Wirral University Teaching Hospital NHS Foundation Trust

Wirral University Hospitals NHS Foundation Trust (the trust) gained foundation status on 1 July 2007. The trust provides services for around 400,000 people across Wirral, Ellesmere Port, Neston, North Wales and the wider North West footprint with 855 beds trust-wide.

The trust manages two hospital sites;

Arrowe Park Hospital is the main site and provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity and gynaecology services and a range of outpatient and diagnostic imaging services. The majority of the trusts inpatient (749) beds located at Arrowe Park Hospital.

Clatterbridge Hospital provides a range of health care services including elective orthopaedic surgery (planned operations), specialist stroke and neuro-rehabilitation services, elderly care and dermatology treatments. The elective surgery and stroke rehabilitation wards each have a total of 20 beds. In addition, the hospital offers a variety of outpatient services for a full range of specialities including dermatology, podiatry, cardiac, plastics, phlebotomy, x-ray, and the Wirral Breast Centre. Magnetic Resonance Imaging (MRI) scanning appointments were available but delivered by an external provider.

We previously inspected this trust in May 2015 as part of a responsive unannounced inspection as a result of concerns regarding nurse staffing. We found that there were shortages of nursing staff on some medical wards in Arrowe Park Hospital and we told the trust it must address this important issue quickly. The trust responded positively to this inspection and when we carried out our comprehensive inspection on 16 – 18 September and 24 September 2015 (unannounced), we found that nurse staffing levels had improved, however further work was required to ensure that wards and departments were adequately staffed at all times.

Overall, we rated the trust as ‘Requires Improvement’. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe, effective, responsive to people’s needs and that services were well led.

Our key findings were as follows:

Vision and values

The trust had a vision ‘to be the first choice healthcare partner to the communities we serve - from home to the provision of regional specialist services’.

The vision was underpinned by the PROUD values; Patient, Respect, Ownership, Unity and Dedication.

Staff were aware of and could articulate the organisational vision and values. There were examples of the trusts vision and values being put in to practice on display throughout the trust.

The trust was working with health partners in the locality, leading one of the national vanguard sites to develop new healthcare models. The new models of care sought to bring together GPs, community services, mental health and hospital services to re-shape services and support the improvement and integration of services for the benefit of patients.

Leadership and Culture

The trust was led and managed by a visible executive team. There had been recent changes within the senior team following the resignation of the Director of Finance, the Executive Director of Operations and the imminent retirement of the Director of Nursing (DON). The trust had plans in place to reappoint to these positions and had good interim plans in place until the appointments were made. The trust was planning to appoint a new Chief Operating Officer and Deputy Chief Executive early in 2016.

In addition, a new Director of Nursing had already been appointed and was working closely with the current DON to facilitate and ensure a smooth and seamless handover.

The senior team were known to staff and it was evident that in response to a disappointing staff survey (which indicated a disconnect between the senior team and frontline staff) they had made considerable efforts to engage and include staff in the change and improvement agenda. The trust had developed and implemented a Workforce and Organisational Development Strategy to support the securing of a healthy organisation and a sustainable and capable workforce. The Trust had also implemented a range of communication and inclusion initiatives to promote staff engagement and inclusion. The Listening in Action programme was an example of the trust hearing and responding to staff concerns and issues.

The trust was aware of the challenges it faced and the areas we have as identified as requiring improvement were known to the trust and plans were either in place or being developed to improve performance. For example, the trust was facing significant financial difficulties and had worked with our partner regulator Monitor to develop a recovery plan. At the time of our inspection the trust was making steady progress regarding the delivery of the plan and was delivering improvements within agreed targets and time frames.

However, we were concerned in respect of the lack of leadership and strategic approach in services for patients at the end of life. There was a draft three-year vision developed by the trust’s end of life care committee. However, we found no evidence that this had been communicated to staff. There was no overarching monitoring of the quality of the service across the trust. We also found that the trust performed worse than the England average in the National Care of the Dying Audit, published in May 2014.

