Archived: Royal Liverpool Site

The Royal Liverpool University Hospital is a large 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). The Royal Liverpool University Hospital is one of the largest hospitals in Merseyside and Cheshire, based close to the city centre, providing care and treatment to patients from across the North West of England, North Wales and the Isle of Man.

The Royal Liverpool University Hospital is the main site operated by the trust, with a total of 857 beds, 792 of which are inpatient beds and 65 are reserved for day case procedures. This hospital provides a range of services, including urgent and emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, and a range of outpatient and diagnostic imaging services. The hospital also houses St Paul’s Eye Unit which provides a range of outpatient services and elective and unplanned ophthalmology surgical services to patients locally, nationally and internationally. The unit sees in the region of 9,000 outpatients each month.

The trust started work on a new Royal Liverpool University Hospital in February 2014 and construction is underway, with the opening planned for 2017. The new Royal will be one of the biggest hospitals in the UK to provide all single en-suite bedrooms on each inpatient ward. There will be 23 wards, including a large clinical research facility and a 40-bedded critical care unit and the new Royal will have 18 state-of-the-art operating theatres. The emergency department will be one of the largest in the North West of England with its own CT scanner and special lifts for patients going straight to the operating theatres on the floor above.

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 the Royal Liverpool University Hospital took place on 15 – 18 March 2016. We also undertook an unannounced inspection on 30 March 2016 at the Royal Liverpool University Hospital. As part of the unannounced inspection, we looked at the emergency department, medical care wards, surgical care wards and the Academic Palliative Care Unit (APCU).

Overall we rated Royal Liverpool University Hospital as ‘Good’. We have judged the service as ‘good’ for safe, effective, caring and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs.

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.

• ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.

• Almost all of the areas we visited were found to be visibly clean and tidy. However, the podiatry room within the Diabetes Centre was noted to have dust on the work tops and behind the examination couch and the refrigerator contained a box with mould on it.

• 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.

• The majority of areas were staffed with sufficient numbers of suitably qualified nurses at the time of the inspection. However, staffing throughout the medical services had been identified as an issue for the trust. At the time of our inspection we found some areas were still experiencing issues with capacity and ability to manage the wards with the correct staff mix.

• 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 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.

• The Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance states there should be a minimum of one whole time equivalent (WTE) consultant per 250 beds. The trust employed four WTE consultants at the time of the inspection, which was slightly more than recommended.

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. However, these were not minuted in some areas.

• 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.

• Critical care services provided continuous patient data contributions to the intensive care national audit and research centre (ICNARC) which allowed outcomes for patients to be benchmarked against similar units nationally. The most recently validated ICNARC data for the period July 2015 to September 2015 showed that the mortality ratio was within the expected range for comparable units. In addition, for the intensive therapy unit (ITU) the data showed that ventilated patients, patients admitted with severe sepsis and patients admitted following elective or emergency surgery, mortality was similar to or better than similar units nationally.

• Data for the high dependency unit (8HDU) in the same period showed that for elective and emergency surgical admissions the mortality was better than comparable units. However, for admissions with trauma, perforation or rupture, the mortality were was worse than similar units.

• Evidence based pathways were in place for common causes of mortality in the trust using the Advancing Quality programme.

• The renal medicine service had developed a clinical pathway for new dialysis patients. The pathway was designed to address the high 90-day mortality rates by targeting: improved rates of transplantation; better enabling self-care; improved vascular access, better medicines management; earlier access to psychological support.

Nutrition and hydration

• 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 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.

• In order to meet the guidelines for the provision of intensive care services (GPICS) standard for dietetic support the unit should have 0.1 whole time equivalent (WTE) of a dietician per critical care bed. However, the current allocation for critical care was 0.04 WTE per critical care bed.

• The trust scored about the same as other trusts of a similar size in England for the one question related to nutrition and hydration in the Accident and Emergency (A&E) survey 2014.

We saw several areas of outstanding practice including:

• The emergency department worked collaboratively with local support groups and charities to provide excellent in reach and outreach services to sections of the local population. This meant patients received the best possible care which met their individual needs.

• The emergency department’s practice development team provided excellent support and education to the staff within the department. They were responsive and provided tailored training programmes in response to issues identified through incidents and debriefing sessions which ensured that the staff within the department were equipped with the skills and training necessary to provide high quality patient care.

• The emergency department provided an education programme and outreach service to local education establishments on the dangers of knife crime with the aim of reducing this particular type of crime in the local population.

• The critical care team led by a designated consultant was developing guidance for staff in the application of the Mental Capacity Act (MCA) 2005 and associated deprivation of liberty safeguards (DoLS) in the critical care setting. It was hope that this guidance once approved would be adopted across both the local and national critical care networks.

• The electronic whiteboard system used across the trust provided staff with information as to the bed allocated to each patient and to whether patients had particular assessments completed, for example venous thromboembolism (VTE). The board was also used to highlight vulnerable patients. We viewed the whiteboard on ward 3X where staff were piloting an increased functionality such as access to the National Early Warning Score (NEWS), referrals, graphs of patient’s results over time and interaction with medical staff via the white board. We found this to be good practice and innovative.

• The trust had a comprehensive end of life vision and strategy set out for 2013- 2018. Their vision was to deliver the highest quality healthcare driven by world class research for the health and wellbeing of the population. End of life services had partnered with Marie Curie Palliative Care Institute Liverpool (MCPCIL) to further research and develop end of life services and collaborated with the Cheshire and Merseyside end of life network group to share research findings. This collaborative working helped support the commissioning and provision of excellent and equitable end of life services for the people of Merseyside and the surrounding boroughs.

