All inspections: University Hospital Aintree

Urgent and Emergency Care Services at the University Hospital Aintree are provided by Liverpool University Hospitals NHS Foundation Trust. The trust was created on 1 October 2019 following a process of acquisition, in which Aintree University Hospital NHS Foundation Trust acquired Royal Liverpool and Broadgreen Hospital NHS Trust.

In the last year, 310,869 patients have attended urgent and emergency care services at the trust. On 17 September 2023, 411 patients attended Aintree University Hospital emergency department.

The emergency department saw higher numbers of very unwell patients (requiring majors or resus care) when compared to the regional and England average. Compared to the regional average of 29.6% and England average of 30.8%, only 15.2% of patients who attended Aintree University Hospitals emergency department, required minor care or treatment

Following an inspection in June 2021, under Section 31 of the Health and Social Care Act 2008, we imposed urgent conditions on the trust’s CQC registration as we believed people were being exposed to the risk of harm within the Emergency Departments.

We carried out this unannounced focused inspection to review the safety and performance of the Emergency Departments at the Royal Liverpool Hospital and University Hospital Aintree following a comprehensive programme of improvement work which was implemented by the trust in response to the concerns that we raised.

We visited the Royal Liverpool Hospital and University Hospital Aintree on 27 September 2023. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. We only inspected urgent and emergency care during this inspection. We did not rate the services at this inspection.

We considered nationally available performance data and feedback we had received from people who use services. We inspected against the safe, responsive and well led key questions.

Following this inspection, we removed the conditions that were imposed on the trusts CQC registration in June 2021.

We carried out this unannounced focused inspection because we received information of concern about the safety and quality of the urgent and emergency care service.

We took into account nationally available performance data and the concerns we received about the safety and quality of the service. We inspected against the safe, effective, caring and responsive key questions.

Urgent and emergency services at University Hospital Aintree are provided by Liverpool University Hospitals NHS Foundation Trust. The trust was created on 01 October 2019 following a process of acquisition, in which Aintree University Hospital NHS Foundation Trust acquired Royal Liverpool and Broadgreen Hospital NHS Trust.

We visited University Hospital Aintree as part of our unannounced inspection of the emergency department from 19 October to 27 October 2022. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

We did not rate this service at this inspection. Following an inspection in June 2021, the emergency department at University Hospital Aintree was rated Inadequate. We placed conditions on the trust’s registration to improve practice. The previous rating of inadequate and the imposed conditions remain in place.

See the urgent and emergency care section for what we found.

How we carried out the inspection

As part of this inspection, we observed care and treatment of patients in waiting, triage and treatment areas including those receiving care on a main corridor within the department. We looked at 10 care records. We spoke to 14 patients. We spoke with 11 staff members across the department including staff nurses, senior nurses, consultants, matrons, service managers, and members of the executive team. We also observed two bed management meetings.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We carried out this unannounced focused inspection under our pressures resilience five (PR5) focused inspection guidance.

We took into account nationally available performance data and concerns we had received about the safety and quality of the services. We inspected against the safe, responsive and well-led key questions. We inspected key lines of enquiry relevant to the pressures resilience five programme. We also inspected the trusts response to conditions imposed on their registration following our last inspection.

We inspected the urgent and emergency services and medical care core services during this inspection.

We did not inspect surgery because the services had not had time to make the improvements necessary to meet legal requirements as set out in the action plan the trust sent us after the last inspection. We are monitoring the progress of improvements to services and will re-inspect them as appropriate.

Urgent and emergency services and medical care services at University Hospital Aintree are provided by Liverpool University Hospitals NHS Foundation Trust. The trust was created on 01 October 2019 following a process of acquisition, in which Aintree University Hospital NHS Foundation Trust acquired Royal Liverpool and Broadgreen Hospital NHS Trust.

We visited University Hospital Aintree as part of our unannounced inspection from 22 March to 31 March which included the emergency department, acute medical assessment unit and the discharge lounge . Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

A summary of CQC findings on urgent and emergency care services in Cheshire and Merseyside (Liverpool, Knowsley and South Sefton).

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Liverpool, Knowsley and South Sefton within the Cheshire and Merseyside ICS below: Cheshire and Merseyside (Liverpool, Knowsley and South Sefton)Provision of urgent and emergency care in Cheshire and Merseyside was supported by services, stakeholders, commissioners and the local authority. We spoke with staff in services across primary care, integrated urgent care, acute, mental health, ambulance services and adult social care. Staff had continued to work hard under sustained pressure across health and social care services.

Services had put systems in place to support staff with their wellbeing, recognising the pressure they continued to work under, in particular for front line ambulance crews and 111 call handlers. Staff and patients across primary care reported a preference for face to face appointments. Some people reported difficulties when trying to see their GP and preferred not to have telephone appointments. They told us that due to difficulties in making appointments, particularly face to face, they preferred to access urgent care services or go to their nearest Emergency Department. However, appointment availability in Cheshire and Merseyside was in line with national averages.

