The Care Quality Commission
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Alder Hey Children's NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

14 Jan to 13 Feb 2020

During an inspection of Child and adolescent mental health wards

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

  • The service provided safe care. The wards had enough nurses and doctors. Staff assessed and managed risk well. They minimised the use of restrictive practices, managed medicines safely and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the children and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The ward team included or had access to the full range of specialists required to meet the needs of children on the wards. Managers ensured that these staff received training and appraisals. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare.
  • Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed good practice with respect to young people’s competency and capacity to consent to or refuse treatment.
  • Staff treated children with compassion and kindness, respected their privacy and dignity, and understood the individual needs of each child. They actively involved children, families and carers in care decisions. Consideration was given to children‘s care after they were discharged and the service offered extensive support to carers to ensure they could support children after discharge from the service.
  • Staff planned and managed discharge well and liaised well with services that could provide aftercare. As a result, discharge was rarely delayed for other than a clinical reason.
  • The service was well led, leaders had the skills knowledge and experience to perform their roles, staff felt respected and valued and performance and risks were managed well.

However:

  • The ward environment was not well maintained. There were a number of maintenance jobs that had not been completed. There were infection control risks on the ward that had not been identified. We found equipment that was out of date. Checks on equipment were not up to date. Cleaning records were poor and did not provide assurances of regular cleaning and clean stickers were not in use.
  • There were no personal emergency evacuation plans to provide guidance to staff around the evacuation of individual children. We raised this and personal emergency evacuation plans were put in place by the second day of our inspection.
  • Clinical supervision levels were low at 54%, staff received other methods of supervision but these were not always recorded and it was not clear whether staff were receiving the level of supervision they needed.

14 Jan to 13 Feb 2020

During a routine inspection

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

  • We rated effective, responsive and well-led as good. We rated caring as outstanding and safe as requires improvement.
  • We rated all seven services we inspected as good. This included improvements in the overall rating in three core services. In rating the trust, we took into account the current ratings of the five services not inspected this time.
  • Across the trust we found that children had good outcomes because they received effective care and treatment that met their needs.
  • We found that children’s’ needs were met through the way services were organised and delivered.
  • We saw evidence that people were truly respected and valued as individuals and were empowered as partners in their care.
  • We noted improvement in the leadership and culture, which were used to drive and improve the delivery of high-quality person-centred care.

However:

  • Although we found the trust’s services largely performed well, it did not meet some legal requirements relating to the safe domain, meaning we could not give it a rating higher than requires improvement in this domain.
  • We found some risks which had not been identified by the trust’s internal governance structure. We escalated this to the trust at the time of the inspection, who took appropriate action.

14 Jan to 13 Feb 2020

During an inspection of Specialist community mental health services for children and young people

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

  • The service provided safe care. Clinical premises where children and young people were seen were safe and clean. The number of children and young people on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each child the time they needed. Staff managed waiting lists well to ensure that children and young people who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
  • Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of children and young people. Staff engaged in clinical audit to evaluate the quality of care they provided.
  • The teams included or had access to the full range of specialists required to meet the needs of children and young people. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
  • Staff understood the principles underpinning capacity, competence and consent as they apply to children and young people and managed and recorded decisions relating to these well.
  • Staff treated children and young people with compassion and kindness, respected their privacy and dignity, and understood the individual needs. They actively involved children, young people and families and carers in care decisions.
  • The service was easy to access. Staff assessed and treated children and young people who required urgent care promptly and those who did not require urgent care did not wait too long to start treatment. The criteria for referral to the service did not exclude children and young people who would have benefitted from care.
  • The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

6 to 28 Feb 2018

During a routine inspection

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

  • We rated well-led as good because the trust had a vision for what it wanted to achieve with plans to turn it into action. Staff throughout the trust were aware of the vision and values. There was an experienced and stable leadership team who were committed to improving services, through learning research and innovation. The trust had made improvements to the fit and proper person process since the last inspection.
  • The trust had an experienced and stable leadership team with the skills and commitment to provide high quality services. The trust was committed to improving services when things go well and when they go wrong. They promoted training and research.
  • Although the trust had an up to date policy for duty of candour we found that this was not always being applied consistently when it had been required.
  • Although there was a system in place for identifying and managing risks we found that these were not always being managed in a timely way. There was limited evidence of discussion and challenge at key executive led meetings and there were examples of when actions from meetings did not have targeted completion dates.

19, 20 April 2017 and 5 May 2017

During an inspection looking at part of the service

Alder Hey Children’s NHS Foundation Hospital is one of the busiest children’s hospital in Europe and provides care for more than 270,000 children, young people and their families every year. The trust provides a range of services and leads on research into children’s medicine. The trust also provides child and adolescent mental health inpatient and community services.

