The Care Quality Commission
  • Hospital
  • NHS hospital

New Royal Liverpool University

Overall: Requires improvement read more about inspection ratings

Prescot Street, Liverpool, Merseyside, L7 8XP (0151) 706 2000

Provided and run by:
Liverpool University Hospitals NHS Foundation Trust

Important: The provider of this service changed. See old profile

All Inspections

27 September 2023

During an inspection looking at part of the service

Urgent and Emergency Care Services at the Royal Liverpool Hospital 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, 563 patients attended the Royal Liverpool 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 16.8% of patients who attended the Royal Liverpool Hospital 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.

22 March 2022

During an inspection looking at part of the service

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 Royal Liverpool Hospital 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 Royal Liverpool Hospital as part of our unannounced inspection from 22 March to 24 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.

29 June 2021 - 26 July 2021

During a routine inspection

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

Emergency department

  • Medical staffs mandatory training compliance was low. Staff did not always have the correct level of training on how to recognise and report abuse. The service did not control infection risk well. Staff did not always manage clinical waste well. Staff did not always recognise or respond appropriately to signs of deteriorating health or medical emergencies, exposing patients to the risk of harm. The service could not always demonstrate that staff had the right qualifications, skills, training and experience to keep patients safe. Patient notes were not always stored securely. The service did not always use systems and processes to safely prescribe, administer, record and store medicines. Staff did not always recognise and report incidents and near misses. Action plans to improve care and treatment were not evident. The service did not always manage patient safety incidents well and did not always share lessons learned with the whole team.
  • Staff did not always provide care and treatment based on national guidance and evidence-based practice. Fluid documentation was not always accurate and complete. Staff could not demonstrate that they monitored the effectiveness of care and treatment. They could not demonstrate they used the findings to make improvements and achieved good outcomes for patients. Staff did not always assess and monitor patients regularly to see if they were in pain and gave pain relief in a timely way. The service did not always make sure staff were competent for their roles. There were gaps in management and support arrangements for staff. We observed staff and it was not clear that discussion of patient care and treatment were taking place, oversight was not clear. Staff did not always give patients practical support and advice to lead healthier lives.
  • Staff did not always respect patient’s privacy and dignity and did not always keep care confidential.
  • There were ineffective processes in relation to access and flow of patients into and through the emergency department. These were creating and contributing to significant delays in admitting patients onto wards. This meant they did not always receive timely and appropriate care and treatment. The service did not always plan and provide care in a way that met the needs of the local people and the communities served. The service did not make it clear if reasonable adjustments were in place to help patients access services. The service did not always demonstrate managing patient safety incidents well, and learning was not always put into practice to improve care and treatment.
  • Senior leaders were not always visible and approachable. Senior leaders did not always have a clear understanding of the risks, issues and challenges. They did not always act in a timely manner to address risks and issues. Senior leaders did not have a clear strategy to turn their vision into action. Staff did not always feel respected, supported and valued by the wider hospital and senior managers. Leaders were not always focused on the needs of patients receiving care. Leaders did not always operate effective governance processes, throughout the service, across both sites and with partner organisations. They did not always have regular opportunities to meet, discuss and learn from the performance. Leaders and teams did not always use systems to manage and understand performance effectively in order to make decisions and improvements. The information systems were not integrated. Paper records were not always stored securely. We saw limited examples of continual learning and improving services.

However:

  • Overall, nursing staff mandatory training compliance was above the trust target. Staff understood how to protect patients from abuse. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. The department was well designed in the major’s area with individual rooms with glass sliding doors.
  • The service had up-to-date policies. Staff gave patients enough food and drink to meet their needs and improve their health. The service adjusted for patients’ religious, cultural and other needs. Doctors, nurses and other healthcare professionals held regular effective multidisciplinary meetings to discuss patients and improve their care. Key services were available seven days a week to support timely patient care. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent and supported patients who lacked capacity or were experiencing mental ill health.
  • Staff treated patients with compassion and kindness 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 worked with others in the wider system and local organisations to plan care. The service was inclusive and took account of patients’ individual needs and preferences.
  • Departmental leaders were visible, approachable and had oversight of the challenges in the service. The service had plans to cope with unexpected events. Senior leaders collaborated with partner organisations to help improve services for patients. Local leaders were seen in the department and supported staff throughout the unprecedented attendances and throughout the pandemic.

Surgical services

  • Whilst leaders and teams identified and escalated relevant risks and issues and identified actions to reduce their impact, they did not use systems to manage performance effectively. We identified poor performance in key processes such as mandatory training, patient access and flow, patient outcomes and complaint management. We were not assured the surgical services had implemented suitable remedial actions to demonstrate an improvement in key performance and compliance measures.
  • 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.
  • Whilst staff monitored the effectiveness of care and treatment, most clinical audit outcomes were worse than expected national standards. The service also had a had a higher than expected risk of readmission when compared to the England average.
  • 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.
  • The environment across the surgical wards and theatre areas was not always dementia friendly.
  • 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.
  • Whilst there had been improvements in nurse staffing levels, not all surgical wards had 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.
  • Complaints were not always responded to within the timescales specified in the trust complaints policy.
  • An effective work culture focused on patient safety had not been fully embedded across the surgical teams in theatres.