We identified capacity in extended hours GP services which wasn’t being utilised and could be used to reduce the pressure on other services. People and staff also told us of a significant shortage of dental provision, especially for urgent treatment, which resulted in people attending Emergency Departments. Urgent care services, including walk-in centres were very busy and services struggled to assess people in a timely way. Some people using these services told us they accessed these services as they couldn’t get a same day, face to face GP appointment. We found some services went into escalation. Whilst system partners met with providers to understand service pressures, we did not always see appropriate action taken to alleviate pressure on services already over capacity.

The NHS 111 service, which covered all of the North West area including Cheshire and Merseyside, were experiencing significant staffing challenges across the whole area. During the COVID-19 pandemic, the service had recruited people from the travel industry. As these staff members returned to their previous roles, turnover was high, and recruitment was particularly challenging. Service leaders worked well with system partners to ensure the local Directory of Services was up to date and working effectively to signpost people to appropriate services. However, due to a combination of high demand and staffing issues people experienced significant delays in accessing the 111 service.

Following initial assessment and if further information or clinical advice was required, people would receive a call back by a clinician at the NHS 111 service or from the clinical assessment service, delivered by out-of-hours (OOH) provider. We found some telephone consultation processes were duplicated and could be streamlined. At peak times, people were waiting 24-48 hours for a call back from the clinical assessment and out of hours services. We identified an opportunity to increase the skill mix in clinicians for both the NHS 111 and the clinical assessment service. For example, pharmacists could support people who need advice on medicines. Following our inspections, out of hours and NHS 111 providers have actively engaged and worked collaboratively to find ways of improving people’s experience by providing enhanced triage and signposting. People who called 999 for an ambulance experienced significant delays.

Whilst ambulance crews experienced some long handover delays at the Emergency Departments we inspected, data indicated these departments were performing better than the England average for handovers, although significantly below the national targets. However, crews found it challenging managing different handover arrangements at different hospitals and reported long delays. Service leaders were working with system partners to identify ways of improving performance and to ensure people could access appropriate care in a timely way. For example, the service worked with mental health services to signpost people directly to receive the right care, as quickly as possible.

The ambulance service proactively managed escalation processes which focused on a system wide response when services were under additional pressure. We saw significant levels of demand on emergency departments which, exacerbated by staffing issues, resulted in long delays for patients. People attending these departments reported being signposted by other services, a lack of confidence in GP telephone appointments and a shortage of dental appointments. We inspected some mental health services in Emergency Departments which worked well with system partners to meet people’s needs. We found there was poor patient flow across acute services into community and social care services. Discharge planning should be improved to ensure people are discharged in a timely way. Staff working in care homes (services inspected were located in Liverpool and South Sefton)reported poor communication about discharge arrangements which impacted on their ability to meet people’s needs.

The provision of primary care to social care, including GP and dental services, should be improved to support people to stay in their own homes. Training was being rolled out to support care home staff in managing deteriorating patients to avoid the need to access emergency services. We found some examples of effective community nursing services, but these were not consistently embedded across social care. Staffing across social care services remains a significant challenge and we found a high use of agency staff. For example, in one nursing home, concerns about staff competencies and training impacted on the service’s ability to accept and provide care for people who had increased needs. We found some care homes felt pressure to admit people from hospital. Ongoing engagement between healthcare leaders and Local Authorities would be beneficial to improve transfers of care between hospitals and social care services.

In addition, increased collaborative working is needed between service leaders. We found senior leaders from different services sometimes only communicated during times of escalation.

We visited University Hospital Aintree as part of our unannounced inspection from 29 June to 1 July 2021. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity.

Emergency department

We rated this service as inadequate because:

The service did not make sure all staff completed mandatory training in key skills. The design, maintenance, use of facilities, premises and equipment did not always keep people safe. Patients did not always receive appropriate care and treatment in a timely way, exposing them to the risk of harm. Nursing and medical staff did not have the required levels of training to keep patients safe from avoidable harm and to provide the right care and treatment. The service did not always have enough medical staff. Staff did not always keep detailed records of patients’ care and treatment. The information needed to plan and deliver effective care, treatment and support was not always available at the right time. The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
Staff did not always provide care and treatment based on trust policies. Fluid documentation was not always accurate and complete. Staff could not demonstrate that they monitored the effectiveness of care and treatment. There were gaps in management and support arrangements for staff, such as appraisal and supervision.
The service did not always plan and provide care and treatment in a timely way that met the needs of local people and the communities served. The service did not always work with others in the wider system and local organisations to plan care. Ineffective access and flow processes were creating and contributing to significant delays in admissions to the wards. Waiting times were not in line with national standards.
Senior leaders did not always have a clear understanding of the risks, issues and challenges in the service. We were not assured local leaders and staff understood the vision and knew how to apply and monitor its progress. Staff did not always feel respected, supported and valued by the wider hospital and senior managers. The service did not always have an open culture where patients, their families and staff could raise concerns without fear. Leaders did not always operate effective governance processes, throughout the service, across both sites and with partner organisations. Leaders did not always use systems to manage performance effectively. The service used multiple clinical systems which were impacting on patient safety and effective care. The information systems were not integrated. Leaders and staff did not always actively and openly engage with patients, staff, equality groups, the public and local organisations to plan and manage services. They did not always collaborate with partner organisations to help improve services for patients.

