the HSPCteam. Training in end of life care was provided within thehospital and collaboratively with other providers in thearea.

• All staff had access to e-learning modules on palliativeand end of life care and the trust extranet also includedsupporting information for out of hour’s teams.Opportunities for days with the team were in place forstudent nurses and medical students also spend timewith the team on a regular basis. Doctors reported theywere well supported by the HSPC team with reviews andadvice on prescribing during the working day sevendays a week.

• Communication skills had been initiated in January2017 as part of consultant mandatory training; this wasalso provided to senior nursing staff.

• Ad hoc 1:1 or group sessions on the wards were alsooffered to staff about the Amber care bundle, individualplan of care or any individual palliative care learningneeds.

• Training in end of life care was provided within thehospital and collaboratively with other providers in thearea.

• Records showed that “symptom control” training wasprovided at least twice per year to both the Medical andSurgical trainee doctors during their rotations throughthe specialities. Presentations were also given duringthe “grand round” clinical meetings.

• The HSPC team were well qualified and attendedrelevant course to extend and update their skills andknowledge including advance communication training.

• Trust data showed 100%of the HSPC team hadcompleted their annual appraisals during

• the year.

• There was no formal process for clinical supervision butstaff felt they could access support from any member ofthe team.

• Team meetings were held monthly and provide updateson audits and opportunities for reflection and learning.

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• A robust palliative care link nurse programme was inplace with training provided on subjects related topalliative and end of life care which could then becascaded to other staff on the wards.

• Staff confirmed that they had received trainingregarding the implementation of the Amber care bundleand individualised end of life care plans.

• We were shown copies of “Palliative Matters” a quarterlynewsletter circulated electronically through thecommunications department to all staff. The newsletterprovided information for staff and included updates ontopics such as the individual plan of care. The HSPCTteam attend and contribute to the local economyIntegrated Clinical Network meetings and educationand training Meetings. There are frequently cross settingeducation events and documentation around end of lifecare is consistent across the Warrington geographicalarea regardless of care setting.

• As part of the inspection we requested information onthe numbers of staff trained in the use of syringe drivers.The trust informed us that at present there was noformal process to provide the information on a trustwide basis. We were told and shown a self-declarationnursing staff completed each year regarding theircompact to use identified clinical equipment such assyringe drivers but we were not assured how well thesystem was being monitored. The lack of clearinformation may affect the provider’s availability toensure that all staff are trained appropriately to provideappropriate pain relief through the use of syringedrivers.


• Patients received comprehensive support from amultidisciplinary team (MDT), which included specialistpalliative care nurses and a consultant. The records wereviewed showed that patients regularly had input intotheir care from other health professionals, including thepain team.

• Although the trust did not employ dedicated end of lifetherapists the multidisciplinary team worked welltogether to coordinate and plan care for patients at theend of their lives. The team included occupationaltherapy, physiotherapy, chaplaincy support andmembers of the discharge planning team.

• The HSPC team worked closely with the pain team toensure that people at end of life had appropriate painmanagement.

• The hospital held regular multidisciplinary team (MDT)meetings to review patients at both Warrington andHalton hospital as required.There was a weeklyintegrated MDT meeting attended by the HSPC team,allied health professionals, discharge planning teamand chaplaincy. The palliative care consultant from thelocal hospice attended MDT meetings via avideoconferencing facility. New patients, patients whoselocation of care was changing, or who had complexneeds, were discussed at this meeting. Outcomes andattendance at the MDT meetings were recordedelectronically on the trust’s patient record system.

• For patients already known to community specialistservices in both Warrington and Halton, teams wouldroutinely liaise with their professional counterparts. Thiswas an informal arrangement, strengthened by theclose working relationships between Warrington andHalton hospital, local community specialist palliativecare teams and the local hospices. All of the partnerswere active members of the local Cheshire and MerseyPalliative Care Network.

• There was a weekly integrated MDT meeting with videoconferencing across Warrington hospital, the localhospice and community services. Patients whoselocation of care was changing or who had complexneeds were discussed at this meeting.

• There was also a weekly discussion with the palliativemedicine consultant at another local hospice andpatients transferring care settings were discussed at thismeeting.

• Staff working in the trust emergency admission areaswere encouraged to refer patients to the SPCT at thepoint of admission if requiring specialist input.

• There was work on-going within the community tocreate ceiling of care documents to be shared with thehospital teams if admission is necessary.

• The hospital team attended and contributed to theHalton and Warrington Integrated Clinical NetworkMeetings and Education and Training Meetings. We saw

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End of life care


evidence of frequent cross setting education events anddocumentation around end of life care to ensureconsistency in approach across the Warringtongeographical area regardless of care setting.

Seven-day services

• At our last inspection we found there was no access tospecialist palliative care medical support out of hours.At this inspection we found this was still the case withno access to out of hour’s specialist palliative caremedical support. Senior managers told us that they hadimproved access to support and advice through thehospital intranet and the lack of specialist palliativemedical support had been identified on the trust riskregister.

• We reviewed the register and found no active plans toprovide a full seven day consultant service to enhancethe care and treatment of patients who are at the end oflife. Senior clinical staff told us they had carried out areview of potential requests for out of hour’s supportwhich were found to be very low. They also continued toup - skill members of the hospital specialist palliativecare team (HSPC) to provide further specialist advice atweekends. Staff felt they managed the situation withgood will from the consultant to provide support for afew very complex urgent cases.

• Out-of-hours medical cover was provided to patients onthe wards by junior and middle grade doctors as well ason-site and on-call consultant cover.

• The HSPC nurses worked on a rota basis seven days perweek, in order to make sure that their support wasavailable at weekends as well. The HSPC team provideda specialist on site service.

• Microbiology, imaging (e.g. x-rays), physiotherapy andpharmacy support was available on-call outside ofnormal working hours and at weekends.


• As part of the inspection process, although data wasprovided it was acknowledged by senior managers thatthere had been a gap in data collection in the twelvemonth period prior to our inspection. The matron hadinputted all the data retrospectively however the lack oftimely access to live data may impact on the ability ofthe service in monitoring the quality and efficiency ofservice delivery.

• All staff had access to the information they needed todeliver effective care and treatment to patients in atimely manner including x-ray results.

• There was a clear process in place to communicate withcommunity staff and ensure that records were availablefor patients on discharge. Copies of discharge letterswere forwarded to relevant persons involved in thepatient’s care, and copies of the letter were heldelectronically on the trust’s patient records system..

• Records confirmed that letters were sent to a patient’sGP on discharge and if any changes in medication hadbeen made to pain relief then this would be faxedthrough to the individuals’ GP.

• Any care plans and DNACPR forms moved across withthe patient to ensure that information was sharedappropriately.

• The trust was working with its community partners andlocal hospices to develop an Electronic Palliative CareCo-ordinating System (EPACCS) records system toenable sharing of records to improve continuity of careand communication with people involved in the care ofpatients receiving end of life care.


• Data showed 100% of the HSPC team had completedtheir Mental Capacity Act (MCA) training. However atDecember 2016, 67% of medical staff and 78% ofnursing staff had completed their Mental Capacity Act(MCA) training. The lack of appropriate training meantthat staff may not understand the implication of the acton patient care such as considering capacity, consentand deprivation of liberty. Staff we spoke withunderstood the legal requirements of the MentalCapacity Act 2005 and Deprivation of LibertiesSafeguards (DoLS) in order to protect patientsappropriately.

• We found staff were clear about how they soughtinformed verbal or written consent before providingcare and treatment.

• If a patient was assessed as lacking the capacity tomake specific decisions staff made recorded decisions

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End of life care


about care and treatment in the best interests of thepatient. Patients’ representatives and other healthcareprofessionals were consulted with in determining thebest interest of the patient.

• There was a trust-wide safeguarding team that providedsupport and guidance for staff for mental capacityassessments, best interest meetings and DoLSapplications.

• The trust had signed up to the NHS North of EnglandNorth West Unified Do Not Attempt Cardio Pulmonaryresuscitation form (DNACPR) policy. The policy coveredall aspects of consent; including responsibilities for theconsent process, mental capacity guidance anddocumentation for gaining consent. Medical staff wespoke with were able to describe the procedures forDNACPR and the decisions that were made by a seniorclinician.

• Staff used the same DNACPR form as their communitypartners in order to improve communication betweenthe patient, families and health professionals. Thepurpose of a DNACPR decision is to provide immediateguidance to those present (mostly healthcareprofessionals) on the best action to take (or not take)should the person suffer cardiac arrest.

• We reviewed 17 DNACPR forms and found they weremostly stored correctly and completed appropriatelywith the relevant signatures in place in line with the trustguidance. However we found that out of 17 records sixhad not recorded the completion of a mental capacityassessment. It was not possible to identify if theassessment had not been completed or not recorded.The lack of a clear mental capacity assessment meantthat the service could not be clear how much thepatient understood the care they were receiving and itmay not have access to reasonable adjustments such asaccess to specialist support. Despite this when bestinterest decisions were recorded, we found them to beappropriately documented.

• The trust had commissioned an external audit of theuse of the DNACPR policy as well as its own internalaudit. Results showed there were a number ofoccasions, where documentation in relation to DNACPRforms has not been in line with Trust Policy. Engaging indifficult conversations with patients, family or carers isnot always fully recorded within the case notes. Patient’s

wishes were not appropriately discussed and recorded,and as a result, they are not treated appropriately Wereviewed the action plan which had been put in place toensure the staff training and monitoring of the DNACPRpolicy was strengthened.to ensure that the DNACPR’sare completed accurately with the medical rationale fornot attempting resuscitation and discussions withpatients and family being recorded appropriately.

Are end of life care services caring?

Good –––

At the previous inspection in January 2015 we rated caringas good. Following this inspection we have rated caring asgood because:

• All the feedback we received was overwhelminglypositive showed a committed and passionate workforcerelating to the provision of end of life care in the trust.

• The specialist palliative care team (HPCT) had worked toensure that all ward staff recognised that it waseveryone’s responsibility to provide compassionate,high quality end of life care.

• We found several examples of staff on the wards and themortuary consistently providing a service to patients atthe end of their lives that went beyond what couldreasonably be expected of them and they regarded thatas their everyday job. This was recognised by the trust inpresenting an award to the mortuary service for theirwork out of normal working hours with a number ofbereaved families. Members of the trust had beeninvited to a funeral by a family for whom they hadprovided especially attentive care.

• The HSPCT spent time building a rapport with patientsand their families. They were knowledgeable aboutpatients’ background, wishes, spiritual and culturalbeliefs.

• Staff had raised funds for end of life patients to provideextra items to support patients and relatives at end oflife on the wards. This showed a strong commitment toproviding the best end of life care.

However:

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End of life care


• Some themes from relative feedback related to wardsstaff being busy and not always being able to spendsufficient time with relatives to talk through theirconcerns.

Compassionate care

• We spoke to four patients and their relatives during theinspection and observed interactions between staff,patients and their loved ones. We also reviewedfeedback to the trust in the form of thank you letters andcards as well as feedback from the relative survey. Allthe feedback we received was overwhelmingly positiveand showed a committed and passionate workforcerelating to the provision of end of life care in the trust.One person said “the doctor was very kind considerateand clear” another told us “the doctor was so gentle andkind. “

• We found numerous examples of staff providing caring,compassionate and individualised care. We found staffto be caring and understood the need for sensitivecommunication with patients who were approachingthe end of life. . Documentation showed that staff wereable to identify individual spiritual and religious needs,which were followed through both at end of life careand in the care of the deceased person.

• Patients and relatives told us conversations were heldregularly where they were updated on their progress orcondition.

• Staff were positive about the hospital specialistpalliative care team (HSPC) team and felt supported bythem to deliver compassionate end of life care on thewards. Patients were treated with respect, and dignityon the wards. We found staff understood the need forsensitive communication with patients who wereapproaching the end of life.

• We saw examples of privacy and dignity signs used on aside room where end of life care was being delivered inorder to respect and protect the person’s privacy. Staffknocked on the patients’ doors before entering andintroduced themselves to the patient and their relatives.

• We observed the HSPC team following up new patientsreferrals on the wards. The HSPC staff spent time withthe patients and their families, discussing the patients’preferred place of care. A patients’ family expressed an

interest in the local hospice and this information wasprovided promptly by the HSPCT nurse with a fullexplanation of the differences between the hospital andthe hospice.

• Ward staff demonstrated flexibility and kindness inmeeting people’s wishes, consistently going above andbeyond to accommodate requests. Staff had arrangedfor a visit for members of a local football team to visit apatient on the ward. Other examples included:arranging several weddings, accommodated a marriedcouple to spend their last hours together and enabled apet dog to visit a patient after a full risk assessment.

• We were told and observed that when a patient wasidentified as end of life their relatives would receive freeparking to support relatives at a difficult time.

• Staff attended the wards quickly when notified a patienthad died and required moving to the mortuary. Themanager of the service reported the care standard fromeveryone within the trust in relation to end of life carewas excellent. If there were any issues they would beescalated and dealt with promptly.

• The mortuary team had won a trust award forexcellence. One of the mortuary technicians had alsobeen nominated for a trust award for excellence relatingto the care and support given to a family that lost achild. the family invited the mortuary technician to thechild’s funeral, which the staff member felt was a“privilege”.

• The mortuary had links with the butterfly suite on thelabour ward and would facilitate the movement ofbabies from the mortuary to the butterfly suite for theirfamilies to spend time there.

• Mortuary staff reported deceased bodies were properlyprepared on the wards with a high regard to dignity andrespect and transported to the mortuary in a timelymanner.

• Staff had raised funds for end of life patients to provideextra items to support patients and relatives at end oflife on the wards. and had a strong commitment toproviding the best end of life care. One example was thepurchase of a discreet chiffon bag to carry jewellerybelonging to recently deceased patients when returnedto a family in a sensitive manner.

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End of life care


• We visited the bereavement office as part of theinspection and the staff demonstrated a caring attitudeto deceased patients and their relatives. Staff told usthey were very aware of “what is valuable” to relativessuch as a treasured photo which they took pride inkeeping safe for relatives.


