Liverpool Heart and Chest Hospital NHS Foundation Trust

Liverpool Heart and Chest Foundation Trust provide specialist services in cardiothoracic surgery, cardiology, respiratory medicine including adult cystic fibrosis and diagnostic imaging, both in the hospital and in the community, from locations in the Boroughs of Liverpool and Knowsley.

Liverpool Heart and Chest Hospital provides a full range of heart and chest services with the exception of organ transplantation. Throughout 2015/2016 these services included, procedures used to visualise the coronary arteries and treat narrowing’s using balloons and stents (coronary angiography and intervention).

The implantation of pacemakers and other devices & treatments used to control and restore the normal rhythm of the heart (arrhythmia management). Surgical procedures used to bypass coronary arteries, replace the valves of the heart, and complex surgical correction of the major vessels in the chest (cardiac surgery).

Surgical procedures used to treat many major diseases affecting the lungs; these can include partial or complete lung removal.

Surgical procedures used to treat many diseases affecting the gullet and stomach (thoracic surgery). The trust also provided drug management of asthma, chronic obstructive pulmonary disease and cystic fibrosis (respiratory medicine). Community cardiovascular and chronic obstructive pulmonary services were provided for the residents of Knowsley.

We visited the hospital on 26- 29 April 2016. We also carried out an out-of-hours unannounced visit on 13 May 2016. During this inspection, the team inspected the following core services:

• Medical care services
• Surgery
• Critical care
• End of life Services
• Outpatients and diagnostic services
• Community Services for Adults

We rated Liverpool Heart and Chest Hospital outstanding . We have judged the service as ‘good’ for safe and effective and outstanding for caring, responsive and well - led.

We rated the community service as outstanding overall.

Overall, we rated Liverpool Heart and Chest NHS Foundation Trust as good in safe, effective. We rated caring, responsive and well - led as outstanding, the trust was rated outstanding overall.

Our key findings were as follows:

Leadership of the trust

• The trust was led and managed by a stable, visible and accessible executive team. The senior team led the trust with a strong focus on service quality and positive patient experience.
• All staff we spoke with were familiar with the senior team and felt that managers listened to and acted upon matters of concern.
• All the staff we spoke highly of the senior team and board members. Staff gave examples of positive interactions and collaborative working between the board and staff in order to improve care, treatment and outcomes for patients.
• There was effective teamwork and clear leadership and communication in services at a local level. Managers and leaders were visible and approachable. Staff we spoke to felt supported by their managers and supported and encourage to raise concerns and ideas.
• However, there were some concerns regarding the leadership styles in some isolated areas in the medical division. Some staff raised with us that the leadership of the service at a local level could be improved in terms of approach and attitude. A small number of staff told us that the local leadership would benefit from a more open, equitable and flexible approach to their management and development, as at times the leadership style could occasionally feel repressive .

Culture within the trust

• There was, in the main a very positive culture throughout the trust.
• Staff of all grades were committed to the continuous improvement to the quality of care and treatment delivered to patients.
• Staff felt comfortable and confident in respect of raising matters of concern. In addition staff felt that they could share ideas for improvement and innovation and that managers and the senior team would support the implementation.
• There was a range of reward and recognition schemes that were valued by staff. Staff were encouraged to be proud of their service and celebrate their achievements.
• However, there were also some (historical) concerns regarding the culture in the Critical Care Service and some additional concerns about the culture in parts of the medical services. The trust was sighted on the issues in both areas and had plans in place to develop leaders and improve the culture in both areas.
• Overall, we found that staff were proud of the services they delivered and proud of the trust.

Governance and risk management

• The governance arrangements were centred on three divisions, Medicine, Surgery and Clinical services. Each division was managed by a triumvirate of an Associated Medical Director, Divisional head of Operations and a head of nursing. The triumvirates reported to the board through a well-developed committee structure that included, people, quality, integrated performance, audit, charitable funds and Nomination and remuneration for Executives.