However:

The service controlled infection risk well and kept equipment and the premises visibly clean. The service managed patient safety incidents well. Staff recognised and reported incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service.
Staff protected the rights of patients subject to the Mental Health Act 1983. Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.
Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients' personal, cultural and religious needs. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.
Frontline nursing and medical leaders were visible and approachable within the service. Staff were focused on the needs of patients receiving care. There were plans to cope with major incidents.

Medical care

We rated this service as requires improvement because:

The service did not have enough staff to care for patients and keep them safe. Staff did not always have training in key skills or manage safety well. The service did not control infection risk well. Staff did not always assess risks to patients, act on them or keep good care records. They did not always manage medicines well. The service did not always learn lessons from safety incidents.
Staff did not always give pain relief when people needed it. Managers did not always monitor the effectiveness of the service or make sure staff were competent. Staff did not always have access to good information. Key services were not always available seven days a week.
The service did not consistently plan care to meet the needs of local people, take account of patients’ individual needs or make it easy for people to give feedback. People could not always access the service when they needed it.
Leaders did not always run services well using reliable information systems and did not consistently support staff to develop their skills. Staff did not understand the service’s vision and values. Staff did not always feel respected, supported and valued. The service did not engage with the community to plan and manage services.

However:

Staff understood how to protect patients from abuse.
Staff collected some safety information and used it to improve the service. They gave patients enough to eat and drink.
Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients.
Staff were clear about their roles and accountabilities. They were focused on the needs of patients receiving care.

Surgery services

We rated it as requires improvement because:

The service did not always manage patient safety incidents well. Whilst managers investigated never events, lessons learned were not always shared with the whole team and remedial actions taken did not minimise the risk of reoccurrence. We were not assured that the service had effective systems in place for identifying and reporting never events.
Not all patients could access the service when they needed it and receive the right care promptly. The services performed worse than the national average for the percentage of cancer patients treated within 62 days. The average length of patient stay was worse than the national average. The total number of patients on the waiting list continued to increase since January 2021. Whilst the service did not achieve national standards for waiting times from referral to treatment; they performed better than the average when compared with other trusts in the region.
Mandatory training compliance was below trust targets for a number of training modules, such as paediatric life support and higher level resuscitation training.
The number of staff that had completed the higher level of adult and children’s safeguarding training did not meet trust targets.
Complaints were not always responded to within the timescales specified in the trust complaints policy.
Not all patients could access the service when they needed it and receive the right care promptly. The services performed worse than the national average for the percentage of cancer patients treated within 62 days. The average length of patient stay was worse than the national average. Whilst the service did not achieve national standards for waiting times from referral to treatment; they performed better than the average when compared with other trusts in the region.
An effective work culture focused on patient safety had not been fully embedded across the surgical teams in theatres.

However:

The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
Local leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued by their line managers. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities.

Key facts and figures

Services at University Hospital Aintree are provided by Liverpool University Hospitals NHS Foundation Trust. The trust was created on 01 October 2019 following a process of acquisition, in which Aintree University Hospital NHS Foundation Trust acquired Royal Liverpool and Broadgreen Hospitals NHS Trust.

Liverpool University Hospitals NHS Foundation Trust is a major city centre acute trust. During the week in which this inspection took place Merseyside was in a Tier 3 COVID-19 area and therefore facing higher community infection rates which would impact on the activity of the trust.

We carried out a focused, responsive inspection at Royal Liverpool University Hospitals on 28 and 29 October 2020 to review the processes, procedures and practices within the medical care core service. We looked at parts of the safe, effective, caring and well-led key questions. We did not rate services because this was a focused, short notice inspection in response to specific areas of concern.

We observed care and treatment and specific documentation in eight patient records, including do not attempt cardiopulmonary resuscitation (DNACPR), mental capacity assessment, care plans and intentional rounding documentation. We also interviewed key members of staff, medical staff and the senior management team who were responsible for leadership and oversight of the service. We spoke with 18 members of staff. We did not speak with any patients during this focused inspection however we conducted a short observational framework for inspection (SOFI), observed patient care, the environment within wards and safety briefings to capture patient experience.