• The end of life service had a clear process for seekingfeedback from patients and families. There was a localSpecialist Palliative Care Bereavement Questionnaire.Results were collected monthly and fed through to bothbusiness unit meetings and individual team meetings.The overwhelming majority of responses were positiveabout the care provided for patients at end of life.However some themes related to wards staff being busyand not always being able to spend sufficient time withrelatives to talk through their concerns. Another themewas the number of different staff relatives had to meetwhich had an impact on communication and peoplehaving to “retell their story.”

• Patients who were at end of life were identified byexperienced clinicians. Referrals were made to the HSPCto support the care of the patient and their families. Allstaff we spoke with were positive about the supportprovided by the HSPC team. End of life patients weresupported on all wards.

• The trust “Individual end of life plan of care”incorporated the principle of care that the needs offamilies and others identified important to the dyingperson are actively explored, respected and met as faras possible. This was clearly documented in the careplans we reviewed. Staff told us the new end of life careplan had helped them to start those conversations andensured that detailed discussions were held withpatients and families and that these conversations wererecorded in a sensitive way.

• Hospital staff demonstrated a clear empathy for peoplewho were at end of life. Side rooms were available forpatients if they wished and relatives were encouragedand guided to help provide care for example, mouthcare. We observed that nurses explained the reasons forcare they provided.

• Staff spoke to patients who were not conscious andtheir loved ones in a kind and caring manner andexplained what they were going to do and why, givingthe family the opportunity to ask questions.

• Patients and relatives we spoke with reported they hadbeen involved in making decisions about their care andtheir wishes had been taken into account. One persontold us “I feel well informed and glad my relative is beingso well cared for”. Feedback from another relative stated“the plan was to move my relative but I was glad theystayed on the same ward with familiar faces.”

• Patients and families were involved in the assessmentand planning for their end of life care. Information withregard to support services, e.g. community specialistpalliative care teams, hospice inpatient and day therapyunits, local support groups, and the local informationcentre were offered to patients and reinforced withwritten information leaflets.

• The electronic discharge summary had been updated toallow information about the use of the “AMBER” carebundle in the hospital to be reflected in the summary sothat healthcare professionals were aware of thediscussions had with patients during the acuteadmission. There was work on-going within thecommunity to create ceiling of care documents to beshared with the hospital teams if admission wasnecessary.

• We saw that on all wards there were end of life noticeboards with literature available for relatives of thosepatients at the end of their life that helped to addressfears and explain what was going to happen – forexample, changes to breathing and what relatives coulddo whilst sitting with a relative.

• Staff told us they could provide leaflets in differentlanguages or other formats, such as braille, if requested.However we did not see we did not see many examplesof information leaflets for people whose first languagewas not English or for people who were visuallyimpaired. This did not assure us people had access toinformation in a format they could understand.

• The trust had developed plans to involve families at anearlier stage for difficult conversations following theresults of a DNACPR audit. We found that within the

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End of life care


DNACPR policy was a copy of information booklet forpatients and carers explaining the process of obtaininga Do Not resuscitate order and the roles andresponsibilities of staff and their duties within the policy.

• Following the death of a patient, families were offeredadvice, guidance and support through the process. Theservice provided a resource pack with guidance forbereaved relatives on procedures such as registering adeath and arranging a funeral.

• The mortuary had flexible out of hours viewing timesand could arrange for deceased patients to be releasedquickly if required.

Emotional support

• There was a functional multi-faith room which staff,patients or families could access for prayer and spiritualsupport.

• The palliative care team, the chaplaincy, clinical staffacross the trust, the bereavement service and mortuarystaff provided emotional support to patients and thoseclose to them.

• We observed staff talking to patients and relatives in acomforting and reassuring way. Staff were supportive topatients and those close to them, and offered emotionalsupport to provide comfort and reassurance. Whenrelatives became tearful, staff were kind and offeredsupport.

• Out of 12 bereavement questionnaire forms betweenSeptember and October 2016 ten people reported theyfelt supported in dealing with their feelings surroundingthe death of their relative and had been given theopportunity to talk with any doctors involved in theirrelatives care. All of the respondents reported they hadbeen able to spend time with their loved one after theyhad died which they found very positive and supportive.

• Staff were supportive towards patients and those closeto them, and offered emotional support to providecomfort and reassurance. Patients and relatives weresignposted to counselling services throughout theirjourney.

• There was a single viewing room where relatives wereable to spend time with their deceased relative.

• Chaplaincy support was available 24 hours a daythrough an on-call system. There was access to spiritual

support for other faiths, which was coordinated throughthe chaplaincy. There were appropriate provisions ofcare for the deceased and their families that met theirpersonal or religious wishes.

• There was a single viewing room where relatives wereable to spend time with their deceased relative.

• Staff had access to psychological support throughoccupational health, managers told us and recordsshowed that sessions had been held for particularlycomplex cases to offer staff the opportunity to talkthrough the case and receive peer support.

Are end of life care services responsive?

Good –––

At the previous inspection in January 2015 we ratedresponsive as good. Following this inspection we havemaintained the overall rating because:

• Services were planned and delivered to meet the needsof local people. There were systems in place to supportpatients with particular needs.

• There were good examples of collaboration with localcommunity providers to produce joint protocols forexample joint prescribing guidelines and crossboundary documentation.

• The trust worked with other services that provided endof life care in the Warrington area to carry out a jointself-assessment identifying areas for development topromote excellence in end of life care.

• There was routine engagement with staff from theneighbouring provider, such as the local hospice andcommunity trust to improve continuity of care.

• The trust had fully implemented an individual end of lifecare plan of care (IPOC) when patients were identified asapproaching end of life. This was a stand-alonedocument which had been based on the principles andessential elements of excellent end of life care asoutlined in the “One chance to get it right.”

• At our last inspection found that there was limitedaccess to single rooms and dedicated relatives roomson some of the wards where sensitive conversationscould be conducted in private. At this inspection we

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found the end of life service had carried out regularaudits of side room availability and the latest resultsshowed 80% of patients had access to a side roomwhich was a significant improvement.

• The rapid discharge pathway was available to enablepatients to be discharged from the acute hospital tohome in the last hours/days of life. Rapid response fordischarge to the preferred place of care was coordinatedby the palliative care team. There were very closeoperational links with the HSPC team and the dischargeplanning co-ordinators who were employed by anotherlocal community trust.

• At a local service level we found very few complaintsrelated to end of life care. Managers told us that theywould be involved in any complaint relating to end oflife care anywhere in the trust.

However:

• There was no rapid discharge home to die policy inplace at the time of our inspection.

• There was limited access to dedicated relativesaccommodation throughout the trust although somewards had provided a recliner for relatives to sleep innext to their relatives.


• Services were planned and delivered to meet the needsof local people. There were systems in place to supportpatients with particular needs.

• There were good examples of collaboration with localcommunity providers to produce joint protocols forexample joint prescribing guidelines and crossboundary documentation.

• The trust worked with other services that provided endof life care in the Warrington area to carry out a jointself-assessment identifying areas for development topromote excellence in end of life care.

• There was routine engagement with staff from theneighbouring provider, such as the local hospice andcommunity trust to improve continuity of care.

• Bi monthly end of life steering group meetings wereheld with to drive service delivery across the trust andWarrington area.

• The trust was committed to working towards improvedend of life care in the local region and was part of theCheshire and Merseyside palliative and end of lifenetwork audit group. This group was made up ofdifferent health care professionals and includedrepresentatives from hospitals, the community andhospice settings to use audit projects to developstandards and guidelines to support specialist palliativecare professionals.

• The HSPC service was widely embedded in all clinicalareas across the trust and had been involved inplanning and delivering end of life services. All staff wespoke with were very positive about the support andadvice received from the hospital specialist palliativecare team.


• The trust had fully implemented an individual end of lifecare plan of care (IPOC) when patients were identified asapproaching end of life. Care was based on meetingindividual needs such as symptom relief, and care ofthose close to the patient. This was a stand-alonedocument which had been based on the principles andessential elements of excellent end of life care asoutlined in the “One chance to get it right". This putpatients and their family’s needs at the centre of clinicalcare and practice. The decision to use the IPOC wasmade by senior members of the multidisciplinary teamsinvolved in caring for the patient and the decision hadbeen communicated with the patient (if appropriate)and the patient’s family/carer.

• Once a patient was placed on an Individual plan of care(IPOC), their family could stay with them overnight andvisit at any time. There were no separateaccommodation for relatives staying at the hospital butthey were offered chairs they could sleep in.

• Conversations with patients and families aroundsupporting care with an IPOC were further supportedwith the provision of the leaflet ‘what happens whensomeone dies’.

• At the initial assessment visit every patient was giveninformation about their specialist palliative care keyworker and information about the specialist palliativecare team (including how to contact them).

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End of life care


• The end of life service reviewed patients daily and theircontact details were placed in the patient’s records inorder for staff to contact the team if a patient’s conditiondeteriorated and they required advice from the HSPCteam. At each handover the HSPC nurses checked thepatient understanding of their condition and anysignificant issues that needed to be communicated.From observing the handover the team demonstratedthey understood the needs and wishes of the patientsand their loved ones. Staff we spoke with on the wardswere also able to demonstrate they understood theindividual needs of patients receiving end of life care ontheir wards.

• Documentation showed that staff were able to identifyindividual spiritual and religious needs, which werefollowed through both at end of life care and in the careof the deceased person.

• Translation services were available for people whosefirst language was not English. 24 hour access to face toface, telephone and written translation.

• Information was available on the trust intranet for staffto access linked to the learning disabilities community.This document provided advice to staff on a range ofissues, including reasonable adjustments, carerinvolvement, communication, consent and advocacy forpeople with learning disability to ensure that individualneeds are met.

• We saw examples of privacy and dignity signs used on aside room where end of life care was being delivered inorder to respect and protect the person’s privacy.Patients at the end of their lives were discreetlyidentified with a purple butterfly symbol on the door oftheir room or in the ward bay.

• Patients with dementia were identified using the ForgetMe Not flower symbol on the electronic patientinformation system. This was used throughout the trustto highlight to the staff that this person required extratime to communicate and adjustments to care may berequired. The wards also used a “this is me" booklet tosupport communication between patients and staff. Thebooklet was completed by a close relative or loved oneexpressing the likes, dislikes and history of the patient.

• Staff we spoke with and records confirmed the actiontaken if there were issues related to the care of thedeceased for transportation to the mortuary. Staff wereclear about escalating issues to their manager foraction.

• There was a functional multi faith room which staff,patients or families could access for prayer and spiritualsupport with washing facilities to support people tomeet their religious observance.

• The mortuary had a quiet garden area for time relativesto visit if they needed to leave the building. The facilitiesfor visiting and viewing loved ones were quiet andwelcoming and provided a space for families to sit withcomfortable furniture, before moving into the viewingroom, which was well decorated, calm and quiet. Themortuary had a quiet garden area for time relatives tovisit if they needed to leave the building.

• Information leaflets about services were readilyavailable in all the areas we visited. Staff told us theycould provide leaflets in different languages or otherformats, such as braille, if requested. There was accessto support for patients with hearing impairment for signlanguage support, advice and advocacy.

• Details of procedures for care before and after deathwere documented in order to ensure that all thespiritual and physical care was carried out to take intoaccount their cultural and religious beliefs. We foundseveral examples when the mortuary service had takensteps to support families to meet these needs. Forexample dressing a deceased patient in an outfit in linewith their cultural beliefs.

• Feedback from families also showed that conversationshad taken place to take into account any spiritual needsand they had been offered the appropriate service suchas the chaplaincy.

• Patients property was well managed we saw evidence ofa checklist being completed to ensure all patientproperty returned to their relatives.

Access and flow

• The hospital had an electronic referral process to thepalliative care team which ensured that there was timely

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End of life care


referral to the service when required. Staff explainedhow they would refer a patient to the palliative careteam and systems were in place for urgent referrals via ableep system.

• Patients attending the Emergency Department requiringskills within the Specialist Palliative Care Team werereferred via the normal hospital referral method.

• Data provided by the trust showed the service met itslocally set target of assessing 95% of urgent referralswith 24 hours and non-urgent assessments within 48hrs.

• As part of the assessment process for all referredpatients, staff told us that the patients preferred place ofcare /death was ascertained. If the patient's conditiondeteriorated and patient/family had chosen analternative place of care other than hospital, thedischarge planning team were alerted to the wishes ofthe patient and any necessary paperwork wascompleted as a matter of urgency.

• The trust collected data in line with the nationalminimum data set (MDS) for palliative care. For theperiod1 April 2016 – 1 March 2017 data showed that 678patients had been seen by the HSPC team of which 347end of life patients died in hospital.

• The data identified that 67 % of patients died in theirpreferred place of death. Senior managers confirmedthat it was not always possible to achieve the identified?particularly if clinically, this was not possible such asdifficulties with care at home and the patient changingtheir identified PPC.

• Data provided by the trust showed between April 2015and March 2016, 731 referrals were made to thespecialist palliative care team of these referral 475 werecancer related and 256 were non-cancer related. Thisbreakdown was similar to the previous reporting year.We did not have access to the full data for the periodApril 2016 to March 2017 but managers told us the newreferrals remained on average 16 per week.

• There was access to spiritual support through thechaplaincy on-call if a patient needed an urgent visit.Achaplain attends the palliative care multi-disciplinaryteam meetings. The chaplaincy team worked closelywith other religious faiths to ensure all patients religiouswishes were adhered. The service was accessible 24hours, seven days a week.

• The trust acknowledged there was no “Rapid DischargeHome to Die Policy” in place at the time of ourinspection. However we found very clear processes inplace to manage discharge. The service had a rapiddischarge pathway for discharge to a preferred place ofcare.

• The rapid discharge pathway was available to enablepatients to be discharged from the acute hospital tohome in the last hours/days of life. Rapid response fordischarge to the preferred place of care was coordinatedby the palliative care team. There were very closeoperational links with the HSPC team and the dischargeplanning co-ordinators who were employed by anotherlocal community trust. During our inspection weobserved close liaison with community nurses, nursing/care homes, social workers and continuing health careto facilitate a safe and timely discharge home to die onan individual case by case. The HSPC team liaised withcommunity specialist palliative care teams andadditional services in the appropriate area.