• Mechanisms were in place to ensure that committees were led and represented appropriately, to ensure that performance was challenged and understood. There was good challenge and scrutiny by non-executive directors who were well sighted on both risk and quality.

• The Board Assurance Framework (BAF) was suitably aligned to strategic objectives and was linked appropriately to divisional risk registers that were regularly reviewed.
• We noted that the trust  had an over-all trust risk register,  processes were in place to ensure that both operational and strategic risk and performance issues were reported and mitigated though monthly management meetings chaired by the Chief Executive.
• There were divisional governance meetings where performance, risks and learning was discussed and shared. Staff had access to robust data to support good performance which included thematic reviews and correlation of data to promote early identification of poor performance that supported remedial action planning.
• Locally staff were aware of the risks and challenges to both their service and the wider trust.
• Staff understood the risks and the actions in place to mitigate risks.
• The trust had a data quality strategy in place aimed at improving and maintain good data quality to underpin planning and performance management.

Mortality rates

• Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by robust and well understood procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients and prevent avoidable deaths. Key learning Information was cascaded to staff appropriately. Monitoring arrangements were in place at board level to ensure that opportunities for learning and improvement were implemented.

• 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. Specialist acute Trusts do not calculate their mortality rates using the summary hospital-level mortality indicator (SHMI).Due to the specialist nature of its services, Liverpool Heart and Chest Hospital has implemented the risk prediction equations published by the British Cardiac Interventionist Society and the Society of Cardiothoracic  Surgery to derive estimates of mortality expected from the case mix of patients being treated. Measures of observed and expected mortality are updated and compared monthly as part of its performance management arrangements and reported to the Trusts Clinical Patient Family Experience Committee. Between January and December 2015, mortality rates within the trust had remained at or below the expected levels.

Safeguarding

• Accessible policies and procedures explained the processes for safeguarding vulnerable adults and children.

• Safeguarding practice was supported by mandatory training. Training statistics provided by the trust showed that 91% of staff had completed level 1 safeguarding adult training and 76% had completed level 2 training. This was below the trust target of 95%
• The trust target for safeguarding children was 95% and compliance rates for safeguarding children level 1 was 92% and level 2 was 88%. Again below the trusts target of 95%.
• Data received from the trust  showed that training rates for safeguarding, ranged from 98% to 20%. It was noted that some departments had very small numbers of medics which accounted for the low percentage in some areas. We did not have access to individual training records for exact figures .

• A trust safeguarding team advised on adult safeguarding concerns. The team included a lead nurse for patient and family centred care and safeguarding. Support was also provided for patients with additional and/or complex needs.
• The lead nurse worked with patients and families to develop plans of care in order to fully meet the patients’ individual needs. This included support for people living with dementia, a learning disability, autism spectrum conditions, patients with physical disabilities and patients with mental health and capacity issues.

Equality and Diversity

• The trust had developed an Equality and Inclusion Strategy. The aim the strategy was to support the further development of the trusts approaches to promoting equality, managing diversity and ensuring that it was effective and efficient in taking a human rights based approach as a health care provider and an employer. Staff and patient representatives had participated in the strategy development.

• The trust has developed high level aims and categorised the activity planned under four clear outcomes aligned with the refreshed Equality Delivery System (EDS2) Outcomes:

• Better Health Outcomes
• Improved Patient Access
• Empowered Engagement & Well Supported Staff
• Inclusive Leadership
• We analysed data from the NHS Staff survey regarding questions relating to the Workforce Race Equality Standard (WRES). The results for the trust were generally positive in most areas.

Nurse Staffing

• There were processes in place to ensure ward staffing levels were monitored on a daily basis. Senior nurses and matrons met each week to discuss nurse staffing levels across services to ensure that that there were sufficient numbers of staff to meet patient needs.

