Warrington Hospital

Updated 17 January 2024

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Warrington Hospital.

We inspected the maternity service at Warrington Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The Warrington Hospital provides maternity services to the population of Warrington and Halton.

Maternity services include an early pregnancy unit, an antenatal day unit, triage assessment unit, a joint antenatal and postnatal ward (c23), birth suite, midwifery led birthing centre (The Nest), two maternity theatres, 1 high dependency room or enhanced maternal care room on the birth suite and a bereavement suite. There are approximately 2600 babies were born at Warrington Hospital per year.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital stayed the same. We rated it as good because:

• Our rating of good for maternity services did not change the ratings for the hospital overall. We rated safe as good and well-led as good.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the maternity triage service, birth suite, midwifery led birthing unit (The Nest), The bereavement suite, theatres, and the antenatal and postnatal ward (C23).

We spoke with 4 doctors, 11 midwives, 1 maternity support worker, 2 domestic members of staff, 2 women and birthing people and 1 birthing partner. We received 27 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 12 patient care records including observation and escalation charts and 5 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

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.

Updated 24 July 2019

Our rating of this service improved. We rated it as good because:

• The trust provided mandatory training for staff and managers ensured staff completed this. This had improved since the last inspection.
• Staff were aware of safeguarding issues and followed trust safeguarding procedures when required.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean and implemented control measures to prevent the spread of infection.
• Staff kept appropriate records of care and treatment. This had improved since the last inspection.
• Staff reported incidents when these arose and there were established systems for managers to share any learning with staff. This had improved since the last inspection.
• The service monitored the effectiveness of care and treatment and used audit results to make improvements.
• Staff gave patients enough food and drink to meet their needs and improve their health, responding to patients’ individual preferences.
• Staff of different kinds worked well together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff cared for patients with compassion and involved patients and their families in decisions about their care. Feedback from patients confirmed that staff treated them well and with kindness.
• The trust planned and provided services in a way that met the needs of local people. People could access the service when they needed it and the service responded to patients’ individual needs.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff. This had improved since the last inspection.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Managers had a vision for the service and had involved staff and patients in developing this.
• Managers across the service promoted a positive culture that supported and valued staff. Staff at all levels were extremely positive and enthusiastic about working for the trust.
• The service used a systematic approach to continually improving the quality of its services, with effective systems for identifying and managing risks. This had improved since the last inspection.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• The service was committed to improving, by learning from when things go well and when they go wrong, promoting training, research and innovation.

However:

• The service did not always have enough staff with the right qualifications, skills, training and experience to meet its planned staffing levels, although it had processes to review staff shortages and take action to keep people safe.
• The service prescribed, gave, and stored medicines well. Although not all medicines prescribed had a signature or appropriate code to indicate if the medicines had been administered and some medicines were not available.
• Audit results for patients following a stroke and for patients with lung cancer had been below England average. Improvement plans were identified and arrangements for transfer of hyper-acute stroke services to a neighbouring trust were imminent.

Updated 27 November 2017

Staff could demonstrate the process to report incidents.

The wards and clinical areas were visibly clean. Staff were aware of and adhered to current infection prevention and control guidelines such as the ‘bare below the elbow’ policy.

Staff were aware of their safeguarding roles and responsibilities and knew how to raise matters of concern appropriately.

Paediatric consultants who took part in a “Consultant of the week” rota were present in the hospital during times of peak activity.

Age dependant pain assessment tools were in use in the children’s unit and analgesia and topical anaesthetics were available to children who required them.

The National Paediatric Diabetes Audit 2014/15 showed that Warrington hospital performed better than the England average for the number of individuals who had controlled diabetes.

Staff were observed treating patients and their relatives with kindness and respect both in person and on the telephone. Facilities were available for parents to stay with their children.

Specialist nurses were in post in a range of specialities including Epilepsy and Diabetes and provided support to young people transitioning to adult services.

A Child and Adolescent Mental Health Services (CAMHS) worker was present in the paediatric emergency department between 5pm and 11pm seven days per week to ensure timely assessment of children and young people.

The Paediatric Acute Response Team (PART) worked with a local community trust to reduce the need for children and their families to attend hospital.

Data from the trust showed 90.5% of patients referred to paediatric services were seen within the 18-week standard.