• The hospital has an agreement with the localambulance Service for a rapid transfer, which includedthe transport of those patients who are returning hometo die or being transferred to an appropriate communitybed. The response time aimed to meet these requestswithin a 2 hour window from initiation.

• The bereavement service was very responsive and didnot close for lunch in order to accommodate bereavedfamilies so that they didn’t have to wait at such adifficult time. It also provided support for traineedoctors who did not have experience in end of lifeprocesses and procedures.


• At a local service level we found very few complaintsrelated to end of life care. Managers told us that theywould be involved in any complaint relating to end oflife care anywhere in the trust.

• We reviewed one complaint regarding a relative’sperception of the involvement of the HSPC team withtheir relatives’ care. The HSPC had taken steps toimprove communication with wards and families toclarify the role of the team and the provision of anadditional specialist service to the patient in additionnot the overall care/treatment they continue to receiveon the wards.

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• Patients and relatives we spoke with knew how to raiseconcerns or make a complaint. We found there wasinformation on wards to inform people of the complaintprocess and staff were able to describe process if apatient or their family wanted to raise a concern or acomplaint.

Are end of life care services well-led?

Good –––

At the previous inspection in January 2015 we rated wellled as good. Following this inspection we have maintainedthe overall rating because:

• The trust had a clear mission and vision statement. Thiswas to provide high quality, safe healthcare. All staff wespoke with were able to describe the vision and strategy.

• Since our last inspection the hospital specialistspalliative care team (HSPCT) had reviewed the strategyfor end of life care and had undertaken aself-assessment structured around the six nationalambitions for palliative and end of life care.

• We reviewed the trust self-assessment and action planfor ensuring the implementation of the “Ambitions forPalliative and End of Life Care” to improve the provisionof better care for patients at end of life. Actions includedthe development of more leaflets for relatives toimprove communication and active engagement inregional audits to ensure the HSPCT is complying withbest local and national best practice.

• The hospital specialist palliative care team (HSPCT) hadan annual work programme in collaboration with othercommunity partners. There was a clear purpose linkedto an end of life work plan.

• At our last inspection we found the new consultant hadbeen in post for three weeks and there were no firmplans for nurse leadership succession planning. At thisinspection we found the service had undertaken a skillmix review and strengthened its nurse clinicalleadership. The HSPC team showed clear leadershipand their leaders fully understood the complexities ofproviding high quality end of life care across the trust.

• There was routine engagement and collaboration withstaff from the neighbouring provider, such as the localhospice and regular multidisciplinary team meetings.

• Staff received communications in a variety of ways suchas newsletters, emails and briefing documents andregular staff and clinical meetings.

However:

• There were a few risks on the corporate and divisionalrisk register relating to end of life care at the time of ourinspection. All had action plans to mitigate risk andreview dates however the risk related to out of hoursmedical cover had been on the corporate risk registersince our previous inspection. We discussed this withthe lead clinician who identified that the trust continuedto review the impact of the lack of cover but had putsteps in place to increase access to advice for staff onthe trust intranet and staff also had access to specialistnursing advice seven days a week.

• We found that at the time of our inspection there was avacancy for a non-executive director with responsibilityfor End of Life Care. This role was being covered on atemporary basis by another non-executive and the newpost holder was due to take up post in April 2017.

• The trust wide electronic record system had enabled theteam to use electronic Multi-Disciplinary team (MDT)documentation from the outset improvingcommunication within the teams. We found theintegrated MDT and information sharing across theWarrington area to be innovative and included the useof video links to the hospice.

• The team had fully embraced the new electronic patientrecord and was planning to move the “individual plan ofcare” into an electronic format which would then bepart of the strategy to share information withcommunity services.


• The Chief Nurse represented end of life care at anexecutive level. However we found that at the time ofour inspection there was a vacancy for a non-executivedirector with responsibility for End of Life Care. This rolewas being covered on a temporary basis by anothernon-executive and the new post holder was due to takeup post in April 2017.

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End of life care


• At our last inspection we found the new consultant hadbeen in post for three weeks and there were no firmplans for nurse leadership succession planning. At thisinspection we found the service had undertaken a skillmix review and strengthened its nurse clinicalleadership. The HSPC team showed clear leadershipand their leaders fully understood the complexities ofproviding high quality end of life care across the trust.

• Senior managers told us there had been some capacityissues until recently. The managers were now able tofocus on driving forward the service vision. Themanagers told us the trust had also undertaken aclinical business unit restructuring in last twelve monthswith end of life care reporting under specialist medicinein the acute care division. Senior staff told us this newarrangement was working well and they felt supportedand had a clear structure for promoting end of life care.


• The trust had a clear mission and vision statement. Thiswas to provide high quality, safe healthcare. All staff thatwe spoke with were able to describe the vision andstrategy.

• Since our last inspection the hospital specialistspalliative care team (HSPC) had reviewed the strategyfor end of life care and had undertaken aself-assessment structured around the six nationalambitions for palliative and end of life care.

• The hospital specialist palliative care team (HSPC) hadan annual work programme in collaboration with othercommunity partners. There was a clear purpose linkedto an end of life work plan including; supporting deliveryof high quality care and support to patients and theircarers under the care of the trust as inpatients andoutpatients, providing leadership through education,audit and service development and maintaining linkswithin the locality, regionally and nationally to ensureup to date guidelines and evidence based practice wasutilised.


• The HSPC team annual work programme was reviewedbimonthly at the trust end of life care steering group to

drive through improvements in end of life care such asthe introduction of new clinical guidance. Meetingminutes could be accessed by all staff on the trustintranet.

• The results from the 2015 end of life audit were in themajority positive. We reviewed the end of life care team2016 annual clinical audit report and associated qualityimprovement action plan put in place to furtherimprove results in the next round of audits. We wereassured the end of life service had clear processes inplace and was proactive in reviewing the quality ofservice delivery and service improvement.

• There were systems in place to audit the quality of endof life services. Quality and performance weremonitored through divisional dashboards and includedpatient experience including complaints, workforcerecruitment and attendance at essential training. Thesewere reviewed at both team and clinical meetings.

• Although we observed there was a rapid dischargepathway in place to ensure patients returned home totheir preferred place of care, there was no supportingpolicy to ensure that this process was followed.

• The trust had reconfigured its reporting structure in2015. Palliative care medicine now reported through thespecialist medicine clinical business unit in the acutecare division through to the board. Senior managerssaid they welcomed the new structure, and we sawevidence of reporting to relevant trust qualitycommittees. We were told and records showed apalliative care assurance and action plan was submittedthrough the clinical business unit (Specialist Medicine)Quality Governance meeting as part of the revisedgovernance processes. However we found thatcommunication and performance reporting structuresstill needed to be strengthened to fully engage the endof life service both within the clinical business unit andacross the whole trust.

• Corporate and divisional risk registers were in place,managers knew the risks and mitigating actions withintheir departments. However we found there was nospecific risk register for end of life care.

• There were a few risks on the corporate and divisionalrisk register relating to end of life care at the time of ourinspection. All had action plans to mitigate risk andreview dates however the risk related to out of hours

Endoflifecare

End of life care


medical cover had been on the corporate risk registersince our previous inspection. We discussed this withthe lead clinician who identified that the trust continuedto review the impact of the lack of cover but had putsteps in place to increase access to advice for staff onthe trust intranet and staff also had access to specialistnursing advice seven days a week. The lack of timelyresponse to risk may impact on the provider’s ability toeffectively monitor and deliver services.

• We reviewed the trust self-assessment and action planfor ensuring the implementation of the “Ambitions forPalliative and End of Life Care” to improve the provisionof better care for patients at end of life. Actions includedthe development of more leaflets for relatives toimprove communication and active engagement inregional audits to ensure the HSPC team is complyingwith best local and national best practice.


• The HSPC team was well embedded in the trust andworked closely across the local clinical network toimprove the quality and visibility of end of life services inthe Warrington and Halton areas. We found a culture ofcontinuous improvement throughout the service.

• The HSPC team and ward staff were passionate aboutthe provision of end of life care in the trust. We observedand staff told us there was close collaboration betweenthe HSPC team and ward staff. We found staff keen toimprove services so that patients received the best carepossible.

• Ward staff were overwhelmingly positive about theHSPC team and felt that they were now more visiblesince the last inspection but had continued to be bothresponsive and supportive to staff managing the needsof patients requiring end of life care.

• The HSPC staff reported they were well supported bytheir managers and felt able to raise any concerns if theyneeded to.

• We observed staff interaction with patients and theirrelatives and found them to be open and honest in theircommunication.

Public engagement

• The service was continually looking for ways to improvethe care for patients and worked closely with the

bereavement service. The bereavement team gave outquestionnaires to bereaved relatives. Response rateswere around 10%. Feedback from the questionnaireswas reported to the End of Life Steering group on abimonthly basis.

• The trust had a disability equality group to discuss theinterpretation and communication needs of hearingimpaired.

• Information about how the public could providefeedback was displayed in the departmental areas andfeedback mechanisms for the public to engage with thetrust were also on the internet site.

• The trust was a member of the Cheshire and Merseysidestrategic clinical network which had set up an auditfocus group to invite the public to have discussions onstandards and guidelines on a number of clinical andnon-clinical topics such as hydration and bereavement.

Staff engagement

• The HSPC team and ward staff were passionate aboutthe provision of end of life care in the trust. We observedand staff told us there was close collaboration betweenthe HSPC team and ward staff. Staff were keen toimprove service is so that patients received the bestcare possible.

• There was routine engagement and collaboration withstaff from the neighbouring provider, such as the localhospice and regular multidisciplinary team meetings.

• Staff received communications in a variety of ways suchas newsletters, emails and briefing documents andregular staff and clinical meetings.

• Staff supported each other well and there were regularopportunities to share ideas and meet together.

• Results of the 2016 NHS Staff Survey showed the trustscored better than the national average for acute trustsfor support from immediate managers and recognitionand value of staff by managers and the organisation.However the trust scored worse than the nationalaverage for acute trusts for staff recommendation of theorganisation as a place to work or receive treatment.

• Physical and psychological support services wereavailable to staff and staff were aware of how to accessthese services.

Endoflifecare

End of life care


• Results of the 2016 NHS Staff Survey showed the trustscored better than the national average for acute trustsfor support from immediate managers and recognitionand value of staff by managers and the organisation.However the trust scored worse than the nationalaverage for acute trusts for staff recommendation of theorganisation as a place to work or receive treatment andthe percentage of staff reporting good communicationbetween senior management and staff.


• Since our last inspection the HSPC team had appointeda clinical educator for palliative care to improve theeducation of staff across the trust in the management ofend of life care as well as the use of amber care bundles.

• A programme of four days simulation training had beendevised and was being delivered as part of a patientcentred care approach.

• The trust wide electronic record system had enabled theteam to use electronic Multi-Disciplinary team (MDT)

documentation from the outset improvingcommunication within the teams. We found theintegrated MDT and information sharing across theWarrington area to be innovative and included the useof video links to the hospice.

• The team had fully embraced the new electronic patientrecord and was planning to move the “individual plan ofcare” into an electronic format which would then bepart of the strategy to share information withcommunity services.

• The End of life team had signed up to the nationalquality transform programme for improving end of lifecare in hospitals.

• The HSPC team described their initiative to develop a"Grab Bag" containing relevant medications and syringedriver to enhance the quality of service delivery in atimely manner.

Endoflifecare

End of life care



Effective Not sufficient evidence to rate –––





Information about the serviceWarrington hospital served a population of approximately200,000. The hospital was centrally located and the largesthospital in the trust. The trust provided outpatient clinicsfor all specialties and diagnostic (scanning) services at bothWarrington and Halton so people could access their initialappointments close to home wherever possible. They alsoprovided some outpatient services in the local community.

Between October 2015 and September 2016 there were337,557 outpatient appointments at Warrington. The mainoutpatient clinic was centrally located on the ground floorof the hospital and consisted of six clinical areas each withsmall waiting areas that hosted 22 consultation rooms intotal.

Some specialities had dedicated outpatient areas includingophthalmology, breast screening, physiotherapy, diabetes,gynaecology and obstetrics clinics. There was a separatechildren’s outpatient clinic on the hospital site. Warrington& Halton hospitals main outpatient clinics hosted over 300clinics per week, which included 65 ophthalmology and 51trauma and orthopaedic clinics.

Diagnostic Imaging sat within the Diagnostic CBU in AcuteCare Services along with Pathology and Cardio-Respiratoryservices. The Trust provided imaging in various modalitiesfor both inpatients and outpatients, magnetic resonanceimaging (MRI), computerised tomography (CT), x-ray/Primary Imaging, Nuclear Medicine, DEXA, Ultrasound andInterventional Radiology. The Trust also led on theoutpatient breast screening service across the Warrington,Halton, St Helen’s and Knowsley area.

During the inspection at Warrington, we spoke to 107 staff,54 patients and inspected 30 sets of patients paperhealthcare records and 10 further electronic records. AtWarrington we visited x-ray, CT, MRI, Interventional, A&Ex-ray, nuclear medicine (NM), ultrasound (US), Generaloutpatients, Ophthalmology, Maxillo-facial, Physiotherapy,Hydrotherapy, Urology, ECG/Physiology, Phlebotomy,Cardiac, Rheumatology, ENT, Colorectal, Fracture, Breastscreening, Orthoptics and Medical Records.


Outpatients and diagnostic imaging


Summary of findingsWe rated this service as requires improvement because:

• The CT waiting area was not suitably designed tokeep people safe. The area was too small and lackedequipment that would be required in an emergency.The area lacked also privacy and dignity.

• We found three breaches of Health and SafetyExecutive guidance note PM77 ‘Equipment used inconnection with medical exposure’ Reg 36 wherethere was no record that the equipment had beentested and signed back into use following faultrepairs in the CT department.

• Audit evidence showed poor compliance with theWHO (World Health Organisation) surgical safetychecklist in interventional radiology

• We found six separate breaches of Ionising RadiationRegulations 99, regulation 32, which refers to routinequality assurance of equipment used in diagnosticimaging.

• There was a lack of available rooms for counsellingpatients in the breast screening clinic.