In the critical care service there was no clear, shared vision or strategy for the service. There was a governance structure in place although at times, it was unclear how risks were being, monitored, managed and reviewed.

However, we found that staff employed by the trust were proud of the work they did and demonstrated a commitment to providing patients with high quality services. Morale was improving and staff were aware of the challenges faced by the trust and the plans in place to address them. Staff were more positive about the visibility and accessibility of the senior team as well as the improvements in staffing made since our last inspection.

Although there was an improving culture in most areas, there were still some staff groups that felt the trust still had work to do to address their concerns and improve engagement. This was particularly evident in maternity services and in operating theatres.

Nurse Staffing

As previously indicated, the trust had made a positive response to the findings of our previous inspection and had worked hard to actively recruit additional nursing staff. As a result, nurse staffing had improved considerably since our inspection in May 2015. The nurse vacancy rates had reduced to 7.66%.The Trust had employed over 50 new nurses, however staff turnover, although reducing, meant that there were still 70 nurse vacancies across the trust in July 2015.

The trust was still recruiting nursing staff on a rolling programme and although improved, there were still times when the wards were not appropriately staffed. This was an area of concern both in Arrowe Park Hospital (in particular medical services) coupled with concerns regarding the number of nurses on duty during the night at the Clatterbridge Rehabilitation Centre (CRC) and ward 36 (both of these wards provided medical care) on the Clatterbridge site.

In addition, there was no recognised acuity tool used on the paediatric ward to determine staffing numbers. In maternity, the management of the electronic rostering system meant the skill mix on the delivery suite and antenatal/postnatal unit was unpredictable. Staff told us that the same staff could be rostered onto different units at the same time. In addition, midwives were also able to swap shifts without reference to shift leaders or the maternity matron and so skill mix and experience could not be guaranteed.

To manage and mitigate shortfalls in staffing and skill mix, matrons met each day to discuss nurse staffing levels across the divisions to ensure that staff and skills were appropriately deployed across all wards and departments. In addition nurse staffing concerns were escalated to managers for action. However, there were occasions when managers were unable to secure additional resources and wards were short staffed as a result. This was a particular issue in medical services.

The staffing and skill mix on surgical wards and in theatre areas was sufficient, with some infrequent periods of reduced staffing as a result of unplanned absence.

Medical staffing

Medical treatment was delivered by skilled and committed medical staff.

The vacancy rate for medical staff at the time of our inspection was 12.4%. Vacancies, extra staffing over and above normal levels and additional ward rounds were supported by the use of locum /agency doctors. The total number of shifts covered by locum medical staff in medical services trust wide between April 2015 and September 2015 was 1,428.

In addition, the number of palliative care consultants was below the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance.

There were also medical vacancies across in the diagnostics and imaging services.

At Clatterbridge hospital there were sufficient numbers of suitably qualified medical staff during the daytime hours. However, there was only one junior or middle grade doctor on duty during the night and at weekends. There were no surgical doctors, anaesthetic or critical care support available on the Clatterbridge site after 8pm. If a patient’s condition deteriorated the staff at the hospital would transfer the patient to the acute site, however there was no locally agreed protocol in place to support safe transfer of patients.

The trust was aware that the current vacancy position and the use of locum and agency doctors presented a (potential) risk to patient care and safety and were focused on appointing additional medical staff as a matter of priority. Nevertheless, we remained concerned that the lack of medical staff was having a negative effect on the timely care, treatment and review of patients in the care of the trust.

Mortality and Morbidity

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 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. Between October 2013 and September 2014 the trust score was 97.

Monthly meetings were in place where mortality, incidents, actions and opportunities for learning were discussed. Information was then cascaded to senior staff via email to enable sharing with other staff to support improvements in practice and outcomes for patients. However, in medical services it was unclear if any actions for improvement were agreed at the meeting and as a result opportunities for learning may have been missed.