There was no dedicated paediatric pharmacist for the children’s unit which is not in line with accepted best practice. There was not always a nurse on duty on the children’s unit with Advanced Paediatric Life Support (APLS).

Staffing within the children’s unit did not follow Royal College of Nursing (RCN) standards (August 2013) and neonatal nurse staffing did not meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM).

Adult areas were children were seen with the exception of ophthalmic clinic, lacked any child friendly decoration or activities.

Updated 24 July 2019

Our rating of this service improved. We rated it as good because:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean.
• The service had suitable premises and equipment and looked after them well. The design, layout and maintenance of the unit was utilised well and kept people safe.
• The service had enough medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
• Staff always cared for patients with compassion. Patients and family members said staff consistently treated them well and with kindness. Staff respected and valued patients’ personal, cultural, social and religious needs.
• People’s emotional seen as being as important as their physical needs. Staff provided emotional support to patients to minimise their distress.
• The trust planned and provided services in a way that met the needs of local people. Patients were well supported on transfer or discharge and were invited to follow-up clinics and support groups, which offered a variety of help and advice following their stay in critical care.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively. Staff were actively engaged, and their views were reflected in the planning and delivery of services.

Updated 27 November 2017

At the previous inspection in January 2015, we rated this service as Good. Following this inspection we have  maintained the overall rating because:

Since our last inspection the hospital specialists palliative care team (HSPCT) had reviewed the strategy for end of life care and had undertaken a self-assessment structured around the six national ambitions for palliative and end of life care.

We reviewed the trust self-assessment and action plan for ensuring the implementation of the “Ambitions for Palliative and End of Life Care” to improve the provision of better care for patients at end of life. Actions included the development of more leaflets for relatives to improve communication and active engagement in regional audits to ensure the HSPCT is complying with best local and national best practice.

There were systems for reporting actual and near-miss incidents across the hospital which meant the service was able to monitor any risks and learn from incidents to improve the quality of service delivery.

There were sufficient numbers of trained clinical, nursing and support staff with an appropriate skill mix to ensure that patients receiving end of life care were well cared for in all the settings we visited.

Medicines were prescribed, stored and administered safely. Access to medicines for people needing continuous pain relief was available to ensure patient’s pain was managed.

The HSPC team had received mandatory training such as safety and safeguarding in order to maintain the safety of patients.

To meet patients’ needs the HSPC team had developed a training programme for specialist palliative care across the trust with end of life link nurses for each ward to support, advise and educate other ward staff in relation to end of life care.

The HSPC team was adequately staffed, well trained and received regular appraisals.

A care management approach “amber care bundle” was in place when doctors were uncertain whether a patient may recover and were concerned that they may only have a few months left to live. This is an approach to care management used in hospitals when doctors are uncertain whether a patient may recover and are concerned that they may only have a few months left to live. The trust had appointed a designated member of staff who worked within the palliative care team to facilitate implementation across the trust.

The trust participated in the “End of life care Audit: Dying in Hospital 2016”, which replaced the NCDAH. The audit results showed an improvement in end of life care at the trust. Out of 17 clinical and organisational indicators the trust had performed either better than or in line with national average in the majority of the indicators. The trust performed better than the England average for three of the five clinically related indicators. The trust scored particularly well for having documented evidence that the needs of person(s) important to the patient were asked about, scoring 3% compared to the score of 56%.

However:

At our last inspection, we found there was no access to specialist palliative care medical support out of hours. At this inspection, we found this was still the case with no access to out of hour’s specialist palliative care medical support.

Senior managers told us that they had improved access to support and advice through the hospital intranet and the lack of specialist palliative medical support had been identified on the trust risk register.

The trust had commissioned an external audit of the use of the DNACPR policy as well as its own internal audit. Results showed there were a number of occasions, where documentation in relation to DNACPR forms has not been in line with Trust Policy.

Engaging in difficult conversations with patients, family or carers was not always fully recorded within the case notes. Patient’s wishes were not appropriately discussed and recorded, and as a result, they are not treated appropriately We reviewed the action plan which had been put in place to ensure the staff training and monitoring of the DNACPR policy was strengthened.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.

The lack of a clear mental capacity assessment meant that the service could not be clear how much the patient understood the care they were receiving and it may not have access to reasonable adjustments such as access to specialist support.

