Alder Hey Children's Hospital

Alder Hey Children’s NHS Foundation Hospital is one of the busiest children’s hospital in Europe and provides care for more than 270,000 children, young people and their families every year. The trust provides a range of services and leads on research into children’s medicine. The trust also provides child and adolescent mental health inpatient and community services.

Before visiting the trust, we reviewed a range of information we held and asked other organisations to share what they knew about the trust

We carried out this responsive inspection on 19 and 20 April 2017 and 5 May 2017 following increasing concerns we had about the services. We inspected surgical and medical care services.

We did not inspect urgent and emergency services, critical care, neonatal services, end of life care, outpatient and diagnostic imaging or transitional services.

We last inspected the services in September 2015 and we rated the hospital as ‘good’ overall.Surgical and medical care services were judged to be good overall however, there were areas for improvement.

At this inspection we judged that surgical services requires improvement and medical care services as good. These ratings did not affect the Alder Hey Children’s NHS Foundation Trust overall rating.

Our key findings were as follows:

Medical care services

• Children, young people, and those close to them were treated with respect, dignity, and compassion.

• Staffing levels at the time of inspection met standards set out by Royal College of Nursing.Staff told us the trust found it challenging to recruit to junior doctor vacancies but had made an investment to train advanced nurse practitioners to partially address the shortfall.

• Medicines were safely stored in areas that were accessible to staff only, and each area had a dedicated pharmacist based on the wards.

• Staff were aware of their safeguarding roles and responsibilities and knew how to raise matters of concern appropriately.

• The environment was suitable and welcoming to meet the needs of children and young people and their parents and carers. The individual needs of patients were met and included children and young people with learning and physical complex needs.

• The ward areas we visited were visibly clean. We saw that staff followed good practice in relation to the control and prevention of infection.

• Assessment of nutrition and hydration formed part of the nursing record and was completed in all of the records we reviewed at the time of our inspection.We observed fluid balance charts recorded on the electronic record and children and young people had their weight recorded to inform dietary requirements.

• A range of menus were available and included age appropriate foods. Children and young people could also request additional options.

• Staff told us they felt supported by their immediate team colleagues and by senior managers and the working relationships between nurses and medical staff, and allied health professionals worked well.

• There were communication systems in place to keep staff informed which included newsletters, emails, and safety huddles. Staff confirmed they received updates and information via these systems.

However;

• We were not assured that children and young people were receiving treatment for sepsis that reflected national guidance. We found delays in the review process but the trust had commenced training to improve the management and identification of sepsis.

• The compliance rate for safeguarding training level three for children was on average 80%, which was below the trust’s target of 90%. This was highlighted as an area of concern following the last inspection, however there had been an increase in compliance since the last inspection.

• There were low levels of compliance with mandatory training for medical staff within the medicine clinical business unit. Only 55.2% of medical staff were up to date at the time of the inspection which was significantly worse than the trust’s target of 90%.

• Medical records were not securely stored on each ward we visited so confidentiality was at risk. Patient privacy and dignity was not fully maintained on wards we visited due to the display screen which was visible to people entering the wards.

Surgical services

• The hospital did not always ensure that a member of staff who was trained in advanced paediatric life support (APLS) was available on each department at all times. This did not meet the Royal College of Nursing (RCN) minimum staffing requirements.The trust had acknowledged this shortfall in a recent review but at the time of the inspection no formal plans had been made to implement the improvements.

• We found that compliance with mandatory training across surgical services was mixed. We had particular concerns that compliance with safeguarding level three training for surgical staff overall was only 67% at the time of the inspection. This had only slightly improved since the last inspection despite actions being put in place to increase compliance. At the last overall compliance with safeguarding level three training was 57%

• On surgical wards there was a risk of abduction or that children were able to leave the ward unnoticed. This was because all doors could be opened from the inside and exit buttons were not out of reach from children. This risk was highlighted when the hospital was built in 2015 but it was unclear if this had been formally risk assessed or what actions had been taken to rectify this and it still remained a risk at this inspection.

• We sampled various departmental and clinical business unit risk registers and found that in a number of cases there was limited or no evidence that the risks had been reviewed fully or details about how the level of risk had been mitigated appropriately.

• Resuscitation equipment was available on every department. However, on the surgical wards the equipment was kept in different boxes and in different locations posing an additional risk.

• Complaince with infection control standards on the wards was consistently low ranging between 54% and 72%.

• There were currently no audits being undertaken measuring if patients were compliant with the fasting guidance before undergoing a surgical procedure.

