Archived: Broadgreen Hospital Site

Broadgreen Hospital is a teaching hospital based in Liverpool and is one of two hospital sites managed by the Royal Liverpool and Broadgreen University Hospitals NHS Trust (the trust). Broadgreen Hospital is the smaller of the two sites operated by the trust and is based on the outskirts of the city centre in Broadgreen, providing care and treatment to patients from across the North West of England, North Wales and the Isle of Man. The hospital is co-located on the same site as a specialist cardiothoracic NHS Trust but they are separate and not part of the same NHS trust service.

Broadgreen Hospital is the smaller of the two sites operated by the trust and has a total of 98 beds, 58 of which are inpatient beds and 40 are reserved for day case procedures. This hospital provides a range of elective general medicine (including elderly care), elective surgery, day case surgery, and, outpatient and diagnostic imaging services.

The trust was inspected previously in November 2013 and December 2013, then again in June and July 2014. These inspections were conducted as part of the initial pilot phases of our new inspection methodology. No ratings were applied and this is the trust’s first comprehensive inspection as part of our new methodology.

The announced inspection of Broadgreen Hospital took place on 16 – 17 March 2016. We also undertook an unannounced inspection on 30 March 2016 at Broadgreen Hospital. As part of the unannounced inspection, we looked at medical care wards and surgical care wards.

Overall we rated Broadgreen Hospital as ‘Good’ across all areas including safe, effective, caring, responsive and well-led. We noted some outstanding practice and innovation.

Our key findings were as follows:

Cleanliness and infection control

• The trust had infection prevention and control policies in place which were accessible to staff.
• Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.
• All of the areas we visited were found to be visibly clean and tidy. ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
• Infection prevention and control audits and hand hygiene audits were carried out on a regular basis. These identified good practice and areas for improvement. Key actions were identified to be implemented by staff.
• Between December 2014 and November 2015, the trust reported a total of 42 cases of clostridium difficile, 26 cases of methicillin-susceptible staphylococcus aureus (MSSA) and two cases of methicillin-resistant staphylococcus aureus (MRSA) infections, which meant that the trust did not meet the national standard.

Nurse staffing

• The trust used recognised and validated tools to determine the required levels of nursing staff.
• There was a sufficient amount of nurses with the appropriate skills to care for patients at the time of the inspection.
• The trust had introduced a red flag system with criteria for staff to raise issues, such as ward staffing. This included a contact number for nurses to call if any situation where, based on professional judgement, patient care was deemed unsafe. The system also had set criteria to aid decision making for the nursing staff, for example a shortfall of more than eight hours or 25% of registered nurse time available.
• Any shortfalls in nurse staffing were generally filled with overtime, bank or agency staff. Matrons attended twice daily staffing huddles to ensure safe levels of nurses on the wards. Staffing was displayed on a live rota using a traffic light system. This included pre-booked staff being allocated to wards as needed.

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.
• The medical staffing skill mix at the trust was sufficient when compared with the England average. Consultants made up 37% of the medical workforce at the trust which was similar to the England average of 39%. There were more registrar group doctors who made up 41% of the medical workforce compared with the England average of 38%. Of the medical workforce, 18% were made up of junior doctors which was higher than the England average of 15%.
• There were generally low levels of locum use, with substantive staff preferring to work additional hours to fill any gaps in rotas.
• There was a sufficient number of medical staff to support outpatient services. We found that the majority of clinics were covered by consultants and their medical teams.

Mortality rates

• Mortality and morbidity reviews were held monthly in most services and bi-monthly in outpatients and diagnostic imaging services. Patient records were reviewed to identify any trends or patterns and ensure that any lessons learnt were cascaded to prevent recurrence.
• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 1 would mean that the number of adverse outcomes is as expected compared to England. A score of over 1 means more adverse (worse) outcomes than expected and a score of less than 1 means less adverse (better) outcomes than expected. Between October 2014 and September 2015 the trust’s score was 1.037, which was within the expected range.
• Evidence based pathways were in place for common causes of mortality in the trust using the Advancing Quality programme.

Nutrition and hydration

• Nutritional risk assessments were completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.
• Staff in surgical services managed the nutrition and hydration needs of patient’s well, both pre and post operatively. Patients were given information in the form of leaflets about their surgery and told how long they would need to fast pre-operatively.
• A coloured tray system and jug systems was in place to highlight which patients needed assistance with eating and drinking. In addition, there were special plates for certain groups of patients with an individual surgical need, such as smaller plates for patients’ who needed to eat small amounts frequently.
• Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.

We saw several areas of outstanding practice including:

• Ward 2 had a designated nutrition room. This room was used to store all equipment and feeding liquids required for supported nutrition. Resources and training materials were also available in this room and this helped ensure a clear focus on patient’s nutritional needs and how staff could help them meet these needs.

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

Importantly, the trust must:

In all areas

• The trust must ensure that fridges used to store medications in all areas are kept at the required temperatures and checks are completed on these fridges as per the trust’s own policy.
• Where fridge temperature ranges are recorded outside the recommended minimum or maximum range, steps must be taken to identify if medicines stored in the fridges are fit for use.
• The trust must ensure that medicines, including controlled drugs and intra-venous (IV) fluids, are securely stored in line with legislation.
• The checking of medication, including controlled medication must be carried out consistently as per trust policy.
• The trust must ensure the expiration date of medicines is monitored. Drugs that are past their expiry date must be disposed of promptly.

In addition the trust should:

In Medical care

• The service should seek greater patient feedback is obtained so that more details on service delivery and quality of care can be obtained to drive improvement.
• The service should continue to strive to improve communication between health professionals, families and patients.
• The service should continue to make sure that patients are discharged in a timely manner.
• The service should continue to provide clear signage on the wards to help maintain patient privacy and dignity.
• The service should improve compliance with mandatory training.
• The service should review the practice of leaving record trolleys containing patient notes opened or larger records unsecured on the trolleys.
• The service should review the Deprivation of Liberty Safeguards (DoLS) paperwork and the issue of nursing staff transcribing information from the medical notes as part of the assessment application process. The service should ensure information is correctly entered on the application forms and all the relevant information related to the patient has been captured.
• The trust should continue to review its management of patient flow and the issues of outliers to make sure patients are treated on wards suitable to meet their needs.

In Surgery

• The trust should improve mandatory training rates and the levels of staff trained in resuscitating patients.
• The trust should ensure that all intravenous fluids are stored securely at all times.
• The checking and labelling of medication, including controlled medication should be carried out consistently as per trust policy.
• The trust must ensure that all medications are within their expiry dates and any expired medications must be disposed of promptly and not stored with other medications which have not expired.
• The trust should manage serious complaints in a timelier manner.
• Checking and maintenance of equipment should be robust and clear.
• The trust should ensure that action plans are in place where areas fall below required standards and they should be reviewed as agreed.

In Outpatients & Diagnostic Imaging

• The trust should ensure staff complete mandatory training when required.
• The trust should monitor patient waiting times following arrival in outpatient departments.
• The trust should take steps to resolve issues for patients attempting to contact outpatient services by telephone.

Professor Sir Mike Richards

Chief Inspector of Hospitals