Safeguarding

There were systems for reporting safeguarding concerns for both adults and children. Staff were able to identify and escalate appropriately issues of abuse and neglect. Practice was supported by staff training. The trust had a safeguarding team that provided guidance during weekdays. Staff had access to advice out of hours and at weekends from the hospital co-ordinator or the local authority duty social worker.

However, the safeguarding children and child protection protocols did not meet best practice guidance in a number of areas. There wasn’t a paediatric nurse as part of the safeguarding team, which is recommended as best practice in the Royal College of Paediatrics and Child Health (RCPCH) guidelines 2014. In addition, the safeguarding policy was updated in December 2014, and referred to “working together 2004” yet no reference was made to the more recent guidance “working together 2010 and 2014” both of which were available at the time the policy was revised. The policy referred to definitions of abuse taken from old guidance ’working together’ (2006). In addition, the safeguarding policy did not fully promote multi-agency working which is key in current child protection protocols, for example there was no mention of notifying school nurses of a safeguarding referral.

The safeguarding training strategy had not been revised since 2009 and was not compliant with RCPCH guidelines 2014, which states that professionals should receive up to a minimum of three to four hours of safeguarding training every three years. Staff were required to complete training every three years but only received two hours of level 2 safeguarding training. In addition, safeguarding level 1 training was a basic overview of safeguarding vulnerable groups of people such as children. This was included in mandatory training as a 30 minute presentation and supplemented by a safeguarding information booklet instead of the recommended two hours.

Access and Flow

The emergency department was under considerable pressure from unplanned admissions and had consistently failed to meet the Department of Health target requiring 95% of patients to be seen, treated, admitted or discharged in under four hours of attendance between December 2014 and June 2015. In April 2015 only 79% of patients were seen within four hours. In June 2015 91% of patients were seen within the time frame. In July 2015 the service met the target with 97% of patients seen within the time frame but by the end of August 2015 the percentage had fallen to 88%. The number of patients waiting between 4 and 12 hours for admission to hospital was worse than the national average between April 2014 and April 2015 and had risen over time. For example in May 2014, a national average of 5 patients waited compared with 13 patients in this trust. By April 2015 this figure rose to 35 patients against a national average of 10.

For patients arriving by ambulance the department consistently took longer to complete an initial assessment (between 10 and 16 minutes) than the national average (between 3 and 6 minutes).

The department reported 952 occasions when ambulance personnel waited longer than 30 minutes to hand over patient information for the 5 months prior to our inspection.

Between March 2014 and May 2015 the trust reported 609 occasions when ambulance personnel had to wait longer than 60 minutes to hand over patient details. This was worst in March 2015 when 36 delays of more than 60 minutes occurred.

Senior staff explained that access and flow was affected by the capacity to admit patients to available beds within the hospital. The trust’s patient flow workgroup focused on strategies to maintain patient flow. These included introducing daily ward reviews to identify patients ready for discharge, implementing early supported discharges through collaboration with social services and expanding the bed base through escalation procedures.

However, between November 2014 and August 2015 data showed that there had been 1,203 medical outliers at the hospital, which is an average of approximately four patients a day. However, at the time of our inspection, there were no medical outliers in the hospital.

Patients who were outliers were reviewed on a daily basis by a member of the medical team and there was an appointed junior doctor to wards that were used for medical outliers.

Cleanliness and infection control

The trust had infection prevention and control policies in place which were accessible to all staff.

Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures. However, in the critical care unit not all staff followed ‘bare below the elbows’ guidance and there was mixed levels of compliance with hand hygiene protocols.

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

The trust had strengthened its systems and processes to prevent and protect people from healthcare associated infections. As a result, there were low rates of catheter associated urinary tract infections reported between June 2014 and June 2015.

In addition the trust had a number of work streams in place for the management and treatment of multi drug resistant organisms.