However,

• There were sufficient numbers of staff on the days of our visit to safely care for patients. This was both on the wards and in theatre. In theatre staffing was in line with national guidance.set by the Association for Perioperative Practice (AfPP).

• We found a strong, person-centred culture. Holistic care was provided by kind and caring staff who made every effort to provide support to patients and their parents.

• Patients and their parents were actively involved with decisions about care and treatment and their views and wishes were respected and valued.

• The surgical clinical business unit (CBU) held monthly morbidity and mortality meetings. We saw evidence of actions and learning that had been implemented following these meetings.

• We observed both the theatre and ward areas to be visibly clean. In theatre, there was an identified lead for infection prevention and control (IPC) and they undertook regular audits which showed that overall compliance had improved to 99%.

• There were procedures in place to provide fasting guidance to patients and relatives at the pre-operative assessment stage.

• Nutrition and hydration assessments were undertaken as part of the pre-operative assessment and for admissions to the inpatient wards. There was access to a dietitian during normal working hours between Monday and Friday if needed.

• A range of menus were available to all patients. We spoke to several patients and relatives, who told us that the food was excellent and that there was a lot of choice. Relatives were also able to order food.

We saw several areas of outstanding practice including:

• Each ward had their own dedicated pharmacist and medication was accessed by fingerprint technology this ensured that medication was secured and stock levels were adequately controlled.

• There was a chef allocated to each ward and all food was prepared on the ward.

• A hybrid theatre had recently been opened and a small number of operations had been undertaken using this facility. This was the first paediatric hybrid theatre to be opened in Europe.

• The hospital innovation team had worked collaboratively with a local university to develop ‘virtual surgery’ and to use high definition 3D printing so that organs can be viewed in much more detail. This allowed staff to ‘virtually walk around’ organs.

• The Trust had pioneered a headspace project which had created the world’s first normal equivalent model of the human head. This enables comparison of pre-operative and post-operative 3D images of craniosynostosis patients.

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

Importantly, the trust must:

• The trust must take action to ensure all staff who are involved with assessing, planning, and evaluating care for children and young people are trained to safeguarding level three in line with the safeguarding children and young people: roles and competencies for health care staff Intercollegiate Document (2014).

• The trust must take action to ensure all children and young people receive treatment in relation to sepsiswithin appropriate timeframes and have a process tomonitor adherence to policy for patient’s treated for sepsis.

• The trust must ensure that there is a member of staff trained in advanced paediatric life support available in every department at all times as outlined in the Royal College of Nursing guidelines.

• The trust must ensure that compliance with mandatory training is improved, particularly for medical staff.

• The trust must ensure that formal risk assessments are undertaken in all departments and all identified risks are captured on the risk register where needed.

In addition the trust should:

• Review the systems in place to enable staff to be clear about their roles and responsibilities during an emergency resuscitation scenario.

• The trust should ensure that all resuscitation equipment on inpatient wards is checked fully in line with the hospital resuscitation policy.

• Review the systems in place to mitigate the risk of children and young people absconding or being abducted from the ward areas.

• Expedite plans and actions to enable all staff to improve compliance with mandatory training to the trust’s target of at least 90%.

• Have safe storage facilities in place for medical records on all wards to protect children and young people’s confidentiality.

• Have disease specific pathways in place that are based on up to date evidenced based practice and a system for assurance during the period of transition from paper to electronic pathways.

• Improve staff appraisal rates to reach the at least the trust’s target of 90%

• Consider training on the Mental Capacity Act for clinical staff being part of the mandatory training.

• Ensure visual display screens on the wall behind the desk to the entrance of wards do not compromise patient confidentiality.

• Identify review dates on all risk registers and review monitor that actions identified to mitigate risk are in place in medical services and surgical services

• Consider implementing a schedule for replacing curtains in the ward areas.

• The management team should consider ways in which to improve monitoring of surgical site infections for patients who have undergone non-specialist surgery.

• The management team should make sure that discarded controlled drugs across all departments are recorded appropriately.

• The management team should consider ways in which to improve the meditech system so that it accurately reflects the time that medicines had been administered, reducing the potential risk of a medication overdose.

• The hospital should find ways in which to make sure that there is always a supernumerary co-ordinator available in all areas, at all times to support staff.

• The management team should ensure that all staff receive a full annual appraisal in line with the trust supervision policy.

• The hospital should consider ways in which to reduce the number of cancelled surgical procedures, and when this does happen to facilitate a further appointment within 28 days of the cancellation.

Professor Ted Baker

Chief Inspector of Hospitals