However:

  • The service had enough medical staff to care for patients and keep them safe. Staff 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, collected safety information and used it to improve the service.
  • Staff 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. The service planned care to meet the needs of local people and took account of patients’ individual needs.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Medical services

  • The service did not always have enough staff to care for patients and keep them safe. Staff did not always have training in key skills and safeguarding. The service did not always control infection risk well. They did not always prescribe and administer medicines in line with requirements.
  • We could not be assured that staff received a regular review of their performance or were supported with regular supervision. Key services were not always available seven days a week.
  • People could not always access the service when they needed it and flow in and out of the hospital was poor.
  • The service did not have clear governance structures in place and did not always manage risk issues and performance well.

However:

  • Staff understood how to protect patients from abuse, and managed safety well.
  • Staff assessed risks to patients, acted on them and kept good care records.
  • The service managed safety incidents well and learned lessons from them
  • 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.
  • 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.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well and supported staff to develop their skills. Staff were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with staff were committed to improving services continually.

28 and 29 October 2020

During an inspection looking at part of the service

Key facts and figures

Services at Royal Liverpool Hospital 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 NHS trust. During the week this inspection took place, Merseyside was in a tier 3 COVID-19 area, and therefor 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 12 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 14 members of staff and 13 patients.

We observed patient care, the environment within wards and safety briefings.

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).

- Ward 9Y had opened at the Royal Liverpool University Hospital site with no staff, no equipment including resuscitation equipment, and this was highlighted as being dangerous to patients and staff. This was raised immediately with the Trust to ensure appropriate emergency equipment was available.

- we received whistleblowing concerns about safe staffing, particularly with regard to wards 3a and 9Y at Royal Liverpool Hospital

Immediately prior to the inspection CQC received further concerns from patients and relatives that: - Staff did not appear to be adhering to social distancing at all 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 their acquiring pressure sores and patient's hygiene and nutritional needs were not always being met adequately.

The concerns also included allegations of neglect, mismanagement and miscommunication.

These concerns were mainly related to medical wards at both Royal Liverpool Hospital and University Hospital Aintree and specifically to wards 3A and 9Y at Royal Liverpool Hospital. 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 at the trust and asked for information of how the trust was assured of patient safety at the point of care delivery. The trust provided information to confirm that ward 9Y had since been safely staffed and that emergency resuscitation equipment was available, in line with their established escalation processes.

They also gave some assurance about senior nurse review of clinical areas, including the environment, patient experience, and infection prevention and control, in relation to the other concerns that had been raised. However, there was no specific evidence or information provided that patients had their health needs assessed, appropriate risk assessments were completed, or that care plans reflected the patient’s needs.

There was a lack of clarity regarding any continued actions to ensure risk assessments were completed and reviewed in a timely way, particularly 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 Royal Liverpool 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 rate the service.

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. 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.

The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Staff did not always have access to enough suitable equipment.

Staff completed but did not always update risk assessments to safely manage and mitigate the risks to patients. Staff did not always follow all the systems that were in place to identify and take action where patients were at risk of deterioration.

The service did not always have enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.  Frequent staffing shortages meant there were occasions when staff were unable to meet the basic care needs of patients.

Staff kept records of patients’ care and treatment. Although records were clear and easily available to all staff providing care, they were not always up-to-date or stored securely.

The service used systems and processes to prescribe, administer and store medicines but staff did not always follow processes for recording medicines administration. Agency staff did not always have access to the electronic patient medication system.

Staff recognised but did not always report incidents and near misses.

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. This meant patients may or will be exposed to the risk of harm. However, from our observations on the days of inspection we saw staff gave patients enough food and drink to meet their needs. The service made adjustments for patients’ religious, cultural and other needs.

Staff treated patients with compassion and kindness, respected their privacy and dignity, but did not always take account of their individual needs in a timely way. Staff did not always provide emotional support to patients to minimise their distress.

Leaders were not always visible and approachable in the service for staff.

Culture in the service was mixed and not all staff said they felt respected, supported and valued, or able to raise concerns without fear.

Leaders did not always operate effective governance processes throughout the service and with partner organisations. Ward quality audits had been commenced but were not fully embedded. 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-19 incident control function using the NHS England Emergency Preparedness, Resilience and Response (EPRR) framework.

Leaders did not always identify and escalate relevant risks and issues or identify actions to reduce their impact. However local teams used systems to manage performance effectively.

However:

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 for the trust’s 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.

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.