There had not been any cases of methicillin resistant staphylococcus aureus (MRSA) bacteraemia infections or clostridium difficile infections identified in surgical services across the trust between March 2015 and August 2015. However, in the same period, medical care services reported 21 cases of clostridium difficile infections, two cases of MRSA and six cases of MSSA.

According to the submitted and verified intensive care national audit and research centre data (ICNARC), the critical care unit performed as well and sometimes better than similar units for unit acquired MRSA and clostridium difficile infection rates.

Concerns regarding sepsis were raised by HM Coroner in relation to a delay in the administration of antibiotics for a patient in September 2014. In response, the service implemented plans to improve sepsis care, which included introducing a sepsis care pathway and extra training for staff. In addition, the trust developed an electronic systemic inflammatory response syndrome (SIRS) tool. The tool worked as an adjunct to the clinical assessment to support the recognition of potential sepsis and prompt early intervention. It was developed using evidence based international standards. Following implementation of the action plan and introduction of the electronic SIRS tool, the trust reported a positive increase in the identification and treatment of patients with potential sepsis.

Overall, infection rates were within an acceptable range for a trust of this size.

Patient-led assessments of the care environment (PLACE) audits for 2013 and 2014 scored higher than the national average for cleanliness across the trust.

Nutrition and Hydration

Most patients confirmed they were happy with the standard and choice of food available.

A nutritional risk assessment was in place and consistently used by staff to determine patients individual needs. This helped identify patients at risk of malnutrition and helped staff meet existing or changing nutritional and hydration needs.

Specialist dietary support was available for patients who required specialist diets.

A coloured tray system was in place to highlight which patients needed assistance with eating and drinking. Support was given discreetly and sensitively.

We saw several areas of outstanding practice including:

• The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘A’ which was an improvement from the previous audit results when the trust was rated as a grade ‘B’. Since October 2014 the trust had either been ranked first or second regionally in the SSNAP audit.

Arrowe Park Hospital

• Senior clinicians on the emergency surgical assessment unit had recognised that fluid balance monitoring could be improved and introduced a training programme for health care support workers to achieve this aim. Health care support workers told us they felt empowered by the training and saw fluid balance monitoring as an integral part of their role after it. Audits showed that the completion of fluid balance charts had improved since the training and senior clinicians reported that there had been a significant reduction in the number of patients developing acute kidney injuries (a condition associated with dehydration).

Clatterbridge Hospital

• We observed staff displaying a very caring, person-centred attitude which went beyond what was expected. Staff encouraged patients and their relatives to be active partners in their care. Staff went above and beyond to meet patient’s preferences. There were strong relationships between staff, patients and their relatives.
• Patients’ needs and preferences were central to the planning and provision of services. One example of this was the repurposing of a clinical area into a domestic dwelling. This was designed to help prepare medical and surgical patients for discharge to their own home and bridge the gap between acute patient care and community rehabilitation. Patients could ‘move’ into the dwelling with their relatives for short periods before discharge. This helped staff identify whether any further measures were needed before patients were discharged. It also empowered patients to maintain their independence and improve their confidence prior to discharge. Staff told us that this had been introduced partly due to issues which were raised around patients discharge home when they felt they weren’t ready.

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

Importantly, the trust must:

Arrowe Park Hospital

Urgent and emergency care

• Ensure call bells are available in every bay and placed with patients.

• Staffing continues to remain a focus and that shifts are adequately staffed to meet the needs of patients.

• Ensure that risks are always managed and mitigated in a timely way.

Medical care (including older people’s care)

• The trust must ensure that robust information is collected and analysed to support improvements in clinical and operational practice.

• The trust must ensure that care and treatment is only provided with the consent of the relevant person and if a patient lacks capacity to consent, the Mental Capacity Act (2005) principles are adhered to. This must be supported by staff receiving training in consent and the principles of the 2005 act.

• The trust must deploy sufficient staff with the appropriate skills on wards, especially on the medical short stay ward and on ward 16 at night.