• Staffing on a day to day basis was reviewed as part of the trust bed management strategy. Shortfalls were subject to management action and risk mitigation.
• Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff
• An induction process was in place for new and temporary staff to familiarise them with the trust’s operational policies and procedures.
• Nursing handovers were structured and information handed over to the incoming staff included allergies, mobility of patients, incidents and expected date of discharge. Each member of staff on the ward had access to a copy of the handover sheet at the beginning of each shift.
• However, nurse staffing levels remained a challenge, particularly in critical care and surgery. Nurse staffing was identified on both operational and corporate risk registers. At the time of this inspection there were 50 nursing staff vacancies across the trust and additional posts had been made available in order to support the increased requirements across the hospital.

Medical Staffing

• At the time of our inspection in surgical services there were appropriate numbers of medical staff to meet the needs of patients.
• Health and Social Care Information Centres (HSCIC) statistical data from September 2004 to September 2014 showed that the proportion of consultants was 51% compared to the England average of 41%; middle career doctors were 4% compared to the England average of 11%. The registrar group was 39% compared to an England average of 37%, whilst the proportion of junior doctors at the trust was 6% compared to an England average of 12%.
• Trust staffing data dated December 2015 confirmed planned medical staff – consultant or equivalent grade as 74.00 and of this 73.89 whole time equivalent (wte) consultant staff were employed. In addition an additional two consultants were due to join the trust in July 2016.
• In medical services there was an on call rota which ensured there was a consultant available on site, 24 hours a day seven days a week for advice and support..
• The percentage of consultants working in medical services trust wide was 42% which was higher (better) than the England average of 34%. The percentage of registrars was 46% which was above (better) than the England average of 39%. The percentage of junior doctors was 12% which was lower (worse) than the England average of 22%. There were no middle grade levels compared with the England average of 6%.
• In December 2015 there were 3.5 whole time equivalent medical staff vacancies in medical services.
• The trust had an ongoing medical recruitment programme.

Cleanliness and infection control

• Clinical areas at the point of care were visibly clean, trust had infection prevention, and control policies in place that were accessible to staff and staff were knowledgeable about their role in controlling and preventing infection.

• Staff followed good practice guidance in relation to the control and prevention of infection in accordance with established trust policies and procedures.
• There was an ample supply of personal protective equipment available such as aprons and gloves that were accessible for staff and was used appropriately.
• There were established audit programmes in place related to the prevention of infection, which included hand hygiene, infections within a central line (a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products) and methicillin-resistant Staphylococcus Aureus (MRSA). Compliance rates were high and where practice shortfalls were identified there was action planning to secure improvement.
• There were no cases of trust reported MRSA reported between August 2014 and August 2015. There were three cases of Clostridium difficile and 12 cases of Methicillin-susceptible staphylococcus aureus (MSSA) reported over the same period.
• The MSSA infection rate was higher than the England average in seven out of 12 months. However; the counts of infections have not been adjusted to give a standardised rate considering factors such as organisational demographics or case mix.

Nutrition and Hydration

• As part of CQC inpatient national survey, between August 2015 and January 2016, a questionnaire was sent to 1250 recent inpatients at each at Liverpool Heart and Chest Hospital NHS Foundation Trust. Responses were received from 819 patients; these responses rated the Hospital as better when compared with other trusts in relation to both the quality of food and the assistance given to support people to eat.
• The trust score the same as other trusts in relation to the choice of food being offered to patients.
• We found that that there was a comprehensive selection of meals available was available for patients. Meals were also available for patients with different dietary, cultural and religious requirements; for example, halal meals.
• When patients had a poor intake of food due to their condition, medical staff prescribed appropriate dietary supplements. There were also dedicated chefs on the cystic fibrosis wards to ensure that patients had the correct diet when they required it.
• Support for patients who required assistance with eating and drinking was given in a discreet and sensitive way.
• Patient led assessments of food and hydration (PLACE) in 2015 showed a standard of 99%. This was higher (better) than the England average of 89%.