Why we inspected

Over a three-week period in October 2020, CQC had received a number of enquiries from patients, relatives and staff which related to poor patient care and experience. These concerns related to nutrition and hydration, hygiene needs; staff being unable to provide care; infection prevention and control and staffing concerns.

There were continuing concerns about patient care and safety at the trust’s two main hospital sites. We heard from patients, relatives and staff that:

- COVID -19 and non COVID -19 patients were mixed in ward areas, that there were increasing infection transmission rates within the trust and staff were not complying with requirements for use of appropriate personal protective equipment (PPE).

- staffing levels were unsafe in ward 22, ward 25 and other unidentified ward areas at University Hospital Aintree.

- basic care needs of patients, including nutrition and hydration needs, were not being met and there was neglect of vulnerable patients.

We continued to receive concerns about patient care and safety at the trust’s two main hospital sites, including two notifications of potentially unsafe discharge of patients from University Hospital Aintree to care homes. We also heard concerns that a patient at risk of falls had sustained an injury during admission after falling from their bed due to mitigating actions not being taken.

Immediately prior to the inspection we received further enquiry concerns from patients and relatives that:

- staff did not appear to be adhering to social distancing and that some staff were walking around wearing their masks under their chin and not covering their nose.

- basic care needs were not being met and patient care plans were lacking. Some patients did not receive pressure care resulting in them acquiring pressure sores and patient’s hygiene and nutritional needs were not always being met adequately.

These concerns were mainly related to medical wards at both Royal Liverpool Hospital and University Hospital Aintree and specifically to wards 22 and 25 at University Hospital Aintree. In accordance with CQC procedures, due to the significant concerns raised, enquiries were also referred to local authority safeguarding services.

What we did

We initially raised the concerns with senior leaders and asked for information of how the trust was assured of patient safety at the point of delivery.

The trust provided details of their assurances about nurse staffing, senior nurse review of clinical areas, including the environment, patient experience, and infection prevention and control. However, there was no information provided to support that patients had their health needs assessed, appropriate risk assessments completed, or that care plans reflected the patient’s needs. There was lack of clarity regarding any continued actions to ensure risk assessments were completed and reviewed in a timely way in response to changing patient needs. In addition, there was no detail of how any concerns identified from matrons’ weekly checks would be monitored actions taken and followed up to ensure these actions had resolved the issues.

We carried out a focused, short notice inspection in response to the specific areas of concern. We inspected medical care core services at Aintree University Hospital on 28 and 29 October 2020 and our findings are summarised below. We did not inspect all the key lines of enquiry or domains and therefore have insufficient evidence to change the ratings.

What we found

We found evidence to support the serious concerns that had been raised regarding patient care, as follows:

The service did not always control infection risk well. Senior managers did not have clear oversight of infection control relating to bed spacing. The systems in place to manage infection prevention and control were not always followed by staff. There was no evidence of leaders taking action to ensure compliance and mitigate these risks, which meant patients could be exposed to the risk of harm. We observed doors to side rooms and bays on some wards were not consistently kept closed. We observed non-adherence to national guidance in relation to COVID-19 and social distancing.

Staff inconsistently completed and updated risk assessments for each patient and action to remove or minimise risks was unclear. Staff did not always maintain accurate records to confirm how frequently patients required care.

Although managers regularly reviewed and adjusted staffing levels and skill mix the service did not always have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. We saw this particularly affected ward 25, services for stroke patients, and ward 24 at night. We were not assured that patient acuity and dependency, or staff experience was always taken into consideration and this impacted on their ability to manage frail patients requiring additional support. The stroke ward had a high sickness rate following positive screening of COVID -19 with a number of staff who were required to isolate in line with government guidance.

Staff did not always keep up to date fully completed records of patients’ care and treatment. Records were not stored securely on all wards that we visited, and staff used different documents in ward areas within the same hospital.

The service used systems and processes to prescribe, administer, record and store medicines. However, we saw that medicines were not always administered on time and controlled drugs were not always checked in line with trust standard operating procedures. Agency staff did not always have access to the electronic patient medication system.

Not all patients requiring dietetic review received this in a timely way, including some with significant nutritional needs. Through our review of the information we were not assured the trust had a robust system in place to manage patients’ nutritional and hydration needs meaning patients may be exposed to the risk of harm. However, from our observations on ward 20 during inspection we saw staff gave patients enough food and drink to meet their needs; but patients requiring one-to-one supervision on other wards did not always receive adequate support for nutrition and hydration needs.

