The Walton Centre

The Walton Centre NHS Foundation Trust is the only specialist hospital trust in the UK dedicated to providing comprehensive neurology, neurosurgery, spinal and pain management services. The trust receives patients from Merseyside, Cheshire, Lancashire, Greater Manchester, the Isle of Man and North Wales and has a catchment area of approximately 3.5 million people. Due to the areas of expertise the trust often receive referrals from other geographical areas, sometimes this includes international referrals.

Care and treatment is provided from two buildings on the same site; The Walton Centre main building and the purpose built Sid Watkins Building, which was opened in 2015. There are 192 beds, 123 of which are neurosurgery, 29 neurology and 40 for rehabilitation.

We carried out this inspection as part of our comprehensive inspection programme. The announced element of the inspection took place on 5 April 2016 to the morning of 8 April 2016. We also undertook an unannounced inspection on 21 April 2016. As part of the unannounced inspection, we visited Chavasse ward, Lipton ward, Dott ward, Caton ward, theatres, critical care and the complex rehabilitation unit (CRU).

Overall we rated The Walton Centre as ‘Outstanding’. We rated the hospital as ‘Outstanding’ for Effective and Caring. We also rated the hospital as ‘Good’ for Safe, Responsive and Well-Led care.

Our key findings were as follows:

Cleanliness and infection control

• All areas we inspected were visibly clean and well organised. The trust were rated as the overall top acute trust in England in relation to the patient-led assessments of the care environment (PLACE) in 2015. The trust scored 99% for cleanliness and 98% for condition, appearance and maintenance.

• Cleaning schedules were in place, with allocated responsibilities for cleaning the environment and decontaminating equipment. However, on one occasion we found a resuscitation trolley in the critical care area that had not been cleaned despite the records indicating that it had. We brought this to the attention of management and it was rectified immediately.

• We observed staff using personal protective equipment (PPE), such as gloves and aprons, and changing them between patient contacts. We saw staff washing their hands using the appropriate techniques and all staff followed the 'bare below the elbow' guidance. There was ample access to hand washing facilities. Staff followed procedures for gowning and scrubbing in the theatre areas.

• There were regular environmental and hand washing audits across the trust, with generally high levels of compliance.

• The trust had implemented a ‘stop, think, sink’ campaign to encourage visitors, families and patients to wash their hands before entering and leaving clinical areas.

• Staff were aware of current infection prevention and control guidelines, and were able to give us examples of how they would apply these principles.

• We observed that patients with an infection were isolated in side rooms, where possible. Staff identified these rooms with signs and information about control measures in these rooms was clearly displayed. However, one door in the complex rehabilitation unit did not have clear signage indicating that the patient was identified as an increased infection control risk. We raised this with senior staff who rectified the situation immediately.

• Between April 2015 and February 2016, the trust overall reported a total of eight cases of clostridium difficile and one incident of Methicillin-Resistant Staphylococcus aureus (MRSA) infection meaning the trust was on plan to meet its locally set target. In addition, between April 2015 and December 2015, there had been one cohort of carbapenemase producing enterobacteriaceae (CPE) colonisation involving six patients and five incidents of methicillin sensitive staphylococcus aureus (MSSA).

• When there were incidents of hospital acquired infections, a full investigation was carried out using a root cause analysis approach so that lessons could be learnt and improvements made. We saw an example of a change in practice following an incident of pseudomonas (microorganisms that live in water). Regular water testing was being undertaken at the time of the inspection and filters had been put on all taps.

Nurse staffing

• The trust used recognised and validated tools to determine the required levels of nursing staff.

• The majority of areas were staffed with sufficient numbers of suitably qualified nurses at the time of the inspection. However, during our visit we noted there was a lack of visibility of staff on the complex rehabilitation unit (CRU) which had been identified by the service partially due to the layout of the new building.

• Each clinical area openly displayed the expected and actual staffing levels on a notice board and staff updated them on a daily basis. The staffing numbers displayed on the boards were correct at the time of the inspection and reflected the actual staffing numbers in all areas.