• There had been significant changes in the leadershipteam which had the left the staff feelingdisconnected and ensure of the strategy and futurevision of the service.

However:

• We saw evidence of good safe practice within theOutpatient department.

• There was evidence of excellent hand hygienecompliance and monitoring with regular auditsundertaken across six outpatient locations.

• Clinical audits were performed in line with bestpractice and results frequently shared at a regionaland national level.

• We saw evidence that staff from several disciplineswork together to assess, plan and deliver care andtreatment to patients including clinicians and alliedhealth professionals.

• Cross-site culture was good and staff reported goodcollaborative working, staff were happy to movebetween hospital teams.




Are outpatient and diagnostic imagingservices safe?


We rated safe as requires improvement because:

• Serious incidents had undergone investigation andanalysis and assurance measures put in place toprevent reoccurrence where possible.

• The CT waiting area was not suitably designed to keeppeople safe. The area was too small and lackedequipment that would be required in an emergency.The area also lacked privacy and dignity.

• We found six separate breaches of Ionising RadiationRegulations 99, regulation 32, which refers to routinequality assurance of equipment used in diagnosticimaging.

• We found three breaches of Health and Safety Executiveguidance note PM77 ‘Equipment used in connectionwith medical exposure’ Reg 36 where there was norecord that the equipment had been tested and signedback into use following fault repairs in the CTdepartment.

• We found two stock medicines that were out of date inthe cupboard in interventional radiology, and an emptyoxygen cylinder with the resuscitation trolley inultrasound.

• Staff were compliant in mandatory training in all areasapart from medicines management and health andsafety level 3.

• Audit evidence showed poor compliance with the WHO(World Health Organisation) surgical safety checklist ininterventional radiology.

However:

• Staff understood their responsibilities to raise concernsand near misses and nurses, allied health professionals(AHP) and administration staff were able to give usexamples.

• There was evidence of excellent hand hygienecompliance and monitoring with regular auditsundertaken across six outpatient locations.

• The records team had worked hard to make a significantimprovement to the availability of records since the lastinspection. Records audits now demonstrated anaverage of 99.7% of records being in clinic whenrequired. Investigations were undertaken on everymissing record.

• We inspected a sample of 22 patients healthcare recordsin diagnostic imaging areas. All patients had beenassessed for possible contraindications with contrastmedia in CT and all safety screening questions had beenanswered in MRI. Appropriate pregnancy assessmentshad been made in appropriate notes.

• The diagnostics department had an appointed radiationprotection supervisor in each imaging modality.

Incidents

• The hospital provided an electronic system for recordingincidents and staff of all grades were able to identify itsuse and how to access the system. Staff knew how toreport incidents and gave us examples of what shouldbe reported.

• Never events are serious patient safety incidents thatshould not happen if healthcare providers follownational guidance on how to prevent them. Each neverevent type has the potential to cause serious patientharm or death but neither need have happened for anincident to be a never event. Between January 2016 andDecember 2016, the trust reported no incidents, whichwere classified as Never Events in outpatients ordiagnostic imaging.

• In accordance with the Serious Incident Framework2015, the trust reported one serious incident indiagnostics and two in outpatients between January2016 and December 2016.

• One incident involved a delay in treatment due to afailure of the electronic appointments system. This wasescalated and became part of a nationwide issue. Thehospital undertook thorough investigations to ensureno further patients had been affected. An action planwas created and completed, which included newoperating procedures, progress audit and a failsafe plan.

• In diagnostics, we were informed of four level 1incidents that had been investigated in 2016. Threeincidences related to missed diagnoses occurring in




previous years and a further incident relating to apatient fall during an x-ray. Each incident hadundergone investigation, analysis, and conclusionsmade.

• Staff understood their responsibilities to raise concernsand near misses and nurses, allied health professionals(AHP) and administration staff were able to tell us whatsort of incident should be reported and what thereporting process was.

• In outpatients, learning from incidents was shared atmonthly team meetings, in staff emails and on staffcommunication notice boards in staff room areas Weobserved records of sign in sheets kept by localmanagers, which confirmed staff had read thisinformation.

• The radiology department had recorded 118 minor, leveltwo, incidents on the trust reporting system between 1January and 31 December 2016. We were told that theradiology governance lead reviewed every incidentreport that staff added to the system and ensured thegrading was appropriate. The lead told us that incidentswere often downgraded following the assessmentflowchart.

• Incident investigation was undertaken for major andsevere harm (level three or above). As radiology had onlyone incident recorded there were potential missedopportunities to learn from errors recorded as minor.Learning had taken place in some cases where themeshad been identified. We were shown evidence ofprocedural changes made because of some incidents.

• We saw evidence, and discussed with staff, the actionstaken following a patients unintended exposure toradiation. The incident had been reported correctly andanalysis and actions had been taken as a result. Thetrust had five incidents of unintended exposure since2009.

• We spoke to staff who understood that duty of candourmeant being open and honest with patients and familywhen things go wrong. Radiology provided us with anexample when an apology had been given to a patient,which was timely and appropriate.


• The trust had a policy for infection prevention andcontrol, which staff could access on the trust intranet.We observed staff following ‘bare below the elbow’guidance and wearing personal protective equipment,such as gloves and aprons, when delivering care.

• All areas we visited in the outpatients and diagnosticsdepartment were visually clean. Patient areas andstore-rooms were mainly clutter free. The cleaningrecords in some areas of outpatients had not beencompleted for two days at the time of the inspection butevidence of completed cleaning schedules weresubmitted after the inspection.

• Monthly cleanliness audits had been undertaken inOphthalmology. Results for six months from Sept 2016to Feb 2017 demonstrated overall scores between 82and 93%. Comments and actions were planned eachmonth to address issues and improve facilities.

• Staff were trained in hand hygiene techniques andweekly audit checks were performed to assess staff andthe environment. Results were displayed on infectioncontrol notice boards in the clinics. The results of auditsfor six outpatient locations over a six month periodshowed an average of 99.5% compliance, which wasevidence of good standards of hygiene.

• During the inspection, we saw staff using protectiveequipment, and hand washing before and afterdelivering care in several locations includingcomputerised tomography (CT) and Interventionalradiography.

• We saw personal protective equipment available forstaff, where required, such as gloves and aprons.Examination couches were covered with clean paperand hand sanitizer and wash lotion were available at allsinks.

• A member of nursing staff told us when a patientattended with a known infection risk, such asMethicillin-resistant Staphylococcus aureus (MRSA),then the patient was given the last appointment of theday and the examination room used was deep cleanedfollowing the appointment.

• In the hydrotherapy pool, regular water tests wereperformed so ensure there was no risk of infection topatients. Results demonstrated good cleanlinessstandards were maintained.




• The diagnostic imaging department had a lead staffmember responsible for infection prevention. Staff hadadditional training and was available to monitorsystems and processes and advise team members.

• The nuclear medicine department was situated off themain radiology corridor and patients had access to thewaiting area and directly into the scanning room. Staffhowever, had to enter the staff only areas via thedepartments sluice room. At the time of the inspection,the sluice macerator was broken and had been tapedclosed with yellow and black hazard tape. There was alarge yellow, wheeled bin that had waste bags on topand in front of it, as the bin was full. Staff were expectedto use this route to enter and exit their departmentdaily.


• The computerised tomography (CT) department waslocated on the ground floor of the hospital and providedimaging for adults and children as inpatients from wardsand accident and emergency department as well asoutpatients, including prisoners from a nearby prison.There were two CT scanners in the department, whichhad a shared control/reporting room. The waiting areawas directly off the main hospital corridor and providedseating for twelve. There were two individual toiletsdirectly off the waiting area. When an inpatient on atrolley was brought to the department, the onlyavailable space was placing the bed in the waiting areaagainst the wall and directly blocking access to one ofthe toilets. The patient was then lying directly in front ofthe fixed seating, less than one metre away, and in sightof the main corridor. This provided no privacy or dignityfor the inpatient and created a risk to anyone using thetoilet. One member of staff told us of an occasion whenfour inpatients on trolleys were in the department at thesame time. The main hospital corridor had been utilisedat this time.

• If a patient were to require emergency care, there wasno room for staff to provide life support in that area.Inpatients were brought to the department by portersand we were told by a radiology lead that there was anexpectation that clerical staff, responsible for bookingpatients into the department, would monitor thepatient’s condition and alert clinical staff if required.There was no call bell in the waiting area. Resuscitation

equipment was kept on a trolley in one of the scanningrooms, which was not accessible if a scan was inprogress. Portable oxygen was stored in the waitingarea.

• We raised the issue with the radiology governance leadwho told us the area had been risk assessed and placedon the trust risk register in May 2014. The risk wasgraded as high, 16, as a privacy and dignity issue. Sincethen a set of curtains were attached to the ceiling, inorder to give a bedded patient some privacy, however itwas realised that the patient could no longer be seenand there was a greater risk if the patient deterioratedso the curtain was not used. The risk had beendowngraded on 28 Feb 2017 to a 12, and justification forthat change was not provided. There had been anincident where a level 3 patient, who had already hadtwo cardiac arrests, was brought to CT and had to waitin the waiting area for his scan. The patient had a furtherarrest in the CT scanning room. The incident wascategorised as minor (level 2). We escalated ourconcerns during the inspection and received assurancefrom the trust senior management that action would betaken.

• As part of The Ionising Radiations Regulations 1999,regulation 32, a suitable quality assurance programmemust be in place to ensure safe exposure to ionisingradiation. We found several breaches of this regulationduring the inspection.

• The Philips Brilliance CT scanner had no monthly qualityassurance or air calibration checks performed between3 April 2016 and 2 Jul 2016, but was still in use duringthis time.

• Radiation warning light checks, usually performedweekly, had 17 weeks between June 2016 and March2017 when tests were not recorded as being performed.

• X-ray rooms 1 and 3 had no monthly test performed forthree months between Jan 2016 and March 2017.

• The three image intensifiers had not been tested sinceNovember 2016 at the time of the inspection. Threemonthly tests had not been done.

• The AMX 4 had been tested in Jan and Feb 2017, butthere was no record for 2016.




• There were 3 months quality assurance entries missingfor both SCBU and A&E room 2 x ray equipment recordssince July 2016.

• Each imaging speciality had equipment fault reportingbooks with details recorded including fault, log numberand action taken, the information was also recorded onthe trust computer system. We inspected the faultrecords in computerised tomography (CT) and foundthere were three faults recorded where an equipmenthandover form was not present. The faults had occurred15 Jan 2016, 24 Jan 2016 and 12 Oct 2015. Thiscontravenes the Health and Safety Executive guidancenote PM77 ‘Equipment used in connection with medicalexposure’ Reg 36. ‘The regulation states that ‘Noradiation equipment or ancillary equipment should beaccepted back into service until a competent employerrepresentative (such as a senior radiographer or medicalphysicist) has reviewed the service report/summary toconfirm that the equipment has been left in a state fit foruse, and that no alterations have been carried out whichmay significantly affect patient doses or radiationsafety’.

• We found an overfull confidential waste bag in theoutpatients clinic, which was a manual handling risk.

• In treatment room one, we saw an unsafe trip hazardfrom computer wires trailing from a desk to the sockethalfway up the wall approximately 1.5 metres away. Thiswas escalated during the inspection.

• Resuscitation equipment was available in outpatientand diagnostic areas and staff knew where their nearesttrolley was located. Daily checks were made onequipment and expiry of medicines. A logbookaccompanied each trolley and these were found to beup to date. Daily defibrillator tests were done andoxygen cylinders were checked, dated and storedappropriately. We found an empty oxygen cylinder inultrasound, which was immediately escalated.

• We found the policies and procedures relating toIonising Radiation (Medical Exposure) Regulations 2000(IRMER) were appropriate and up to date.Documentation was available to staff via the hospitalinternet and up to date paper copies were also seen. Wereviewed ‘local rules’ in seven locations which were allwithin review dates and appropriate.

• The radiology department had a long-term contractwith a supplier of imaging equipment to service,maintain and replace equipment on a rollingprogramme. This included equipment in plain film x-ray,CT, magnetic resonance imaging (MRI), Ultrasound andInterventional radiology (IR).

• Biennial independent radiation protection surveys hadbeen performed and reports containedrecommendations that had been actioned whereappropriate.

• Staff wore radiation monitoring badges and records ofstaff results were stored on the computer to assessexposure over time and regularly reviewed by the localradiation protection supervisor (RPS).

• There were maintenance contracts in place for radiologyequipment. Staff in nuclear medicine told us thatequipment was repaired quickly and caused minimumdisruption to service.

• All visible electrical equipment was checked forevidence of portable appliance testing and any servicedue dates. Where stickers were not evident, on largerequipment in radiology for instance, staff assured uswith up to date service documentation that ensured theequipment safety.

• We found all quality assurance records were up to datefor testing of protective lead aprons and followedradiation protection guidance.

• We saw good use of handling equipment when a patientwas transferred to the scanning tables in radiologylocations.

• Sharps bins that were in use in clinical areas were notover full, secured to walls and were safe.

Medicines

• During our inspection, we looked at the safe and securehandling of medicines in a variety of clinic andoutpatient settings. Medicines were kept locked insecure cupboards and the keys were held by a seniormember of staff. We were told stock had recently beenreviewed to meet the department’s needs.

• Medicines requiring storage between two and eightdegrees centigrade were kept in locked fridges.Temperatures were monitored daily to ensure thetemperature remained within the recommended range.




• The nurse in charge in outpatients was responsible forcarrying medicine keys and a log of prescriptions issuedthat day, including patient specific information. The logwas locked away each evening and we were told theprocess had been introduced to ensure prescriptionsecurity. The manager had no recollection of the loss ofthis information or any issues with informationgovernance.

• Medicines were prescribed and used correctly ininterventional radiology, though we found twomedicines that were out of date in the stock cupboard.Contrast media in CT was in date and we observedappropriate administration and storage.

• The nuclear medicine department administeredpatients doses in accordance with The Medicines(Administration of Radioactive Substances) Regulations1978. Radioactive medicines were prescribed,administered, stored and disposed of appropriately.

• Anaphylaxis kits were available in the CT and MRI areasof radiology. The kits were made up of injectionsrequired should a patient have a contrast inducedreaction.