Staff cared for patients with compassion and dignity; however, we observed a number of call bells were not always answered in a timely manner due to the high number of patients and low levels of staff on all wards inspected. During the inspection we noted delays in responding to patient call bells in different ward areas.

Local leaders were not always visible and approachable in the service for staff. Although local leaders were supported by Trustwide quality matrons who completed regular walkarounds there was a lack of senior leadership oversight in the service.

Leaders did not always operate effective governance processes throughout the service and with partner organisations. Ward based quality information boards were inconsistently completed and no action had been taken to address this. Although the trust was facing a surge of demand, leaders had taken a decision not to escalate their status through the NHS Operational Pressures Escalation Framework, however we were informed that local arrangements were in place with system partners and being co-ordinated through NHS E/I’s specific Covid incident control function.

Leaders and teams did not always identify and escalate relevant risks and issues or identify actions to reduce their impact. The trust’s response to specific concerns about wards 22 and 25 provided limited information about the effective monitoring of patient risks.

However:

The design and maintenance of facilities kept people safe and most areas had enough equipment for staff to carry out their role.

We observed staff working extremely hard to provide treatment and care under difficult circumstances during the current COVID - 19 pandemic, which had impacted on the numbers of patients and their acuity. During October 2020 the North West region saw an increase in COVID-19 patient activity and through October this trust had the highest levels of COVID-19 activity across the region. As of 19 October 2020, the percentage of beds occupied by COVID-19 patients was 24% (34% including suspected COVID-19 patients), compared to 15.4% in the previous week. The percentage of beds occupied by non-COVID patients was 50% as of 19 October. The number of beds available overall had been below expected since September and numbers decreased further in October.

We spoke with senior leaders on the day of inspection about our concerns and to request that the trust took action to ensure immediate patient safety. The trust identified immediate actions in response to the concerns identified.

Following the inspection, we reviewed information the trust had provided to CQC before the inspection and our evidence gathered during our onsite inspection. We found there was a lack of robust systems and processes to monitor the quality of the care patients received at both hospital sites in the medical core service.

We formally wrote to the trust following our inspection and clearly identified the significant patient safety concerns we had found with regards to nutrition and hydration; infection prevention and control; staffing; assessment of health needs, implementation of care and documentation and operational oversight and governance. We asked the trust to take urgent action and provide a detailed response with action plans to mitigate the risks to patients.

Provider response

The trust provided a detailed response with immediate actions they had taken to mitigate the risks to patients. These included: -

- Identification of additional senior leadership capacity and support for the Specialist Medicine Division.

- A briefing with the Matrons and Ward Managers from the Chief Nurse, focusing on infection prevention and control, staffing, risk assessments and nutrition and hydration.

- Establishment of an overview and scrutiny meeting with the Divisional Director of Nursing and matrons, for review of staffing and quality metrics related to falls, pressure ulcers, nutrition and hydration and the matrons’ checklist.

- Development of a “Safe Nursing” strategy as part of the trust’s approach to quality and safety.

In addition to their assurances of the immediate improvement actions taken, the trust provided further details of their continuing actions to improve the safety and quality of medical care services.

The Trust also informed us it intended to introduce a Paper Lite system in February 2021 which would standardise documents and mitigate the risk of records were not stored securely on all wards.

Following the inspection, we issued the trust with seven requirement notices with actions they must complete.

We will continue to monitor the trust through our engagement to ensure that the risks to patient safety have improved, that there is evidence of continuing and sustained improvements and that these improvements are embedded across the service.

See below for details of individual services.

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

Not all staff were up to date with training in key skills. There were a number of modules where compliance was low, especially for medical staff, and other modules that were below the trust target.
The maintenance and use of premises and equipment did not always keep people safe. Sterilised equipment for surgical procedures was not always in date and some equipment was out of date for servicing. We also found oxygen cylinders were used to prop open doors and were not in appropriate holders as outlined in guidance.
Staff did not always identify and act quickly upon patients at risk of deterioration. Staff did not always complete modified early warning score charts fully or promptly.
The service did not always have enough nursing staff and support staff and relied upon bank and agency staff.
They did not always manage medicines well. Some medications were out of date for manufacturers recommended usage. Governance processes for the management of patient group directives was not always effective.
People could not always access the service when they needed it and at times had to wait long times for treatment. Although the total number of delayed discharges have improved there were still times when patients were in hospital longer than was needed.
Staff did not always ensure records were stored securely and not left unattended.
We were not assured of a robust governance process to ensure that staff members whose professional registration had lapsed were not carrying out registered nursing care.

However,

Staff understood how to protect patients from abuse and they controlled infection well. The service had enough medical staff. There were safeguarding processes in place across services.
The service managed patient safety incidents well and lessons learned from them. Staff collected safety information and used it to improve the service.
Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values. Whilst some staff did not always feel valued, the majority of staff felt respected, supported and valued.
Services engaged well with patients and staff to plan and manage services and all staff were committed to improving services.