• Ward and theatre managers carried out daily staff monitoring and escalated staffing shortfalls to matrons and senior managers.

• In quarter four of 2015/16, the trust had received ‘high assurance’ from its internal auditors, the highest level of assurance possible, for both its daily escalation/staffing actions and the bi-annual reviews.

• End of life care was the responsibility of all staff across the trust and was not restricted to the end of life care (EOLC) team.

• The EOLC team was led by a neurological oncology advanced nurse practitioner who managed one whole time equivalent (WTE) end of life facilitator and a 0.4 WTE amber care bundle facilitator. The facilitators provided advice, support and training to staff and met daily to discuss patients. Each provided cover when the other was not available, for example on leave. Staff told us this worked well.

• In addition, staff had access to the specialist palliative care team at another hospital and a hospice both which located on site. The facilitators told us they would fax referrals along with discussing patients that required reviewing.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.

• The information we reviewed showed that medical staffing was generally sufficient to meet the needs of patients at the time of the inspection.

• On weekdays in the critical care service, the level of consultant cover did not exceed the Intensive Care Society (ICS) standard of a staff to patient ratio of between 1:8 and 1:15. However, at the weekend and during the night the ratio was higher at 1:20. The unit had two Advanced Critical Care Practitioners (ACCPs) to help fill this shortfall but at the time of the inspection, they were only available to cover one in three shifts. There had been no incidents reported about the level of medical cover in critical care and staff told us that they felt that this was being managed safely. Two additional ACCPs had been appointed at the time of the inspection and were due to start in July 2016. Both the medical trainees and ACCP’s who were available on the unit during the night were all trained in advanced airway techniques and were competent in managing a deteriorating patient. There was also out of hours support from the surgical medical assessment Response Team (SMART) when needed.

• Consultants made up 54% of the medical and surgical workforce across the trust which was higher than the England average of 39%. There were less middle grade doctors at 4% compared with the England average of 9%. The number of registrars within the service was higher than the England average at 41% compared to the England average of 38%.

• Consultants provided an on call rota for both Hub and Spoke units within the rehabilitation network, which provided 24 hours, seven days cover. The service had 4.2 WTE consultant cover for the CRU and was available on call from home between 10pm and 8am.

Mortality rates

• Regular multidisciplinary mortality and morbidity committee meetings took place which fed into the monthly mortality and morbidity seminars. We observed the monthly reports for July 2015 to September 2015. The September 2015 report identified eight mortality cases. Patient records were reviewed to identify any trends or patterns. There was evidence of discussion and learning from cases within the report.

• The most recently available and validated Intensive Care National Audit and Research Centre (ICNARC) data (April 2015 to September 2015) showed that the patient outcomes and mortality were similar to benchmarked units nationally. The exception to this was for emergency neurosurgical admissions, where mortality was consistently lower (better) than that of similar units. Subsequently, acute hospital mortality was also consistently lower (better).

• The ICNARC (2013) model mortality was 0.76 for the period July 2015 to September 2015 meaning that the number of observed deaths were less than those predicted. Overall performance was similar to that of other trusts that the unit was benchmarked against. In comparison, the mortality ratio for the same period using APACHE 2 (2013) model was 0.69. (APACHE stands for acute physiology and chronic health evaluation and is a severity score and mortality estimation tool developed in the United States of America). This result was again similar to other trusts.

• Mortality rates were lower (better) than average mortality rates at similar units between April 2012 and March 2015, as reported in the Neurosurgical National Audit Programme.

Nutrition and hydration

• Patients’ nutrition and hydration needs were generally well managed.

• In all the records we reviewed, a nutritional risk assessment had been completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.

• Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.

• The trust had a protected meal time’s initiative which ensured there were minimal interruptions to patient’s meal times. During set times when meals were served all staff were focused solely on meal times and assisting patients. Medical and therapy staff were not able to examine or perform any routine interventions during these times to ensure patients had protected time to eat.

• The guidelines for fasting before surgery (the time period where a patient should not eat or drink) were clear and met national guidance.