• There were patient information leaflets relating tospecific medicines and treatments available inoutpatient areas including the breast screening waitingroom. The leaflets included what the medicine does,how to take and possible side effects.

• Staff in some outpatient areas used patient groupdirections (PGD’s) to administer medicine without adoctor, such as eye drops or contrast media. Theprocedures and staff competencies were inspected andcomplied with standards.

• At the last inspection, there were significant issues withincomplete patient records, with up to 25% of recordsmissing at appointment. A system was introduced thatensured healthcare records were available in time foroutpatient clinics. Continuous audits were undertakento record the response.

• At the time of the inspection the medical recordsdepartment recorded 99.7% availability of records. Weinspected the audit records for a period of 3 months andfound only 11 cases of missing records. Nine werelocated in time for the appointment and two were

duplicated. An escalation process was in place andmissing notes were reported to divisional managementfor investigation. Themes were discussed at outpatientsteering group meetings.

• There were significant national issues with theelectronic records system that had caused difficultieswith follow up appointment letters. Patients across thecountry had either received multiple letters for oneappointment or not received a letter at all. The trust hadidentified the problem and had addressed any potentialconcerns. There had been 200 patients that did notattend their appointment that had been subsequentlycontacted and offered appointments. At the time of theinspection there were 33 patients that still needed afollow up appointment.

• After the introduction of a new IT system in November2015, appointment outcomes were recordedelectronically by Consultant and Specialist Nursing staffon a bespoke system. This removed the risk of paperoutcome forms being ‘lost’ in the system, which mayhave affected patient safety and referral to treatmentrecording. The process was audited daily to ensure anyappointment without an outcome was followed up withthe clinician. A daily check of outcomes against thebespoke system and Lorenzo was also performed toensure all patients were accounted for.

• These issues were recorded on the risk register and therisk of harm due to the missed appointments wasassessed. An investigation identified whereimprovements could be made and these were actioned.

• Case notes were kept in secure trolleys behind the mainreception desk, out of public view.We saw patient recordsheets in preparation for the day’s clinic, with no lettersattached or included. Admission front sheets wereobserved in one patient’s record, with several letters toand from the GP, all filed in date order. These clearlyconfirmed the patient pathway

• We inspected a sample of eight sets of paper healthcarerecords and the electronic records of ten furtherpatients in the outpatients department. Paper recordsincluded diagnostic results, specialist nurse letters andcommunication forms. These were dated and signedwhere appropriate, or recorded as dictated but not




signed. There was evidence of patient allergies recordedand clinic attendances in chronological order. Somepatients with chronic conditions had several volumes ofnotes, which were numbered according to the IT system.

Safeguarding

• The trust had a policy for safeguarding adults andchildren, which informed staff who the namedprofessionals were that could be contacted for advice.We found staff were aware of the policy and gave usexamples of appropriate practice.

• We saw safeguarding information boards in staffingareas that covered issues including safeguardingpatients with learning difficulties and female genitalmutilation.

• The trust provided training in safeguarding adults andchildren. Outpatient and diagnostic staff were trainedup to level 2 for both adults and children. Overall, thetarget of 85% in all levels with all staff groups was met.An appointments officer gave us an example of whenshe raised a safeguarding alert and said she feltconfident and supported throughout the process. Aconsultant told us of an issue he had raised thatuncovered a case of domestic abuse.

• Key staff in outpatients were trained to level threeincluding phlebotomists, nurse specialists andphysiotherapists. The safeguarding lead in ultrasoundwas trained to level 3 in child protection. The lead toldus they actively monitored patients that failed to attenda first trimester appointment. However, dental nurseswho directly cared for children were only trained to level2.

• In radiology, we saw prompts and checklists for staff toensure correct identification was made prior to patientsreceiving any diagnostic imaging. We observed patientsreceiving a full identification check and correct doseinformation being recorded in notes.

• We saw evidence of WHO (World Health Organisation)surgical safety checklists (which aims to decrease errorsand increase communication in any theatre setting)used in interventional radiography when non-surgicalprocedures were performed.

• However, a compliance audit undertaken in August 2016examined 40 patients records and found only 19 hadcompleted checklists. With ‘not appropriate’ and

‘missing records’, the audit determined that there was70% compliance. The audit stated that 100% isexpected but did not have any recommendations,learning or action plans for improvement.

• The maxillofacial department had developed a patientpack that was based on the WHO checklist for patientsundergoing orthodontic surgery. It contained fullinformation for a patient pathway through thedepartment from consent, pre and post procedurechecks and sedation. The department only treatedpatients over 16 years old.

Mandatory training

• Comprehensive corporate and local inductions were inplace at the hospital for all new starters. Staff wereexpected to undergo mandatory training within threemonths of commencing work.

• Mandatory training was delivered face to face and via ane-learning package on the hospital intranet. Learningincluded essential subjects such as health and safety,infection control and moving and handling.

• The trust target for annual attendance was 85%. Staff inoutpatients and diagnostic imaging were compliantwith this target in most topics, apart from medicinesmanagement where compliance ranged from 100% to13% across staff groups with a total compliance as 61%.Health and safety level 3 also had only 77% compliance.


• There were controlled area illuminated warning signs atthe entrance to each diagnostic imaging area thatconformed to radiation regulations and yellow radiationdanger warning signs, however some quality assurancechecks had not been done. Signs were evident in thewaiting room and camera rooms informing patients tolet staff know if they may be pregnant.

• We saw records of training for staff who were radiationprotection supervisors (RPS). There was an RPSavailable in each clinical area where patients and staffwere exposed to radiation who could advise on safety.

• We saw interactions with a patient prior to undergoingMRI imaging. The patient was advised what to expect,and safety precautions were undertaken appropriately.

• We checked the healthcare records of twelve patientsundergoing CT diagnostic examinations and ten




patients attending MRI. All patients had been assessedfor possible contraindications with contrast media in CTand all safety screening questions had been answeredin MRI. Appropriate pregnancy assessments had beenmade.

• A policy was in place that had been developed locally toassess patients for risk of contrast induced acute kidneyinjury (AKI). The policy was developed based on NICEguidance.

• We asked staff how they would manage a patient whosecondition deteriorated during their appointment. Areceptionist and two radiographers and four healthcareassistants we spoke to were able to explain theprocedure. Staff were confident in their response andknew how to act appropriately and where the nearestresuscitation trolley was stored. This included calling forassistance and pulling an emergency alarm.

• There were sufficient emergency call bells in radiology.We tested emergency call bells in two areas and bothalarms were in working order. Staff responded quickly tothe alarm.

• The resuscitation trolley in the CT department was keptin one of the two scanning rooms. Due to the potentialradiation risk, this room was not accessible when in use.This presented a risk of delay to treating a patientoutside of the room. We escalated this issue to theradiology governance lead.

• The physiotherapy department had a referral policy inplace and assessment criteria prior to a patientcommencing pool therapy. The policy ensured patientswere not at risk in the pool. If a patient did collapseduring hydrotherapy treatment, a procedure foremergency evacuation of the pool gave clearinstructions to staff how to manage the situation.

Nursing staffing

• The hospital had undertaken an outpatient staffingreview and nurse staffing in outpatients waspredominantly health care assistants (HCA). Of the 36whole time equivalents, there were 24 HCA’s. At the timeof the inspection the nurse manager had only been inpost for seven weeks.

• Nursing staff worked between Halton and Warringtonsites, covering and responding to change in staffingneeds on a day-to-day basis as necessary. Rotas wereplanned ahead according to clinic demands and staffworked flexibly to cover this.

• There were 6.2 whole time equivalent (wte) band 5nurses that worked across the two hospital sites inoutpatients. At the time of the inspection, 2.6wte wereon long-term sickness. This was managed with twotemporary posts.

• The trust submitted data for planned versus actualstaffing figures for one week in January anddemonstrated 75% compliance with planned stafflevels. Where there was shortfalls, numbers were usuallyincreased with staff of other grades. the trust providedinformation to show that at the time of inspection therate was 89% compliance.

• The current turnover rate of outpatient staff was 7.7%qualified staff and 5.4% unqualified. This number wasunusual and did not raise any concerns. The trust hasprovided further information confirming that theoriginal information submitted was not correct and thetrue figure was 0% for qualified and 2.7% unqualifiedstaff.

• In December 2016, the radiology department hadvacancies for both radiologists and radiographers,particularly band 6 grade. There was a shortfall of 25%radiographers in breast screening clinic equivalent to 6.5whole time equivalent staff and 17% vacancy rate inultrasound. This reflected current national shortages.The trust were managing to maintain services by overrecruitment to lower grades and initiatives such asapprenticeships were being explored. The principalradiographer

• The trust also reported vacancies in histopathology andoutpatient appointments staff. Pathology had recruitedover establishment figures in microbiology,histopathology and haematology in order to managehigher-grade vacancies.

• Radiology had a low sickness/absence rate of 3.3%,which was less than other divisions in the trust.Radiology turnover rate was 10%.

Medical staffing




• The trust had 10% vacancy rate for consultantradiologists (1.78 whole time equivalent (wte)) theservice was managed with over-establishment withlower training grade medical staff.

• A local agreement was in place with seven neighbouringtrusts to ensure out of hours scans were reportedquickly. Warrington radiologists participated in anon-call rota currently working 1:10 shifts. There was aconsultant presence at the hospital till 8pm on weekdayevenings and weekend mornings till 1pm. Consultantswere available to be called in to help with reporting orprovide advice/support to the radiology trainees asrequired. All on-call scans reported by the trainees werechecked by the on call consultant for the relevant site assoon as practicable and definitely within 24 hours.Imaging other than CT scans remained theresponsibility of the consultant radiologist on call ateach site. At Warrington this was a 1:15 on call rotacurrently.

• Medical staff were present in speciality clinics asnecessary. Some clinics were run by consultants fromother trusts, or patients were referred to attend otherhospitals when a speciality was not offered such asdermatology.


• The trust had a major incident and business continuityplan. Staff were trained as part of their inductiontraining and details of emergency planning procedureswere available on the trust intranet. Senior nursing staffhad good knowledge of emergency planningprocedures.

• We saw the procedure in accident and emergency x-raydepartment and staff gave us an example of theprocedure in action during a chemical incident at a localfactory. Staff were confident that the process keptpeople safe.

• We asked clinic staff what they knew about thehospital’s major incident policy. We were assured thatstaff knew how to access the policy and what role theytook in the plans. The general continuity plan was thatstaff would be utilised at the acute site.

Are outpatient and diagnostic imagingservices effective?

Not sufficient evidence to rate –––

We inspected but did not rate the effective domain.However, we found:

• We saw many examples of evidenced based care andtreatment in outpatient and radiology. Clinical auditswere performed in line with best practice and resultsfrequently shared at a regional and national level.Results were monitored to ensure consistency andimprovement. Good patient outcomes were evident as aresult of assessments and evidence based treatments.

• Patient outcomes were a priority in clinical areas andfrequent audits undertaken to monitor success.Ophthalmology, physiotherapy and urology gave usexamples of investigations and quality improvementsmade.

• We saw evidence in healthcare records of staff fromseveral disciplines working together to assess, plan anddeliver care and treatment to patients includingclinicians and allied health professionals. The trusthosted several clinics for patients from neighbouringhospitals and in breast screening a weeklymulti-disciplinary team meeting was held byteleconference.

• All staff we spoke with had a good understanding ofwhen consent would be sought, and were able toexplain guidance from the Mental Capacity Act. We sawevidence that the consent process for patients wasmonitored and there was good compliance withlegislation.

However:

• Interventional radiology was only available Monday toFriday between 9 and 5. Urgent patients had to betransferred to another hospital outside these hours.


• There was a multitude of clinical audits performed inline with best practice and results frequently shared at aregional and national level. Results were monitored toensure consistency and improvement. Good patientoutcomes were evident as a result of assessments andevidence based treatments.




• An example of best practice was orthodontic mini-screwtreatment offered in the orthodontic clinic as analternative to jaw surgery.

• In urology, procedures that referenced National Institutefor Health and Care Excellence (NICE) guidance hadbeen devised to maintain staff competency usingbladder scanner equipment.

• The ophthalmology department participated in aseveral patient experience audits and used results toimprove patient outcomes. This included an amblyopiareview, stroke service review and school visionscreening. Standards and outcomes were measuredagainst national standards.

• The radiology governance lead was responsible forensuring all pathways and policies were regularlyreviewed and updated in line with NICE and RoyalCollege of Radiographers guidance. The documents weinspected conformed with current guidance.

• We saw evidence of posters of research workundertaken displayed in radiology. The work hadassessed techniques against NICE guidelines including‘Paediatric elbows’, ‘lumber spine GP referrals’ andPelvic radiography’. The audits ensured continuedquality and best practice.

• The diagnostic reference levels were monitored andassessed during the annual radiation protection advisorinspection. Any discrepancies were highlighted,discussed and actioned.

Pain relief

• The fracture clinic had a supply of the medical gasEntonox to provide patients with pain relief, if required,during examination and treatment. The gas was storedappropriately in a locked store room.

• No other pain medication was available for patients inthe clinic. We were told that patients would be advisedto take oral pain relieving medication at home prior toan appointment if it was deemed necessary, forexample during a dressing change.

Patient outcomes

• We saw evidence in team meeting minutes that patientquality issues including waiting times were discussedand actions were included, where possible.

• The radiology department was involved in a number ofclinical audits including nasogastric tube audit, andstudies in pelvis orientation and chest x-ray referraltimes.

• The physiotherapy department routinely measuredappropriate patients emotional and physical conditionwith a ‘Back to Action’ questionnaire. The backrehabilitation programme was audited every three yearsand measured against NICE guidance.

• The specific learning difficulties department undertookannual monitoring of patient outcomes in order toassess their achievement of goals, including the impactof orthotic intervention on progress and measurepatient and school satisfaction. Results were positiveand actions and recommendations made.

• Urology staff had audited the outcomes of patients withindwelling catheters that had been discharged from thehospital service as part of a quality improvementproject. As a result of patient responses, a patientcatheter passport was developed that was atransferable document between hospital andcommunity services and provided patients withessential information. The passport contained aself-help guide, health and hygiene advice along withspace for personalised information such as productsand equipment types. Staff awareness and training wasundertaken. Staff planned to re-audit patients when thepassport had been embedded.