We undertook this inspection in response to concerns that were raised with us about poor staffing and patient safety on ward 25. Following these concerns being raised, the trust were unable to provide us with sufficient assurances that patient safety was being maintained and that there were sufficient arrangements to monitor the services provided on ward 25.

On 12 February 2019 we carried out a focussed unannounced inspection of ward 25.

As this was a focused inspection we did not inspect all domains therefore, this inspection had no impact on the overall rating of the trust from the previous inspection in October 2018 when we rated it as requires improvement.

Medical care (including older people’s care)

We did not rate the service following this inspection, therefore the rating of requires improvement for medical care services following the previous inspection in October 2018 remained the same.

During this inspection we found the following areas that required improvement;

Although the service had controlled infection risk well on most occasions, we found that daily cleaning checks had not always been completed, particularly for the cleaning of commodes. This meant that there was an increased risk that infection would be spread.
Although the service had suitable premises and equipment, they had not always looked after them well. This was because controlled substances that are hazardous to health had not always been locked away and sharps had not always been managed safely.
The service had staff with the right qualifications, skills and training to keep people safe from avoidable harm. However, there had not always been enough staff care and treatment. Records between the 1 January 2019 and 12 February 2019 indicated that the planned establishment for registered nurses had not been met on 63% of occasions during the day.
Although controlled drugs had been managed in line with trust policy and legislation, general medicines had sometimes been left unsecured in patient areas.
The service had not always promoted a culture that had supported and valued staff. Some staff informed us that although they had raised concerns about topics such as patient acuity or staffing, they were unaware if any action had been taken to make improvements.
The service had not always used a systematic approach to continually improve the quality of its services. Meetings that had been held by the clinical business unit had not been minuted, meaning that it was unclear what had been discussed or what action had been taken to make improvements to areas of poor compliance.
The service had not always collected, analysed, managed and used information well to support all its activities. We saw limited documented evidence of how information about ward 25 had been collected. We did not see documented evidence at any level of discussion about the performance of ward 25.

However, we also found the following areas of good practice;

The service had managed patient safety incidents well. We found that all reported incidents had been investigated in a timely manner and that actions had been implemented to reduce the risk of a similar incident happening again.
Patient risk assessments and patient observations had been undertaken in a timely manner on most occasions, in line with trust policy. For example, the majority of falls risk assessments had been completed correctly.
Staff had kept detailed records of patient’s care and treatment.
There was a clear leadership structure in place to oversee the management of ward 25.
The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

Professor Ted Baker

Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it as requires improvement. This inspection was not rated and therefore did not have an impact on the overall rating for the hospital.

A summary of services at this hospital appears in the overall summary above.

Our rating of services went down. We rated it them as requires improvement.

A summary of services at this hospital appears in the overall summary above.

Aintree University Hospital NHS Foundation Trust (the trust) is a large teaching hospital in Liverpool.

There are 706 inpatient beds, serving a population of around 330,000 in North Liverpool, South Sefton and Kirkby. The hospital provides care and treatment for people living in some of the most deprived areas in England.

The hospital provides a full range of acute services which include: acute medicine, accident and emergency, acute frailty unit, surgical services. In addition to these services, the trust provides specialist services for Merseyside, Cheshire, South Lancashire, and North Wales. These specialist services include: major trauma, complex obesity, head and neck surgery, upper gastrointestinal cancer, hepatobiliary, endocrine services, respiratory medicine, rheumatology, ophthalmology, and alcohol services.

The hospital is one of the largest employers locally with more than 4,000 whole time equivalent staff. The trust gained foundation trust status in 2006 and was one of the first hospitals in Merseyside to do so.

Urgent and emergency services at Aintree University Hospital were previously inspected in March 2014 and were rated as ‘good’.We carried out an unannounced responsive inspection of urgent and emergency services to review pathways of care when patients attended the service were receiving treatment from the service, and when they were transferred out of the service at Aintree University Hospital. The inspection was in response to concerns that were raised with us about the safety and quality of the service provided to patients. This inspection focused predominantly on the safety of the urgent and emergency services provided; however, where inspectors observed practice in other areas we have included this information in our report.

We inspected the hospital during the afternoon and evening of 1 April 2016. We visited the following areas:

Accident and emergency (A&E);
Observation Unit ;
Acute medical unit;
Wards 30 and 31 (which included the frailty unit);
The bereavement centre to review records.

We found that urgent and emergency care services required improvement for safety. This was because the systems and processes for recognising and escalating the deteriorating patient were not always adhered to, to keep people safe.

We reported our findings to senior staff at the trust at the time of the inspection and actions were put in place to address the concerns.