• Patients records showed that those patients identified as approaching end of life had their nutrition and hydration needs evaluated. An audit of 20 patient records from January 2015 to February 2016 identified that, during the dying phase, two patients were able to eat and drink, 18 patients were assessed for clinically assisted nutrition and hydration, with ten of those having clinical assisted nutrition or hydration in place at time of death.

• There was access to a dietetic service. A dietitian was available to attend ward rounds when required during normal working hours.

We saw several areas of outstanding practice including:

• In medical services, we found examples of outstanding care where patients’ individual needs were met using alternative approaches to rehabilitation pathways which involved patients and their families. This included developing a garden area where family were encouraged to attend and garden with the patient.

• The trust had received a Certificate of Recognition Excellence for the National Institute for Health Research (NIHR) for their work in promoting the benefits of clinical research, and encouraging recruitment of patients into clinical trials. In 2014 to 2015 the trust increased their proportion of NIHR studies from 39 to 56 studies compared to the previous year which was more than any other trust in the region.

• The use of functional magnetic resonance (MR) scanning in the diagnosis and treatment of patients. It was usually used for research purposes in other trusts but the trust was developing a range of applications that would improve diagnosis and outcomes for patients.

• The MR claustrophobia clinic was very supportive for patients and following the service winning funding to develop a service the trust had agreed to continue funding to support the service. Other members of staff were now involved in the further development of the service.

• The development of the advanced healthcare scientist role in neurophysiology to support an area that was previously consultant led. The role involved the healthcare scientist undertaking aspects of theatre monitoring that would have previously been the remit of a consultant neurophysiologist.

• The critical care service used an electronic system which identified the need for appropriate risk assessments to be undertaken for patients. This helped to ensure that patients were assessed in a timely manner by providing a visual aid to staff via a television screen in the main area of the unit. This tool was available throughout the hospital.

• The critical care service had introduced a memorial tree for patients who had passed away in the unit and donated organs. A yearly memorial service was held for relatives which had been well attended.

• The trust had developed a ‘home from home’ service which provided accommodation for relatives. The accommodation provided was of a high standard and had been designed as the catchment area for the unit was large, with patients using the services regularly from the Isle of Man and North Wales. The trust had recognised that relatives may have to visit on short notice and may not always bring what they need. Items such as toothbrushes were provided for relatives to use if this was the case. Access to refreshments was also available.

• There was a well-established multidisciplinary team approach that was seen as integral to the critical care service. There were regular meetings through the day with staff from other departments, internally and externally.

• The introduction of the nationally recognised rehabilitation network was found to be outstanding practice due to the focussed approach to rehabilitation and ability to move a patient to the most appropriate setting for care in a timely manner across the hub and spoke model.

• The interactive ‘TIMS’ theatre live tracking system was an innovative system which allowed live tracking of patients through their theatre journey. This system also allowed consultants to book their own patients on to theatre lists while in clinic. A number of other organisations had visited the centre to benchmark against this system.

• The trust took part in the Multiple Sclerosis Trust ‘Generating Evidence in Multiple Sclerosis Services ‘(GEMS) 2014/15. This report documented an extensive service analysis which informed the national GEMS project which in turn was used to support NICE (National Institute for Health and Care Excellence) guidance.The services are then evaluated for compliance with NICE standards.

• The trust participated in the international Spine TANGO program which benchmarked their surgical outcomes against other services across Europe.

• The trust were rated as the overall top acute NHS trust in England in relation to the patient-led assessments of the care environment (PLACE) in 2015. The trust scored 99% for cleanliness; 98% for the food it served; 97% for privacy, dignity and wellbeing; 98% for condition, appearance and maintenance and 95% for patients living with dementia, an average of 97%.

• The trust had been named as an NHS vanguard site after applying for the status in September 2015. The new model of care, the neuro network, should provide additional and more effective support for people with long-term neurology conditions outside the trust hospital site; this should enable patients with spinal conditions across the region to receive more effective and timely care. The network models led by the trust aim to provide a high quality, cost effective and sustainable neuroscience service, working in partnership with other acute trusts and primary care.