• Although there was no formal audit process in place, wewere told that the dressing clinic has positive patientoutcomes. Wounds healed well and there were noreportable infection incidents.

• The audiology department had received an award fromthe National Tinnitus Society for recognition of theirwork with tinnitus patients. This was also published inthe hospital magazine.

• Warrington and Halton hospital trust does not currentlyhave any services registered with the Improving Qualityin Physiological Services (IQIPS) accreditation scheme.

Competent staff

• All trust staff were expected to have a regular annualpersonal development review in line with trust policy.The trust target was 85% and data for January 2017.Compliance ranged between 81% and 100% across the




outpatient and diagnostic divisions. Howeverthe registered nurses was reported as 40%. The reviewwas an opportunity for staff and their line manager todiscuss learning needs and opportunities. The trusthave confirmed that the average compliance is now97%.

• A nurse practitioner told us that she had beensupported by the trust to further her education. Thetrust had funded both her degree and an MSc inadvanced practice.

• Radiographers were registered with the Health and CareProfessions Council (HCPC) and as such maintainedprofessional competency and audited their practice.Staff at Warrington had close ties to a University inLiverpool including lecturing and educationalsupervisors.

• Staff participated in continued professionaldevelopment in the department with regular learningsessions. A presentation was given to diagnostic staff toprovide staff with awareness of complaints, risks andsafe practice techniques.

• The hospital supported radiographers to undergoadvanced practice training and there were seven stafftrained to report diagnostic imaging results at the timeof the inspection.

• Ultrasound staff held regular discrepancy and monthlyaudit meetings in order to learn and improve. Casestudies were presented and discussions took place toshare information and knowledge.

• The hospital had clinical specialist nurses in a variety ofspecialities including urology, ophthalmology andcardiology. The trust also employed a number of nurseprescribers.

• A member of the orthotic team was trained to undertakeintravitreal injections. This enhanced the role of the AHPstaff and also positively contributed to theophthalmology team to manage the increasing numberof patients diagnosed with AMD.


• We saw evidence of collaboration between staff in otherhospital trusts in many areas of outpatients anddiagnostics specialities. Ultrasound, Breast screening,

physiotherapy and urology. Nurse practitioners wereable to refer patients directly to allied healthprofessionals services and physiotherapists couldrequest diagnostic tests.

• An MDT co-ordinator team worked within the breastscreening service. The screening service provided atWarrington covered patients from four geographicalboroughs and Skype meetings were co-ordinated on aweekly basis. Meetings included consultants from othertrusts along with breast care nurses, pathologists andradiographers.

• Service level agreements were in place with other localhospitals to provide services to Warrington patientswhen the trust were unable to provide a local service.Interventional radiology had an agreement for ahospital in Chester to provide care out of normalworking hours when emergency treatment wasrequired.

• Physiotherapy staff participated in clinical meetingsacross many services and divisions in the trust,including trauma and orthopaedics, stroke andrespiratory which demonstrated delivery of coordinatedcare.

• The consultant rheumatologist told us he was theclinical lead for the Halton Physiotherapy Initiative forpatients from the Halton and Widnes areas.

• A patient told us how impressed they were withcommunication between doctors. “they know whyyou’re here, have read your notes and know your fullstory”.

Seven-day services

• Most of the outpatient clinics were open Monday toFriday 8am till 5pm. Waiting time initiatives meant thatsome services provided late night or Saturday morningservices.

• The ophthalmology department provided a regularSaturday morning clinic in order to meet demand.

• Diagnostic services were available seven days a week.Outpatient appointments were available for non-urgentplain film imaging six days per week. MRI appointmentswere available 12 hours per day at the weekend. CTscanning was performed 24 hours a day for inpatients




and at weekend for consultant lists. Ultrasoundprovided a regular Saturday morning and afternoonservice. There were community based radiology servicesthat supported ambulatory care pathways.

• Interventional radiology appointments were available atWarrington hospital between normal working hours.Urgent referrals outside of those hours were managedwith a service level agreement with a neighbouringtrust.


• All staff had access to the most current policies andprocedures via the trust intranet, which could beaccessed at any computer terminal.

• We saw evidence in health care records of informationbeing shared between specialities caring for anindividual. Referrals to other professionals had takenplace and responses received.

• All diagnostic images were reported in time for thepatient’s next appointment, which meant there were nodelays in treatment decisions. This was achieved bytrust radiologists, reporting radiographers and a localagreement with nearby trusts in the area.

• The trust used the Lorenzo electronic records andappointments system. Paper records were still madeavailable in clinic but all clinical staff could securelyaccess patients details from any terminal.


• All staff we spoke with had a good understanding ofwhen consent would be sought, and were able toexplain guidance from the Mental Capacity Act. We sawcopy of the Best Interest Decision Record and given anexample when this might be used.

• The trust reported that between January 2014 andDecember 2016 Mental Capacity Act (MCA) training hadbeen completed by 75% of staff within the outpatientdepartment. Following the inspection the trust haveconfirmed that this has improved to 96%.

• A consent audit was undertaken in September 2016, toassess compliance against seven criteria whenadministering cyclopentolate eye drops to children. The

audit was a retrospective case note study repeated from2015. From 100 healthcare records examined,compliance was 100% which had improved from 99%the previous year.

• We saw evidence of a two-stage consent auditundertaken for laparoscopic cholecystectomy. Recordsbetween April and December 2016 were examined anddemonstrated a compliance rate of 98%, which metresponsibilities within legislation.

Are outpatient and diagnostic imagingservices caring?

Good –––


• We observed many patients receiving considerate,respectful care. Staff gave clear information and keptpatients informed throughout their appointment.

• Patient satisfaction surveys had received feedback froma large number of patients in several clinical areas. Theresults were positive, with an average score of 4.87 outof 5 and nearly all patients stating they wouldrecommend the service.

• Patients told us that their privacy and dignity wasrespected whilst they were receiving care. Staffcommunicated in ways which supported and reassuredpatients when attending appointments, we observedstaff interacting with children in a relaxed and calmingmanner.

• The orthoptics department arranged fancy dress ‘patch’parties for children who needed to wear an eye patchand needed support with compliance. This encouragedchildren and parents to meet and share theirexperiences. The parties received excellent feedbackfrom parents.

However:

• We observed a patient in fracture clinic, in a roomwithout the curtain pulled together, who appeared to bein some pain during a leg examination

Compassionate care




• We observed eight patients receiving considerate,respectful care in outpatients and radiology. Staff gaveclear information and kept the patients informedthroughout the procedure. At sensitive times in theprocess, staff closed blinds in the observation room toprotect the patient’s dignity.

• We observed healthcare assistants interacting withpatients with a sensitive and supportive attitude.Consent was sought prior to observations beingundertaken and staff gave patients clear informationabout their appointment.

• We observed two children interacting with staff inorthodontics. The children appeared happy to be in thedepartment and addressed the receptionist by name.Dental nurses then spoke directly to the children onentering the consultation room.

• We spoke to two healthcare assistants who ensured thatthe clinic was prepared and ready for patients eachmorning by starting work half an hour before the start oftheir shift.

• We observed a patient in fracture clinic, in a roomwithout the curtain pulled together, who appeared to bein some pain during a leg examination.


• We saw evidence of an audit undertaken in eye clinicwhere the opinions of 50 patients were assessed in April2016 and compared results from 2013. Thequestionnaire included 17 questions about making anappointment, clinic experience- waiting times,courteousness and seeing the doctor- length of time,information provided etc. Results were positive andimprovements were seen from the earlier survey.Recommendations and actions were made thatreflected the results.

• The orthoptics and ENT departments undertaken anumber of surveys with different patient groups toassess satisfaction and enable improvement. Thisincluded primary care groups, special educationalneeds and parents of children with amblyopia. Resultswere positive and considerations for improvementsmade.

• We saw a patient satisfaction survey undertakenbetween 1 October and 31 December that included

feedback from 1053 patients. Patient shad attendedaudiology, orthodontics, ophthalmology andphysiotherapy at both Warrington and Halton hospitals.The results were positive with an average score of 4.87out of 5. A total of 96.7% of patients were likely torecommend the service.

• The outpatient manager had reinstated the friends andfamily test in the outpatient clinic but there wasinsufficient data at the time of the inspection.

• We observed interactions between patients and staff inseveral outpatient clinics including audiology,cardiorespiratory and eye clinic. Staff communicatedwith patients well giving clear explanations of theircondition and ensured patients understood results andtreatment.

• A nurse in eye clinic demonstrated an application on herpersonal phone that she used to explain to relatives theaffects of Aged-related Macular Degeneration (AMD). Shetold us it gave the family greater awareness of thecondition and an understanding of how the conditiondevelops over time, without treatment.

• Staff provided patients with written information toexplain their condition. We saw a large range ofinformation for specific conditions including where toseek additional support.

Emotional support

• During the inspection, we spoke with 54 patients thatwere attending the hospital for care. The responseswere positive, apart from car parking issues, and manypraised staff for their caring compassionate attitude. Wewere told ““I think its perfect what they do, treated as anindividual, not a number, they tell you what’s what” and“We are exceptionally impressed with the highlyprofessional service over the last 20-25 years.” “We arereally well cared for here” “Nurses here can’t do better, itis relaxed, caring and helpful”.

• Two patients told us that the specialist nurse hadprovided her mobile phone number to contact directly ifthey had any worries.

• A maternity patient told us they had been offeredcounselling following a miscarriage yet several otheroutpatient services told us there was not access tocounselling services when it would have beenappropriate.




• Orthotics staff with financial assistance from the Leagueof Friends charity arranged ‘patch parties’ for childrenthat were identified as needing additional support withtheir condition. Twice a year the team arranged a fancydress party in the hospital but away from the clinicalenvironment. Children were encouraged to meet andplay games together and parents had the opportunity toshare their experiences. The aim was to improve patchcompliance and provide a link for the parents. Feedbackwas requested and excellent responses received.

• We saw a selection of Thank you cards sent to staff inthe eye clinic. Comments on the cards included “Thankyou for giving me my sight, I would award you 1millionout of 100. The only drawback is I can now see my dust”and “Thank you to everyone in the unit who was kindenough to give me the gift of sight”.

Are outpatient and diagnostic imagingservices responsive?

Good –––

We rated responsive as good because:

• Patients received timely access to initial assessment,diagnostic and urgent treatment at Warrington andHalton hospitals. The referral to appointment timeswere better than the national average in mostspecialties. Rapid access clinics were available whererequired and we saw evidence of this during theinspection.

• Waiting times for referral and treatment for cancer werebetter than the England average against all three cancertargets.

• Diagnostic waiting times were excellent where less than1% of patients waited more than 6 weeks for anappointment. Comparisons with other trustsdemonstrated that Warrington and Halton had shorterthan average waiting times for CT, MRI and ultrasound.

• The outpatient and diagnostic clinics were visibly cleanand had sufficient seating areas to meet demand. Therewas adequate water fountains and food and hot drinkswere available to purchase.

• There were systems in place to meet the needs ofindividuals such as those living with dementia, alearning or physical disability.

• Improvements had been made in recent months to thetelephone answering service as a result of patientfeedback. A month on month improvement had beenseen.

However:

• There was a lack of available rooms for counsellingpatients in the breast screening clinic.


• The hospital provided a free shuttle bus between thetwo sites. This was for patient and visitor use only andmade 11 journeys per day. The hospital websiteprovided the journey timetable.

• Car parking was the biggest concern of outpatientsattending clinic. Patients told us it took longer to find aspace than their appointment. The pay machine wasalso confusing for patients who had to estimate thelength of stay and pay accordingly, incurring a fine ifinsufficient payment was made.

• During the inspection, we encountered a large numberof patients who could not find the outpatient or imagingdepartment that they required. The hospital signagewas difficult to follow and some were misleading.Patients also told us they had difficulty finding thecorrect department

• General outpatients was visibly clean and had goodwheelchair access. There were six clinic areas that eachhad a smaller waiting area. We saw a variety of chairs, ofdifferent heights, in clinic to suit a patients individualneeds. During busy periods there was sufficient seatingto accommodate patients and their relatives. We sawevidence of completed cleaning checklists in the toiletfacilities and the toilets were visibly clean and tidy.There was sufficient water fountains and drinks vendingmachines in waiting areas to meet patient’s needs.

• The electronic system known as ‘Micheckin’ to belaunched in outpatients in the coming months. Staffchampions were trained to help assist patients during




launch. Patients will have the choice to use the systemto avoid queues at the reception desks during busyperiods. Micheckin will be provided via kiosks and amobile phone application.

• Whiteboards were used to inform patients of any clinicdelays. There was a wide range of patient healthinformation leaflets on display in all outpatient areas.

• In the main waiting area for diagnostic imaging therewas a large reception desk that maintained patientsprivacy. The area for waiting was small and seating waslimited. There was no natural light and the décor wasold and uninviting.

• Considerations had been made to accommodate largerpatients and a range of bariatric equipment was seenduring the inspection.

• Childrens' play areas differed in standards across theoutpatient and diagnostic services areas. Inophthalmics, there was a large spacious segregatedwaiting area for children. The area was carpeted, withbright décor and a large number of toys to suit a varietyof ages. However, other areas including ultrasound, CTand the radiology hub there was little or no provision forchildren visiting the department. The fracture clinic hada small area with toddler toys and a television screenwith a cartoon movie playing. We saw evidence inorthodontics that toys were cleaned weekly.

• Public health information was seen in the orthodonticsclinic waiting area with food sugar content, smokingcessation posters and patient information leaflets, somespecifically for children’s conditions. A range of dentalequipment was for sale including toothpaste andinterdental brushes.

• There were counselling rooms available that were usedwhen patients were receiving bad news. The roomswere carpeted and had comfortable seating. The breastscreening department needed additional rooms fordelivering bad news as they held symptomatic clinicsand could see 8 to 10 patients in one clinic session. Theposition of the room did not consider the patient havingto leave via the usual patients waiting area. We sawevidence that options and costings were beingconsidered to solve the issues.