Our key findings were as follows:

Nurse staffing levels were not always filled to the safe staffing establishment, and staffing was below the safer staffing establishment on the SAU, ward 31 and in the accident and emergency department at the time of our inspection. There were periods of understaffing against the establishment over a number of days prior and post inspection and we saw evidence that staff had raised staffing concerns using the incident reporting process. The trust was taking action to address the nurse vacancy rate, but it remained evident that the wards were not always staffed to establishment.
Staff were using a national Modified Early Warning Score (MEWS) tool to help monitor a patient's condition and identify signs of deterioration in their condition. However, we found examples where these were not completed in line with the trust’s MEWS Standard Operating Procedure. This included: MEWS not correctly calculated and repeated observations not being performed in line with the timeframes identified in the trust’s MEWS Standard Operating Procedure. We were concerned that this may not appropriately identify patients who were deteriorating.
We found there was poor staff compliance with the trust’s mandatory training target. The trust had a plan in place to reach 85% compliance by March 2017. However, patients could be at risk if staff were not adequately trained in a timely manner.
There was generally good practice with regard to infection control.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

Ensure staff undertake and record patient observations consistently and accurately.
Ensure that staff adhere to the modified early warning score (MEWS) Standard Operating Procedure and the sepsis clinical guidance document that the trust has in place to minimise risk of harm to patients.
Ensure that staff perform out repeat observations in line with the clinically indicated MEWS trigger.
Ensure that staff are trained and competent to identify and escalate the deteriorating patient.
Improve staff compliance with mandatory training in a timely way.
Ensure that staffing levels in all areas adhere to the safer staffing requirements.
Ensure that patient records are completed contemporaneously and reflect the care provided to patients.

In addition, the trust should:

Put in place robust audit processes to identify any areas where performance or practice requires improvement.
Consider how lessons from incidents are shared and audited to identify if learning has been applied and is embedded throughout the trust.
Have robust procedures to replace equipment on resuscitation trolleys in a timely manner across the trust to reduce the potential risk to patients who experience a cardiac or respiratory arrest.
Review areas used for escalation purposes to ensure they are suitable for the service provided, based on patient need.
Consider options to improve the privacy and dignity for patients during times when the trust is utilising the escalation policy due to periods of increased demand on the services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Aintree University Hospital is a large teaching hospital in Liverpool with 706 inpatient beds, serving a population of around 330,000 in North Liverpool, South Sefton and Kirkby. The hospital provides care and treatment for people living in some of the most deprived areas in England.

The hospital provides a full range of acute services and also works with partners to provide a range of services in community settings including rheumatology, ophthalmology and alcohol services. Tertiary services provided by the trust include respiratory medicine, rheumatology, maxillofacial and liver surgery.

The hospital is one of the largest employers locally with more than 4,000 whole time equivalent staff. The trust gained foundation trust status in 2006 (one of the first hospitals in Merseyside) and has more than 13,000 public and staff foundation trust members.

The hospital is well supported by the local community and has more than 800 volunteers. The Volunteer Department provides a well-respected service with local and national recognition, particularly for its positive contribution to the patient journey and development opportunities for the local population.

All the patients we spoke with were positive about their care and treatment at the hospital. Patients felt that they were well cared for and staff treated them with dignity and respect.

There were effective systems in place to prevent patients suffering pressure ulcers, falls, blood clots and hospital acquired infections.

Staff were trained in identifying abuse and neglect and knew how to report concerns of this nature.

Operating theatre staff were undertaking the ‘five steps to safer surgery’ procedures, and used the World Health Organization (WHO) checklist. However, we found examples of the safer surgery checklist not being completed appropriately in all theatres and have asked the hospital to take action to correct this.

Staffing

All the wards and departments we inspected were adequately staffed. Staff had access to training and development opportunities to improve their knowledge and skills and develop professionally.

Staff were committed and enthusiastic about their work and worked hard to ensure that patients were given the best care and treatment possible. There were good examples of policy and practice being changed as a result of learning from patient experiences. Staff were well supported by their managers and felt confident in raising concerns with them.

Staff sickness rates were below the national average.

Staff were well led at both a local and trust wide level. There were a number of initiatives in place to engage staff in developing future plans for the hospital. The Chief Executive was highly visible and staff were encouraged to share their ideas and suggestions for improvement.

Cleanliness and infection control.

The hospital was clean throughout and there was good practice in the control and prevention of infection. Practice was supported by staff training and a hospital wide control of infection team.

The hospital infection rates for C.difficile and MRSA infections lie within an acceptable range for a hospital of this size

Medicines management

There were good systems in place to manage medicines and ensure that patients’ medicines were provided in a timely way.