We found that patients at the end of their lives could not always be assured of a single room to ensure privacy.

Updated 17 January 2024

Updated 27 November 2017

At the previous inspection in January 2015, we rated this service as Requires Improvement. Following this inspection we have maintained the overall rating because:

The CT waiting area was not suitably designed to keep people safe. The area was too small and lacked equipment that would be required in an emergency. The area lacked also privacy and dignity.

We found three breaches of Health and Safety Executive guidance note PM77 ‘Equipment used in connection with medical exposure’ Regulation 36 where there was no record that the equipment had

been tested and signed back into use following fault repairs in the CT department.

Audit evidence showed poor compliance with the WHO (World Health Organisation) surgical safety checklist in interventional radiology.

We found six separate breaches of Ionising Radiation Regulations 99, regulation 32, which refers to routine quality assurance of equipment used in diagnostic imaging.

Appraisal rates and personal development reviews across the department did not meet the trust target of 85%.

The general outpatient area was difficult to locate with poor signage from the main entrance to the department.

There was a lack of available rooms for counselling patients in the breast screening clinic.

There had been significant changes in the leadership team which had the left the staff feeling disconnected and ensure of the strategy and future vision of the service.

However:

We saw evidence of safe practice within the Outpatient department.

There was evidence of hand hygiene compliance and monitoring with regular audits undertaken across six outpatient locations.

Clinical audits were performed in line with best practice and results frequently shared at a regional and national level.

We saw evidence that staff from several disciplines work together to assess, plan and deliver care and treatment to patients including clinicians and allied health professionals.

Cross-site culture was good and staff reported good collaborative working, staff were happy to move between hospital teams.

Updated 24 July 2019

• Compliance rates for mandatory training met the trust target.
• Staff were aware of their safeguarding responsibilities.
• The service managed cleanliness, infection control and hygiene well.
• The service had good staffing levels.
• The service managed risk and staff knew what to do if a patient deteriorated.
• The service followed evidence based practice to ensure high clinical standards.
• The service made sure patients nutritional and hydration needs were met.
• The service regularly asked patients about their pain levels.
• The service took part in a range of audits and used results to improve outcomes for patients.
• The service supported staff well, and made sure they were competent in their roles.
• The service was caring, and treated patients with dignity and respect.
• The trust provided services to meet the individual needs of patients.
• Patients could access the service when they needed to.
• Referral to treatment times were good and better than the England average.
• The service was well led with a clear governance structure and lines of accountability.
• Senior managers were aware of risks and put actions in place to reduce risks.

Updated 27 November 2017

At the previous inspection in January 2015, we rated this service as good. Following this inspection we have maintained the overall rating because:

On arrival at the hospital, patients were triaged to the most appropriate department to meet their needs. Appropriate risk assessments were in place to protect patients and analgesia for pain relief could be administered to patients. Patients were monitored using appropriate tools and any deterioration in a patient’s condition would be escalated.

There were processes in place to help to keep people safe, incident reporting was good and infection control measures were in place. Medicines were administered to patients in a timely way and there were regular checks of equipment. The nurses had reached the trust target for mandatory training.

Treatment and pathways for patients were developed using national and local guidance and was delivered by competent staff working in multi-disciplinary teams. There were review structures in place so that treatment was up to date and these were monitored by the staff.

Staff were caring and supported patients and their relatives and carers. Privacy and dignity were maintained at all times. Systems had been put in place to improve access and flow through the department and although targets were not been met there had been a continuous improvement in waiting times.

Governance structures were robust and there was strong leadership in the department. Staff were empowered through development and learning opportunities and morale in the department was good.

However:

The department was not meeting Department of Health standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the urgent and emergency care centre.

The department was not meeting the targets for time to initial assessment (emergency ambulance cases only) which should be less than 15 minutes and the time patients should wait from time of arrival to receiving treatment is no more than one hour.

There was insufficient medical cover at night in the department though this had been addressed by the unannounced inspection.

Doctors had not completed their mandatory training. Appraisals for nurses and doctors had not been completed.

The mental health room in the department was not fit for purpose and needed to be improved.

The department needed to work better with patients with learning disabilities to understand their needs.

Reasonable adjustments needed to be made for appropriate patients.