We saw several areas of outstanding practice including:

• Medical services developed the lateral atrial appendage occlusion service (LAAO) which has the highest activity rates in the country and implemented the first leadless pacemaker. LAAO is a treatment to reduce the risk of atrial blood clots entering the bloodstream and causing a stroke.
• A number of staff received external awards for innovative projects; for example, for continuous glucose monitoring and the cardioversion service.
• ‘Back to the Future’ is a multi-disciplinary team model of working that places the patient at the centre of the decision making and builds a trans disciplinary working team (TDT). Pivotal to the delivery of this model of care were the concepts of person-centred coordinated care from the perspective of the individual and reablement using trans disciplinary working.
• A new role to be developed as part of the pilot is the ‘Total Care Practitioner.’ This non-registered member of the care team will play an essential role to support the patient to achieve their agreed goals through facilitation, reablement and delivery of delegated therapy and nursing interventions.
• A chest x-ray competency tool was developed for advanced practitioners and this had been shared both nationally and in Europe. The nurse led chest drain clinic was shortlisted by the Nursing Times Awards to enable patients to be discharged home with a chest drain connected to a flutter bag. An article was also published within the Nursing times. A standardised discharge letter was developed for district nurses with all relevant information. This enabled patients to be cared for at home without frequent trips to the hospital to aspirate fluid, therefore hopefully making the end of life more comfortable and dignified for patients and families.
• The trust had developed the ‘Liverpool Lounge Suit’ that patients could wear during procedures, the suit replaced the traditional hospital gown and supported the patients dignity as the design of the suit meant that only the minimum of exposure was required to carry out the procedure and the patients dignity maintained.

However, there were also areas of practice where the trust should make improvements.

The trust should:

Trust Wide

• Improve adult and children’s safe guarding training compliance rates in line with internally set targets.

In Critical Care Services;

• The management team should ensure that the policy for managing delirium is updated and that a policy for administering medication in end of life care should be implemented to ensure that up to date evidence based practice is followed.

In Surgery;

• The trust should ensure that staff attendance at mandatory and safeguarding training is improved. The trust should ensure medical staff attendance at safeguarding training sessions is documented to determine compliance.
• The trust should ensure that medical trainees can access human factors training, simulation training and formalise cardiac training opportunities.
• The trust should continue to improve WHO checklist completion by staff.

In Outpatients and Diagnostic Imaging;

• The trust should take steps to ensure that resuscitation equipment is checked in line with trust policy, expiration dates are monitored and all emergency equipment is available for use.

In End of Life services;

• The trust should ensure that consultant cover is increased to meet the national standard required.
• The trust should ensure that plans in place are implemented to ensure all staff has access to specific training needs in end of life to deliver effective and high quality care to all.
• The trust should ensure that there are specific medication guidelines in place for patients at the end of their lives who are being cared for in the intensive care environment

Professor Sir Mike RichardsChief Inspector of Hospitals

We rated community services at Liverpool Heart and Chest Hospital as outstanding in caring, responsive and well led key questions. We rated safe and effective key questions as good.

• Feedback from patients and those close to them was consistently positive about the way staff treated them. Staff went the extra mile to provide care and support. There was a strong person‑centred approach to providing care.

• Relationships between people who use services and staff were caring, respectful and promoted people’s dignity.

• Services provided by the trust reflected people’s individual needs and preferences and continuity of care for patients was central for staff. The hospital had implemented a number of schemes to help meet people’s individual needs

• Incidents were reported by staff through effective systems. Lessons were learnt and staff were able to recognise and respond to changes in risk to people who used community services.

• Staff followed good hygiene practices.

• Staffing levels were reviewedto ensure that there were enough staff with the correct skills to keep people safe.

• Best practice guidance in relation to care and treatment was followed and community services participated in national and local audits. Action plans were in place to continuously monitor service quality and delivery and maintain standards. All staff were engage with monitoring and evaluating their services. The service was meeting or exceeding the majority of their key performance targets and met or exceeded outcomes in line with national benchmarking and guidance such as

• Patients were supported to raise a concern or a complaint. Lessons were learnt and improvements made from complaint investigations. Community services captured views of people who used the services with changes made following feedback. The friends and family test showed that people would recommend the hospital to friends or a relative.

• All staff knew the trust and service vision and were committed to driving continuous improvement setting their own internal targets to seek out and trial new models of care in the community.