Complaints management

When we carried out this inspection we worked with colleagues from the Patients Association and looked at how complaints were managed in the trust, as we had identified concerns about complaints management in our previous inspection in September. It was evident that considerable work has been carried out to date to make improvements and that patients were now receiving timely and well considered responses to their complaints. However, this work needs to continue with pace and vigour so that the trust can be assured that complaints are managed effectively on a consistent basis.

Many patients did not know how to make a complaint and there was a lack of accessible information about making a complaint in many of the wards and departments we inspected.

We spoke with many patients during this inspection. Most of them and their relatives spoke positively about their experience and the care they received. They provided positive comments such as:

"My Dad couldn't have been given better care."

'I was seen quite quick when I arrived and then taken to x ray, I am just waiting now to see what's happening.'

We found that all patients when admitted were assessed and a plan of care was put into place. As the care plans were standardised we found that sometimes they appeared inflexible when needs outside of the standard assessment tools were identified. This was particularly so for patients with dementia care needs. We observed felt that patients who had a diagnosis of dementia were not supported with a comprehensive assessment and care plan to adequately meet their needs and their safety at times had increased because of this.

We looked at care and welfare of patients within the Accident and Emergency department. Despite the smooth running of the department we found the area to be under significant pressure as the hospital did not have any empty beds to transfer patients to an inpatient area. We were very concerned to find this resulted in a considerable delay in admitting patients to the hospital.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage them.

People were cared for in a clean, hygienic environment and patients received care, treatment and support from staff that were competent to carry out their roles and responsibilities.

Overall the Trust had systems and processes in place for governance and risk management. However, the implementation and quality of these was variable. Risk Management was a particularly poor area at all levels of the organisation. We found complaints management required improvements.

This was a scheduled inspection and during our visit we followed up a number of areas of non-compliance identified at our last inspection, for which compliance actions were set. We visited three wards, the x-ray department and the discharge lounge over two days. We spent time speaking with eleven patients and a relative and invited them to share with us their experience and views. People we spoke with were mainly positive about their experience at University Hospital Aintree. Patients told us that staff were polite; one patient told us they were 'always treated with respect' and another said staff 'kept the curtains closed and didn't make me feel embarrassed' when providing personal care. We received mainly positive comments about the food and improvements had been made in this area since our last visit.

We asked patients whether they felt safe in the hospital. All the patients we spoke with said they felt comfortable and at ease and one relative told us they felt their mother was 'safe' on the ward. People confirmed they would always be willing to, and knew how to, complain if things were not right and complaints management had improved since our last visit.

Progress had been made in the management of medicines, however there were still areas for improvement in the storage of medicines and the promotion and support available to patients who were able to self medicate. Improvements were also needed in the standards and consistency of record keeping.

Prior to our visit a number of concerns were reported to us relating to the assessment, planning and delivery of care and treatment and support experienced by patients and their relatives.

During our inspection we spoke with a large number of patients in two busy ward areas. We asked them about the care and support they were given during this hospital admission. Mostly patients told us they were well cared for and their needs were fully met. They said that on admission, medical and nursing staff had undertaken a thorough assessment and in particular they 'had been asked about their likes and dislikes'. Many patients were aware they had a care plan, they knew care staff looked at these each day, but they did not fully understand what this was. Patients told us that staff respect their dignity and privacy and curtains were always pulled around for this purpose. We were told that staff generally respond to call bells promptly and one relative commented that they 'had no concerns, it was a very nice ward'.

We had mixed comments made by patients and relatives for the communication opportunities with staff. Some relatives told us it was difficult speaking with medical and senior staff and poor communication had made them more 'anxious' about their relatives care. Other relatives told us communication with more junior staff was good.

We had mixed feedback for the quality of the food. One patient reported positive comments but mostly negative views were expressed to us. The concerns raised were that food had been served cold, it was of a poor quality and patients were disappointed that soup was not available as a food choice. Some patients who had regular admission to the hospital stated that there had been a 'steady decrease' in the overall quality of food provided. One patient told us she was not allowed certain soft foods because these were only available to patients with special dietary requirements.

Patients told us that they did not have any concerns about staff training, nurses were always very competent and patients were 'well cared for'. A number told us communication with staff could be better, and some commented that staff attitude at times was 'poor'.

Overall patients were complimentary of the care they had received and were satisfied that staff fully explained their treatment options.

Patients also reported that their privacy and dignity was maintained whilst they stayed in hospital. In general, they felt involved in decisions about their care though some would have preferred more information about discharge from hospital.

Overall, patients confirmed that they were adequately supported with their nutritional and hydration needs including choices of food and drink and support by staff at mealtimes. There was mixed opinion on the quality and amount of food.

All Inspections

Emergency department

Medical care

Surgery services

Professor Ted Baker

Professor Sir Mike Richards

Staffing

Cleanliness and infection control.

Medicines management

Complaints management