• The trust had developed and opened a new Academic Palliative Care Unit (APCU), providing a 12 bedded unit for patients who were at the end of life.

• The trust had a well-established and well-staffed palliative care directorate that worked closely with other organisations to improve the quality of end of life services in Merseyside.

• The palliative care service was embedded across the trust and held in high regard by all the wards we visited. Palliative care was integral to the trust and had a well-developed and substantial palliative care directorate that was part of the medicine division.

• The trust had a robust education and training programme in end of life care and a formal programme of study days which was co-ordinated by the by the Hospital Specialist Palliative Care (HSPC) team and provided in conjunction with MCPCIL.

• End of life services had a substantial care of the dying volunteer service to ensure that patients and their families were supported. The volunteer service were winners of the Deborah Hutton award in 2015.

• Through working in partnership with the MCPCIL they had developed and appointed two discharge co-ordinators and implemented a rapid discharge home to die pathway. This had achieved excellent results in ensuring end of life patients were supported to be discharged to their preferred place of care.

• Care provided to patients went beyond most people’s expectations. Staff showed care and compassion and went the extra mile to ensure patients at the end of life were well cared for. Care for patients and their families was the responsibility of all staff and not just the HSPC team.

• The mortuary staff were able to carry out reconstruction and camouflage to deceased patients to ensure that bereaved families were able to view their loved one.

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 trust must ensure that emergency resuscitation equipment is readily available in each area, to provide timely access to emergency resuscitation equipment. At the time of the inspection we found equipment shared between wards which meant there may be a delay in accessing emergency equipment.

• The trust must ensure that all emergency equipment is checked regularly in line with trust policy and is ready for use in order to be able to respond safely in an emergency situation.

• 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 Medical care

• The service must ensure controlled drugs are stored in line with the legislation on the Acute Medical Unit (AMU).

• The service must find an acceptable option to ensure its compliance with Health and safety best practice guidance for the storage of portable oxygen.

In addition the trust should:

In Urgent and emergency services

• Take steps to achieve national targets to see, treat and discharge 95% of patients within four hours of arrival.

• The service should take steps to ensure that patient records are updated in a timely way and reflect the care the patient receives.

• The service should ensure that risk assessments are completed as appropriate for all patients who require them.

• The service should improve the compliance with mandatory training and ensure that they are able to access department level data on the number of staff trained in advanced life support.

In Medical care

• In order to maintain the security of patients, visitors were required to use the intercom system outside wards to identify themselves on arrival before they were able to access the ward and staff had access codes. The service should ensure that all of these doors are closed to prevent people from entering the ward without the knowledge of ward staff.

• 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 lack of dedicated endoscopy nursing staff with specialist skills available out of hours.

• 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.

• The service should improve compliance with mandatory training.

• 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.

In Surgery

• The trust should keep revisions to the theatre lists to a minimum to help prevent potential errors.

• The trust should improve the levels of staff trained in resuscitating patients.

• The trust should ensure that patients belongings are safely stored particularly if bed shortages reduce storage capacity.

• The trust should review staff competencies in theatre recovery to ensure they have the necessary competencies to care for high dependency patients if required.

• The trust should manage serious complaints in a timelier manner.

• Checking and maintenance of equipment should be undertaken regularly.

In Critical care

• The trust should take action to reduce the numbers of delayed and out of hours discharges from both level 2 and level 3 critical care facilities.

• The trust should take steps to improve records so that they are not untidy and it is easy to find notes related to the current episode of care.

• The trust should consider how it can develop and expand the critical care outreach service to provide cover 24/7.

• The trust should consider how it can improve the ratio of consultants to patients during the night when the unit is busy so that the ratio does not exceed 1:15.

• The trust should consider how it is going to meet the intensive care society standards for the provision of pharmacy, dietetic and other allied health professional support to the critical care service.

• The trust should take action to ensure that all critical care patients are managed in accordance with the national guidance and standards for critical care.

• The trust should take action to reduce the number of cancelled elective surgical cases.

• The trust should assure itself that the risks associated with storing patients’ medicines in their rooms in the high dependency unit are managed safely.

• The trust should consider re-auditing capacity and demand in the unit as the last audit was conducted in 2014.

In End of life care

• The trust should take action to change the care of the dying document as this does not allow for a person centred and individual care record. It is too close in nature to the Liverpool Care Pathway (LCP) document which was withdrawn from use.

• Action should be taken to ensure that the DNACPR’s are completed accurately with the medical rationale for not attempting resuscitation and discussions with patients and family being recorded appropriately. Where a patient lacks the capacity to make decisions with regards to resuscitation then this must be fully documented and best interest decisions recorded.

• The trust should take action to asses all ligature risks in patient bathrooms and to ensure the safety of those patients with severe mental health conditions are protected. For example on APCU we found a ligature risk in the patient bathroom.

• The trust should take action to protect patient information at all times. For example, the seating area on the Academic Palliative Care Unit (APCU) is behind the reception desk and risks information being seen when the receptionist is using the computer.

• The trust should take action to provide a full seven day consultant service to enhance the care and treatment of patients who are at the end of life.

• The trust should take action to develop a formal handover guidance tool for nursing staff. For example we observed that on the APCU the nurse delivering the handover was using pieces of paper to handover the nursing details of patients instead of a guided handover tool.

In Outpatients and Diagnostic Imaging

• The trust should ensure all equipment is portable appliance tested (PAT) and fit for use.

• The trust should ensure staff complete mandatory training when required.

• The trust should ensure procedural checklists in St Paul’s Eye Unit have patient identifiable information on them.

• The trust should monitor patient waiting times following arrival in outpatient departments.

Professor Sir Mike Richards

Chief Inspector of Hospitals