• The trust had introduced a listening line that patients and their families could call and speak directly to the senior nurse on duty so that the trust could respond to concerns in a timely manner particularly for those patients on the ward at that time.

• The trust held ‘Berwick’ sessions, which were open to all staff to discuss what they are proud of and what keeps them awake at night. The trust considered this a key component of their open and honest culture and staff speaking out.

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

Importantly, the trust must:

In medical care

• Ensure all equipment is available and in date on the resuscitation trolleys on Lipton and Chavasse wards.

In addition the trust should:

Trust-wide

• Review the numbers of staff required to undertake level three children’s safeguarding training.

In medical care

• Schedules for cleaning should be updated and completed.

• All medical consultants should have a completed job plan annually.

• There should be access to lockable boxes for syringe driver pumps.

• Relevant staff should receive training to operate a syringe driver pump.

• The processes in place to request deprivation of liberty safeguards (DOLS) should be reflected in the trust’s policy.

• Training compliance for Mental Capacity Act 2005 (MCA) and DOLs training should be improved to meet the trust target.

• Bed occupancy on Chavasse ward remains within the limits to enable quality of care to be delivered.

• Information should be available for patients and relatives about making formal complaints so that they are aware of the correct process to follow.

• Audit processes should be able to benchmark patient outcomes with other specialist neurology services.

In surgery

• The service should make sure that all areas used to store medications are locked securely.

• The service should improve compliance with all areas of mandatory training.

• The service should improve the numbers of staff that have received their annual appraisal.

In critical care

• The unit should make improvements to the number of delayed discharges from the unit and ensure that all occurrences are reported as clinical incidents in line with trust policy so that improvements can be made.

• The unit should take into consideration the escalation beds that are available in the Short Stay Surgical Unit (SSU) when completing the next staffing review.

• The unit should complete staff appraisals in a timely manner so that they are able to address any requirements for support and development.

• The unit should make sure that staff complete all mandatory training updates when required.

• The unit should consider increasing the number of pharmacists for the unit so the intensive care society guidelines are met.

• The unit should monitor fridges to make sure they are checked on a daily basis and temperatures are recorded in line with trust policy.

• The unit should make sure that resuscitation trolleys are checked in line with trust policy and that tamper tags are replaced when required.

• The unit should collect data to monitor the effectiveness of the surgical, medical acute response team (SMART) team and the use of the track and trigger system.

• The unit should monitor if patients are admitted to the unit within four hours of the decision being made.

• The unit should improve access to information about how to make a formal complaint so that patients are aware of the correct process to follow.

• The unit should ensure that the review dates for risks identified on the risk register are clear.

• The divisional team should make sure that plans for development of the critical care service are clearly documented as part of the plans for divisional service improvement so that progress can be monitored and measured effectively.

• The unit should make sure that staff have a full understanding of the duty of candour and know when this should be applied.

• The unit should consider ways in which to meet the HBN-04-02 standards in the high dependency unit (HDU).

• The unit should consider ways in which to provide immediate life support training to all critical care staff.

• The unit should ensure that the timetable for the planned recruitment and training of advanced critical care practitioners (ACCPs) is met so that the correct staff to patient ratio is met out of hours.

In specialised rehabilitation services

• The service should continue to continuously review its caseload acuity to enable the service to accurately assess the staffing levels required for the provision of specialised rehab services in line with national guidance.

• Review how it proactively supports families and patients to access information on local support organisations and care of the patient requiring specialised rehabilitation

In outpatients and diagnostic imaging

• The outpatient department (OPD) should improve the quality of written patient records.

• The trust should reduce the waiting times for patients in the OPD.

• The trust should consider moving the visual field testing in the OPD from the waiting room to a private area.

• Senior staff in the OPD should have level three safeguarding training for children and young people as some young people in transition between children’s and adult services use the department.

Professor Sir Mike Richards

Chief Inspector of Hospitals