• Nuclear medicine had a separate seating area forpatients that had received a radioactive injection andneeded to be segregated to maintain radiationprotection of the general public.

• The orthotics department had measured the ‘did notattend’ rates for new patients both during and after atext reminder service was in use. They found that werewas an 8% increase of patients failing to attendappointments without the text reminder. Thedepartment had submitted a business case to reinstatethe text reminder service.

• The trust ‘did not attend’ rates were higher than thenational average at 10%. The outpatient manager toldus that this would be addressed when the electronicsystem was embedded and full assurance had beenreceived regarding the appointment issues. Followingthe inspection the trust has confirmed that theoutpatients appointments team is currently running acourtesy calling scheme for Paediatric and ChemicalPathology clinics. This initiative started in June 2017 andhas seen a reduction of 5% in these areas. The Trust iscurrently out to Procurement for an appointmentreminder service which will further reduce the DNA rate.

• The Cardio respiratory department offered open accessappointments to patients with a referral from their GP.The specialist children’s service was a pre booked clinicheld weekly and used toys and games to make thespirometer testing a pleasant experience.

• Spoke with three patients with appointment letters thatwere unhappy with the wording and felt the informationthey received was unclear.

Access and flow

• Almost 337,000 appointments were made at WarringtonHospital between December 2015 and November 2016according to Hospital Episode Statistics. The number ofpatients who did not attend was slightly higher than thenational average. Management were considering how toaddress this.

• The trust provided rapid access clinics for chest pain,gynaecology, breast surgery and head and neck lumps.The ophthalmology department provided a rapid




intervention clinic to provide treatment within 36 hoursfor age-related macular degeneration (AMD). Patientscould receive an appointment within 48hours inaudiology.

• Appointments were generated electronically following areferral. Follow up appointments were made in clinic ifrequired within six weeks, but more distantappointments were sent by post.

• The incomplete referral to treatment targets for Englandis that 92% of patients have an appointment within 18weeks. Between December 2015 and November 2016,94.2% of patients had received an appointment within18 weeks, the trust performed better than the Englandaverage consistently across the 12 month periodrecording over 97% for November and December 2016.Targets were met by waiting time initiative clinics.

• The trust also performed better than the Englandaverage for 2016 for incomplete patient pathways ineleven specialities. Four specialities were just below theEngland average including trauma and orthopaedics,general surgery, geriatric medicine and urology.

• Waiting times for suspected and diagnosed cancerpatients at Warrington were better than the nationalaverage. The two week, 31 and 62 day targets were allexceeded. In the most recent figures reported, 98.8% ofpatients waited less than 31 days from diagnosis to firstdefinitive treatment.

• Diagnostic waiting times for the hospital were excellent.Less than 1% of patients waited six weeks or more for anappointment within the previous 12 months for all tests.A benchmarking exercise comparing Warrington against75 other trusts demonstrated lower than averagewaiting times for outpatients in CT, MRI and ultrasound.An improvement in report turnaround times was alsoseen in most imaging modalities.

• Patients were kept informed if there were delays in theoutpatient clinics. They were informed individually if thedelay was up to 20 minutes and staff wrote on awhiteboard anything longer. Notes in the clinic list weremade if patients had arrived early and left thedepartment to visit the café. We were told that diabeticpatients were offered light refreshments, if required.

• Procedures were in place for reception staff to managepatients that did not attend clinic appointments. A letter

was sent electronically to the GP. If the patient was arapid access or cancer fast track patient then thereceptionist would telephone the patient to offer a newappointment.

• Physiotherapy told us that there had been difficultieswith appointments not being filled due to the bookingprocess for specialist services. Administration staff weretriaging appointments and time was not utilisedefficiently due to lack of knowledge of the service.

• The trust undertook a monthly audit regardinganswering the telephone. Over a four month periodOctober 2016 to January 2017 a marked improvementhad been seen both in the number of calls answeredand the length of time staff took to receive the call. From64% of calls and an average time of 5 minutes inOctober to 90% and 1.5 minutes in January. This was asa response from patient feedback and regarded asimportant patient engagement.

• Work was in progress at the time of the inspection tomonitor patient waiting times after arrival in clinic. Twomonths data had been collected but analysis anddecisions had not been made for improvements.

• The trust submitted data regarding the number ofcancelled clinics within 6 weeks of appointment, whichaveraged 29 and over six weeks, which averaged 201 butdid not provide a time frame for this number. Therewere 260 clinics in operation each week at Warringtonhospital. Reasons for cancellations included annualleave and consultant sickness, over six weeks someclinics had been cancelled for service redesign. Weinspected the audit sheets for 3 months prior to theinspection to assess the number of cancelled patients.There were none, which demonstrated the teamsresourcefulness and dedication.

• The trust provided the additional narrative as follows:

This information was submitted as part of PIR (OPD 3)and indicated the time frame as per the template.(September – December 2016). The monthly numbersgiven before were taken from a PAS report that did notfactor in multiple codes running as part of one clinicssession, therefore these figures are slighly inaccurate.The figure for the overall number of clinics running perweek also did not take this factor into consideration.Therefore the more accurate information is as follows:Across all OPD areas (Warrington & Halton) there are 470




clinics running per average week. This equates toapproximately 1962 per calendar month. Cliniccancellation data for the period Septemberto December 2016 has been reviewed and updated. Theaverage number of clinics cancelled at less than 6 weeksnotice was 171 per month (8.7%) and greater than 6weeks notice was 293 per month (14.9%).


• Patients attending outpatients for the first time werealways given a longer appointment time in order tomake assessments and to allow the patient to askquestions.

• We saw patient information leaflets readily availablethroughout the areas we visited. Information regardingspecific conditions was available along with additionalcontacts and assistance information such as Alzheimer'sSociety advice. Trust leaflets gave details of how toaccess the information in other languages. In theradiology waiting area there was a range of informationleaflets that explained procedures and help patientsknow what to expect.

• In the breast screening unit we saw books for children ofmothers undergoing breast cancer treatment thataddressed the sensitive, difficult issue in a positivemanner. There were two titles aimed at young childrenand 8-15 year olds the patients could take and keep.

• The clinic had a dedicated room used for fittingprosthetics. The room had been designed to put thepatient at ease and resembled a spa rather than aclinical environment. The room was decorated and hada lace window dressing. The examination couch had aduvet and cover to create a ‘homely’ environment. Theroom was scented with candles and had inspirationalmessages on the wall. We were told that patients werealways complimentary about their appointment.

• Services had been planned to allow access to clinics forpatients with individualised needs. Wheelchair accesswas good and there were additional load bearing bedsthat could accommodate larger patients. Largerscanning trolleys were available in x-ray if needed.

• We observed a phone call whilst in ophthalmology. Aknown patient that was experiencing pain was offeredan appointment within two hours. In CT we observed anoutpatient appointment being offered for the sameafternoon.

• A patient in ophthalmology told us he had attended theclinic for a diagnostic test and been offered a consultantappointment the same day for the diagnosed condition.We also observed a patient being offered an urgentappointment within one hour following a telephoneconsultation.

• Translation services and interpreters were available tosupport patients whose first language was not English.Staff confirmed they knew how to access the onlineservice and showed us a laminated card with 28languages for a patient to select. Requirements couldbe noted on the patients electronic healthcare recordthen arrangements could be made prior to their nextappointment.

• The trust had a website that provided patients withpractical information about appointments at thehospital and additional information about theircondition. However, outpatient waiting times displayedon the website that stated updates were every twomonths, had not been updated since March 2015.Following the inspection the trust have providedassurance that this page has now been updated andalso allows patients the option to cancel appointmentsand request a call back to reschedule. Thisaccommodates patients who are not able to contact thecontact centre in hours.


• We saw information leaflets in several locations thatoffered guidance on how to make a complaint and whoto contact if unhappy with the service. The hospital hada Patient Advice and Liaison Service (PALS) who werethe main contact for the patient or relative who wishedto complain.

• We saw evidence in team meetings that incidents andcomplaints were discussed with staff in order to learnfrom experiences and improve service delivery.

• Between January 2016 and December 2016, there were176 complaints relating to outpatient services. The trusttook an average of 117 days to investigate and close




complaints, which was in line with their complaintspolicy, which states complaints should be closed withinsix months. There were 72 complaints open at the timeof submission. They were open for an average of 192days, which is longer than the trust’s timeframe.

Are outpatient and diagnostic imagingservices well-led?



• There was a lack of communication between the staffand management. There had been significant change tothe management structure and changes to the clinicalbusiness units but staff felt disconnected.

• At local level, the staff were conscientious and wereproud of the care they provided. However, there waslittle knowledge of the strategy and future vision of thehospital.

• In radiology there was little evidence of learning fromincidents. A presentation was seen but learning andattendance records were not audited.

• Radiology risks on the register had not been managedand a risk rated 16 (high) had not been actioned from2013. The risk had recently been downgraded but withno evidence or justification provided.

• Some specialist radiographers told us they felt excludedfrom the larger team and specialisms did not mix orwork collaboratively.

• Public engagement took place in some clinical areas buta friends and family test had only recently beenintroduced across the division.

• Engagement sessions had begun in outpatients but theoutpatients department did not fit into any clinicalbusiness unit and therefore lacked a direction within thetrust.

• Whilst we saw there had been significant improvementin completion of annual personal development reviewfor nursing staff at the time of the inspection.

However:

• Following the appointment issues identified ,patientaccess teams have implemented robust systems andpathways to manage patient referrals and follow up,with a daily validation report against this information.

• Cross-site culture was good and staff reported goodcollaborative working, staff were happy to movebetween hospital teams.

• Junior doctors in the region had voted Warrington andHalton hospitals as the ‘Best Training Centre’ from 24local trusts.

• The orthoptics team had produced a large amount ofresearch and audit data to improve the services thatthey provide. The team delivered education to othertrusts and delivered care and treatment to children intheir school to minimise the stress of a hospitalappointment.


• The diagnostic business unit had recently employed anAllied Health Professionals (AHP) lead, who had notstarted employment during the inspection. The localmanagement team were unsure what the role of thislead would be or how their managementresponsibilities would be affected.

• Many diagnostic staff told us they didn’t know theclinical business manager, who had been in post almost12 months, and felt there no connection to the clinicalleads for each speciality. There were regular meetingsbetween clinical leads and business managers but wewere told that there were no all diagnostic staffmeetings. Information was emailed to each clinical arealead to be shared with staff. The principal radiographertold us there was an open door policy within diagnosticimaging for staff with concerns.

• The outpatient’s matron had been in post seven weeksat the time of inspection and staff reported the positivedifference they had experienced.

• Many staff were positive that their leaders were visibleand approachable. Staff told us ‘Supportive linemanager, recommend as a place to work.’ We sawevidence of this in revalidation folders, where linemanagers had supported learning.




• Since the change in directives to CBU some consultantsand their teamswere unsure of who the leaders were.They had not been told the management structure, hadno introductions to their line manager and didn’t knowwho to contact for annual leave.

• We spoke with the nurse manager who had beenaddressing the low appraisal rate since commencing herpost, and had already completed her immediate staffappraisal as a roll out programme and had achieved82% by 31 January 2017. Although this was still belowthe trust target of 85%.


• The trust had a vision that was High Quality, SafeHealthcare which was displayed in outpatient areas andin the corridor outside outpatients. Some staff were ableto tell us what that meant to them.

• There was a lack of communication between the staffand management. There had been significant change tothe management structure and changes to the clinicalbusiness units but staff felt disconnected. this is despitethe trust holding engagement meetings during Februaryat which 83 staff attended. Further engagement washeld in June attended by 99 staff.

• The trust had recently introduced a new organisationalstructure including the formation of 8 new clinicalbusiness units across two divisions. The intention was toimprove the support and engagement with staff at aclinical level and a new AHP lead post had been createdto be part of the leadership triumvirate. The diagnosticsclinical business unit sat within the acute care servicesdivision. The outpatients services however, had notbeen attached to any particular division as the clinicalservices were categorised by speciality.

• At local level, the staff were conscientious and wereproud of the care they provided. However, there waslittle knowledge of the strategy and future vision of thehospital. A doctor told us they did not know who theirline manager was and where to go with human resourceissues such as booking holidays.

• Some departmental managers were planning serviceswith colleagues from the neighbouring trusts inpreparation for the sustainability and transformationplans to be introduced. Plans were established andprogress was being made towards its delivery.

• The hospital had a learning and disability strategy thatgave staff direction for assisting patients while visitingthe hospital as an outpatient. The policy had a flowchart to be displayed in clinics and included reasonableadjustments such as longer appointment times and finda quiet area for the patient to wait.


• In radiology, there was poor evidence of learning fromspecific incidents as incidents were downgraded to acategory that did not require review. There was oneincident reported as serious, however during theinspection we were made aware of four. As incidentswere not reported as level 3 or higher there was noevidence of reviews, root cause analysis or changes andlearning from themes.

• A presentation had been prepared to demonstrateerrors that occur in radiology. We were told this wasshared with staff as evidence of learning, however norecords were provided of when the presentation wasgiven, staff attendance figures or any evidence thatlearning was achieved.

• A consent audit in interventional radiology wasprovided as evidence of quality assurance, however theaudit was undertaken in 2013 and sampled ten patients.This was not a recent or proportionate example.

• There were four radiology risks on the register that weregraded 12 or over. Three risks were originally rated 16and all had been downgraded in January or February2017. Justification for the rating change was not clear onthe register as no mitigating reasons were provided.There was a risk from 2013 relating to the age of MRIequipment and in 2014 the CT waiting area was addedas a privacy and dignity issue and not as a patient safetyissued as we escalated during the inspection.

• We were told by the radiology governance lead, that noformal analysis was performed on rejected images. Theinformation, if collected, could be used as a qualityimprovement tool to reduce patients exposure, reducetime and improve efficiency.




• Radiologists and reporting radiographers did have asub-standard image folder that was monitored andtraining delivered based on analysis of the reoccurringproblems such as poor positioning. We saw evidence ofthis in a presentation.

• The principle radiographer was concerned about futurestaff recruitment. Her ties to the local universityprovided her insight into the low number ofundergraduates and therefore lack of newradiographers in coming years.