• The trust must ensure that learning is shared across all service areas and the reasons for any changes made clear to all staff.

• The trust must ensure that records are kept secure at all times so that they are only accessed and amended by authorised people.

Surgery

• The trust must ensure that there are adequate numbers of suitably qualified staff in theatre recovery areas to ensure safe patient care.

• The trust must ensure that all staff involved with the care and treatment of children receive adequate life support training.

• The trust must ensure that all staff receive are appropriately trained and able to use the incident reporting system.

Critical care

• The trust must address the governance shortfalls in critical care and make sure that the systems and processes in place for assessing, monitoring and mitigating local risk are managed effectively.

• The trust must ensure that all staff understand the thresholds for reporting incidents and are encouraged to use the electronic reporting system.

• The trust must make sure that all staff understand and comply with the best practice in infection prevention and control. This includes appropriate use of handwashing and the use of antiseptic hand gels.

Maternity and gynaecology

• Review the management of the electronic rostering system to ensure it does not allow staff to be rostered on different wards at the same time.

• The provider must deploy sufficient clinical and midwifery staff with the appropriate skills at all times of the day and night to meet the needs of women following the trust risk assessment and escalation procedures.

• The provider must ensure that there is a detailed overview of the types and seriousness of incidents and learning is shared across all service areas and the reasons for any changes made clear to all staff.

• The provider must make sure individual care records are always accurate and completed contemporaneously.

• The provider must make sure community midwives have easy access to the emergency medication and equipment detailed in best practice guidance. The equipment must be checked and items provided within the use by date.

Children and young people’s services

• Resuscitation trolleys must be appropriately checked and the log book must be signed to confirm all items are in working order. The trolley must include a defibrillator at all times.

• Must ensure that there is a robust system to determine staffing numbers which takes into account the acuity of patients and skill mix of staff.

• Information must be collected and analysed to support developments in clinical and operational practice.

• Must review the children’s safeguarding training to ensure it meets Royal College of Paediatrics and Child Health (RCPCH) guidelines 2014.

End of life

• Ensure that any complaint received is investigated and necessary and proportionate action is taken in response to any failures identified by the complaint or investigation.

• Seek and act on feedback from relevant persons and staff teams, for the purpose of continually evaluating and improving services.

• Evaluate and improve their practice in respect of the processing of information relating to the quality of people’s experience.

• Ensure there is a robust vision and strategy for end of life services and all staff are aware of them.

• Ensure that there is an appropriate replacement care plan in place across the trust following the withdrawal of the Liverpool Care Pathway.

• Ensure that all risks associated with end of life services are recorded and monitored with appropriate actions taken to mitigate them.

Outpatients and diagnostics

• The trust must take action to reduce the delay in referral to reporting times of urgent diagnostic investigations.

• The trust must resume radiation safety committee meetings and hold them at least annually.

• The trust must take steps to fill vacancies to ensure compliance against their current staffing establishment.

Clatterbridge Hospital

Medical care (including older people)

• Ensure that robust information is collected and analysed to support improvements in clinical and operational practice.
• Deploy sufficient staff with the appropriate skills on the Clatterbridge rehabilitation unit at night.
• Ensure there is adequate medical cover out of hours for the hospital.
• Ensure there is a clear operational protocol for the transfer of patients whose condition deteriorates

Surgery

• Ensure that all staff involved with the care and treatment of children receive adequate life support training.
• Ensure there is sufficient medical cover out of hours for the hospital.
• Ensure there is a clear operational protocol for the transfer of patients whose condition deteriorates
• The trust must ensure that the doors which lead to high balconies on the ward areas are suitably secured.

Outpatients and diagnostic imaging

• Take action to reduce the delay in referral to reporting times of urgent diagnostic investigations.
• Resume radiation safety committee meetings and hold them at least annually.
• Take steps to fill vacancies to ensure compliance against their current staffing establishment.

Professor Sir Mike Richards

Chief Inspector of Hospitals