• There was a trained radiation protection supervisor foreach imaging modality and protection issues were onthe agenda of each clinical leads meeting. The staffreported a good relationship with the local independentradiation protection advisors, who had responsibility forstaff, environmental and documentation monitoring.

• Following the IT system appointment issues identified,patient access teams have implemented robust systemsand pathways to manage patient referrals and followup, with a daily validation report against thisinformation. A data quality team was also in place tosupport this continuing area of development.


• Cross-site culture was good and staff reported goodcollaborative working, staff were happy to movebetween hospital teams, though regular cross siteworkers complained of commuting and parking issues.Staff were concerned about the planned introduction oftoll fees on the bridge between the two hospitalsites.Staff are supported to attend meetings andprogress.

• Reception staff told us they felt part of the wideroutpatients team. They were included in theengagement process with the clinical manager and feltvalued and encouraged to contribute.

• Some specialist radiographers told us they felt excludedfrom the larger team and specialisms did not mix orwork collaboratively.

• Many staff said they were supported by their managersand felt involved in service developments. We heardconsistent comments from staff about the culture ofopenness and working together at the hospital.

• Staff had access to a “Speak out safely” link on the trustintranet to raise any concern anonymously. Staffdescribed how this would generate a contact emailresponse from the clinical governance department,however, we did not speak with any staff who had usedthis facility.

Public engagement

• Local ‘what matters to you?’ questionnaire undertakenin diagnostic imaging but information had not beencollated or plans made as a result at the time of theinspection.

• Staff at Warrington had adopted the ‘Hello my nameis…’ Kate Granger campaign badges and notices toimprove communication with patients and visitors. Wesaw staff wearing badges and introducing themselves topatients.

• The trust had arranged an open evening with local GP’s,however the meeting was cancelled due to a poorresponse. Further engagement is planned later in theyear.

• There were examples of friends and family test in someof the specialist clinic areas, such as eye clinic butpatients views and experiences were not gathered as awhole. The new nurse manager had reintroduced thefriends and family test but there was insufficient data atthe time of inspection.

Staff engagement

• The outpatient manager had arranged a series ofengagement sessions across the two trust sites andacross all outpatient administrative and clinical staff, inorder to familiarise herself with the team and toencourage staff collaboration. A poster had beenproduced because of these sessions, which includedstaff beliefs and opinions about their role. The managerexplained that her goal was a common vision “pledgefor patients” to be established. Staff were motivated atthese sessions and have ideas to fund raise and providemore health information.

• The ‘what matters to you?’ questionnaire was also givento radiology staff. 175 staff participated but again theresults were not ready to be actioned.




• Dental staff spoke of the positive experience of crosscover working with Halton hospital teams. Themanagers shared practice and discussed issues that ledto an enhanced service.

• Staff told us about the regular weekly communicationfrom the chief executive via hospital email. Staff werepositive and felt connected to the board as a result.

• A staff recognition award scheme was in place, wherestaff could be nominated for ‘going the extra mile”awards. The trust had an employee of the month andteam of the month award.


• The outpatients department had considered the impacton the service during the introduction of the self- servicecheck. Additional staff had been trained in the processand plans were in place to have dedicated assistantsavailable to help during the introduction.

• Urology staff had developed a urinary catheter passportthat provided patients help and guidance along withprovided individualised information regarding care andtreatment.

• The radiology team had won first prize in a poster awardat UKRC in 2015 and were optimistic regarding the 6submissions made in 2017.

• Junior doctors in the region had voted Warrington andHalton hospitals as the ‘Best Training Centre’ from 24local trusts.

• The orthoptics team had produced a large amount ofresearch and audit data to improve the services thatthey provide. The team delivered education to othertrusts and delivered care and treatment to children intheir school to minimise the stress of a hospitalappointment.




Outstanding practice

• The trust had developed the Paediatric AcuteResponse Team to deliver care in a health andwellbeing centre in central Warrington. This allowedchildren and young people to access proceduressuch as wound checks and administration ofintravenous antibiotics in a more convenient

location. It also allowed nurse-led review of a rangeof conditions such as neonatal jaundice andrespiratory conditions in a community setting thatwould have previously necessitated attendance athospital.

Areas for improvement

Action the hospital MUST take to improveMATERNITY AND GYNAECOLOGY ACTIONS

• The hospital must ensure midwifery, nursing andmedical support staffing levels and skill mix aresufficient in order for staff to carry out all the tasksrequired for them to work within their code ofpractice and meet the needs of the patient.

• The hospital must review the safety of the inductionbay environment to ensure patient safety ismaintained at all times and that the premises aresafe to use for the purpose intended.

• The hospital must ensure that that the risk registerand action plans are comprehensive, robust andadequate to improve patient safety, riskmanagement and quality of care.

• The hospital must ensure all necessary staffcompletes mandatory training, includingappropriate levels of safeguarding training.

• The hospital must ensure that the assessment andmitigation of risk and the delivery of safe patient careis in the most appropriate place.

• The hospital must review the impact of outlierpatients on the access and flow within thegynaecology wards.

• The hospital must review the impact of the triagesystem on access and flow and the appropriateassessment of patient safety.

• The hospital must ensure that all staff receivesmedical devices training and this is recordedappropriately.

CRITICAL CARE ACTIONS

• Critical care services must improve compliance withadvanced life support training updates and ensurethat there is an appropriately trained member of staffavailable on every shift.

• The management team must ensure that the formalescalation plan to support staff in managingoccupancy levels in critical care is fully implemented.

• The management team must ensure that there areappropriate numbers of staff available to match thedependency of patients on all occasions.

• The management team must ensure that all risks areformally identified and mitigated in a timely way aspart of the risk management process.

CHILDREN ACTIONS

• The service must ensure staffing levels aremaintained in accordance with national professionalstandards.

• The service must ensure that there is one nurse onduty on the children’s unit trained in AdvancedPaediatric Life Support on each shift.

Action the hospital SHOULD take to improveMATERNITY AND GYNAECOLOGY ACTIONS

• The hospital should ensure that the Early PregnancyAssessment Unit (EPAU) is opened seven days aweek.

• The hospital should ensure that ward managers aresupernumerary in order to support staff and identifyrisks.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• The hospital should improve the multidisciplinaryattendance at local and divisional meetings.

• The hospital should consider the safe storage ofpatient’s notes on the wards.

• The hospital should consider the dignity and privacyof patients within the clinical areas and maternitytheatre.

• The hospital should ensure that all staff are aware ofthe five-year business plan, vision and strategy planand mission statement.

• The hospital should continue to review the medicalcover for the daily obstetric list to ensure patientsafety and avoid unnecessary delays andcancelations.

• The hospital should continue to monitor theinduction of labour rates.

• The hospital should ensure all equipment is checkeddaily in all areas.

• The hospital should ensure that patient identifiableinformation is not on display in public access areas.

• The hospital should ensure that staff are aware oftheir role and the roles of others, should a majorincident occur.

• The hospital should ensure that all staff is aware ofthe Duty of Candour.

• The hospital should continue to review thetransitional care facilities available for babies on thematernity wards to avoid unnecessary separation ofthe mother and baby. Changes in practice should bereviewed and audited to monitor the impact.

• The hospital should ensure that maternity patientsand gynaecology patients are not seated next toeach other the waiting areas.

• The hospital should review the signage to thegynaecology department.

• The hospital should ensure that staff in the clinicalareas are aware of the special equipment availablefor overweight and obesity patients and that they areeasily accessible when needed.

• The hospital should ensure that all midwifery staffperform postnatal routine standard procedures andtests to ensure they maintain their skills and work totheir potential, within their RCM training andcompetency levels.

SURGERY ACTIONS

• The trust should take action to provide and maintainan assurance system that all equipment in theatresis clean and ready for use.

• The trust should take action to provide and maintainan assurance system that all resuscitationequipment and anaesthetic machines are checkedin line with trust policy.

• The trust should take action to provide and maintainan assurance system that all stocks are within theirexpiration date.

• The trust should take action to improve staffinglevels across wards and theatres.The trust shouldtake action to improve the number of suitablyqualified staff in advanced life support.

• The trust should take action to improve in regards todocumenting capacity and best interests decisionsin patient records.

• The trust should take action to improve the numbersof medical outliers on surgical wards.

• Although mandatory training performance hadimproved since the last inspection. The trust shouldtake action to improve their mandatory and clinicalskills training performance across all core modules.

CRITICAL CARE ACTIONS

• The management team should consider ways in whichto make sure that staff understand theirresponsibilities to report near-miss incidents so thatimprovements can be made when needed.Additionally, they should consider ways in which toaction and close all reported incidents in a timelymanner.

• The management team should consider ways in whichto make sure that all mortality reviews are undertakenthoroughly and in a timely manner.




• Critical care services should make sure that all staff,including the management team have a thoroughunderstanding of when the legal responsibility of theDuty of Candour should be applied and discharged.

• Critical care services should consider ways in whichthey can increase the number of pharmacists so thatthey comply with the guidelines for the provision ofintensive care services 2016.

• The management team should consider ways in whichto make sure that fridge checks are always completedon a daily basis, in line with the medicinesmanagement policy.

• Critical care services should consider finding ways inwhich to comply with guidance from theintercollegiate document (2014) when managingadolescents in the unit. This means identifying staffwho would have access to level 3 safeguarding trainingfor adults and children.

• The management team should consider ways in whichto make sure that all records are completed fully forevery patient. This includes but is not limited todocumenting admission times to critical care, allpatient examinations as well as when a ward roundhas been undertaken, particularly in the evening.

• The management team should consider ways in whichto make sure all patients are reviewed fully twice a day,in line with ICS standards.

• The management team should consider providingmajor incident training to all staff so that they are fullyaware of what to do in the event of an adverseincident.

• Critical care should consider providing training in lightrestraint for all staff members.

• The management team should make sure that allstandard operating procedures that are available forstaff are up to date.

• The management team should make sure a MUSTscore is calculated for all patients and that referrals todietetic services are made when needed.

• The management team should consider ways in whichto ensure that full two stage mental capacity tests arecompleted when required.

• The service should reduce the number of delayeddischarges and breaches of the Department ofHealth mixed sex accommodation standard.

CHILDREN ACTIONS

• The trust should ensure cleaning checklists areconsistently completed within all departments.

• Adult areas were children are seen should bechild-friendly.

• The trust should ensure staff attend mandatorytraining as required for their role.

• The trust should ensure daily temperatures ofmedicine fridges are consistently recorded.

• Expired controlled drugs should be returned topharmacy in a timely manner.

• The trust should ensure the temperature of thefridge on the neonatal unit used for the storage ofbreastmilk is consistently recorded in line with trustpolicy.

• The trust should ensure all equipment used toprovide care or treatment to a service user isproperly maintained.

• The trust should ensure supplementary emergencyequipment is checked in line with trust policy.

A&E ACTIONS

Medicines should be reconciled in 24 hours as specifiedin the trust policy.

• The trust should ensure staff attend mandatorytraining as required for their role.

• Adult areas were children are seen should bechild-friendly.

• Mandatory training and safeguarding training ratesfor medical staff .

• The urgent and emergency care department shouldconsider making improvements to the room used tosee patients with mental health problems,particularly to the doors so that they open outwards.

• Reasonable adjustments for appropriate patientsincluding those with a learning disability.

• Improved appraisal rates for nurses and medicalstaff.




Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Diagnostic and screening procedures

Maternity and midwifery services

Nursing care

Termination of pregnancies

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

How the regulation was not being met:

All risks that the service currently faced had not beenformally identified with appropriate controlsimplemented to control the level of risk posed. The levelof risk that had been identified had not always beenreduced in a timely way.

Regulation 17 (1)(2)(a)(b)(c)

Regulated activity



Nursing care



Regulation 15 HSCA (RA) Regulations 2014 Premises andequipment

How the regulation was not being met:

Premises within maternity, gynaecology andradiology services were not suitable for the purpose andnot appropriately located for which they are being used.

Regulation 15(c)(f)

Regulated activity

Assessment or medical treatment for persons detainedunder the Mental Health Act 1983


Family planning services


Surgical procedures

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

How the regulation was not being met:Staff on the children’s unit were not compliant withAdvanced Paediatric Life Support training.

Regulation 12 (2) (c)

Regulation

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices




The assessment and mitigation of risk and was notsufficiently robust to ensure the delivery of safe patientcare is in the most appropriate place.

Regulation 12 (2)(a)(b)

All staff did not receive medical devices training. This didnot ensure all equipment is used in a safe way.

Regulation 12 (2)(c)

In the radiology department, safety and qualityassurance checks were not completed and documentedfor all radiology equipment, in accordance with IonisingRadiations Regulations 1999.

Records of daily checks of resuscitation equipment werenot maintained consistently in radiology departments.

In the radiology department we found thatequipment was not safely maintained at all times andreported repairs were not completed in a timelyway.Ultrasound machines in radiology had been deemedunsafe and these had not been replaced for eightmonths.

Regulation 12 (2)(e)

The CR reader was located outside the X ray room in theCheshire and Merseyside Treatment Centre presenting arisk of radiation exposure. Quality Assurance checks inaccordance with IRR99 regulations for radiologyequipment were not up to date. Records of daily checksof resuscitation equipment were not maintainedconsistently in radiology departments. Ultrasoundmachines in radiology had been deemed unsafe andthese had not been replaced for eight months.

Regulated activity

Assessment or medical treatment for persons detainedunder the Mental Health Act 1983


Family planning services


Surgical procedures

Regulation 18 HSCA (RA) Regulations 2014 Staffing

How the regulation was not being met:The neonatal unit did not have sufficient numbers ofsuitably qualified staff. There was no dedicatedpaediatric pharmacist.

Regulation






Staffing levels and skill mix in maternity werenot sufficient for staff to carry out all the tasks requiredfor them to work within their code of practice and meetthe needs of the patient.

Sufficient numbers of suitably qualified, competent andexperienced persons must be deployed. This wasbecause there were a low number of staff who were upto date with advanced life support training. This meantthat the service could not always ensure that there wasan appropriately trained person on every shift.

Regulation 18(1)




WarringtonandHaltonHospitalsNHSFoundation …...LetterfromtheChiefInspectorofHospitals...

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