Before visiting the trust, we reviewed a range of information we held and asked other organisations to share what they knew about the trust.

We last inspected the services in September 2015 and we rated the provider as ‘good’ overall. In reaching our judgement we told the trust that there were areas for improvement.

We carried out this responsive inspection on 19 and 20 April 2017 and 5 May 2017 following concerns we had about the services and to follow up on concerns from the last inspection in the community child and adolescent mental health services (CAMHS). We inspected surgical and medical care services together with community CAMHS. At the last inspection in 2015, surgery and medical care services were judged to be good overall and CAMHS was judged to be requires improvement overall. At this inspection surgery was judged to be requires improvement overall, medical services was judged to be good overall and CAMHS services was judged to be requires improvement overall.

We did not inspect urgent and emergency services, critical care, neonatal services, end of life care, outpatient and diagnostic imaging, transitional services or CAMHS inpatient services.

We did not rate Alder Hey Children’s NHS Foundation Hospital overall for this inspection. We found that:

  • Safeguarding practice was supported by staff training, although the number who had received training was below the trust target.

  • Serious incidents were not always being reported within the timeframe identified in the trust policy and national guidance. The Trust had recently implemented a 72 hour review following serious incidents, however these were not always being completed within the timeframe and no immediate actions had been identified to mitigate the risk of the incident happening again.

  • We were not assured that children and young people were receiving treatment for sepsis in medical services that reflected national guidance.A training programme for sepsis had been set up and staff were currently undertaking this training but not all clinical staff had yet completed this training. There was no audit or review of the pilot phase of the pathway identified.

  • There was resuscitation equipment available to respond to an emergency, however, this was not kept together in one place on the wards and relied on several staff to collect the equipment in an emergency.There was also a lack of clarity for staff over responsibilities.

  • The hospital did not always ensure that a member of staff who was trained in advanced paediatric life support (APLS) was available on each department at all times. This did not meet the Royal College of Nursing (RCN) minimum staffing requirements. This shortfall had also been acknowledged in a recent nursing staffing review which stated the need for all band 6 co-ordinators to be trained in APLS.However, no formal plans had yet been made to implement the improvements.

  • The personal alarm system in CAMHS community services was a concern at the last inspection.We observed during this inspection the use of alarms was included in the revised lone working policy for child and adolescent mental health services for the Liverpool site. At the Liverpool site, there were portable alarms but they did not work correctly so were not in use. There were no alarms in the Sefton site.

  • At the time of our inspection the numbers of staff who had completed mandatory training varied across the hospital.It was noted that the compliance rate for medical staff was particularly low and the medical director acknowledged this was an area for improvement.

  • The appraisal system was used to underpin on going professional development.However the compliance rate for medical and non-medical staff was below the trust target.This was significantly less than at the last inspection.

  • The trust had recently implemented a model of devolved governance to services.However at the time of the inspection these were relatively new and not all systems and processes had been identified to support continuous quality improvement.Some of the risk registers had no actions identified to mitigate the risk.

  • The trust recruitment policy on pre-employment checks did not comply with the fit and proper regulation (FPPR).Also, the checks to fully comply with this regulation for executives and non-executives had not been completed at the time of the inspection. There was also a lack of assurance that the internal processes to monitor the self-declaration forms for executives and non-executives were robust.

However

  • Children and those close to them were treated with dignity and compassion. Children and young people were very positive about the caring and supportive attitudes of staff. They were active partners in care and felt involved in the decision-making process. Children and young people’s individual preferences and needs were reflected in how care was delivered.

  • The wards were adequately staffed to meet the needs of the patient and there was an escalation process in place for staff to alert managers when they needed additional staff.

  • Medical staff were highly skilled and comptetent. Doctors were committed to the care and treatment of children and young people. Staff were highly motivated to offer support to children and young people which was kind and caring and they were willing to go the extra mile.

  • Care and treatment was evidenced based and the policies and procedures and pathways followed recognisable and approved guidelines. There was good use of clinical audit to monitor and improve performance and Multi-disciplinary team work was well established and focused on ensuring the best outcomes for children and young people.

  • The Trust were one of only two paediatric centres nationally who were able to provide extracorporeal membrane oxygenation (ECMO). ECMO is used to support patients whose heart or lungs are unable to provide an adequate amount of gas exchange to support life.

  • At the last inspection waiting lists in CAMHS community services were found to be over the operational national standard, and the trust did not monitor them effectively. At this inspection we found that the waiting lists and the time people wait had reduced.

  • Staff were responsive to the individual needs of patients and those close to them. There was good evidence of personalised care planning that focused on the needs of children and young people.

  • Staff understood the process for receiving and handling complaints and were able to give examples of how they would deal with a complaint effectively. Staff knew about their responsibilities in relation to duty of candour and knew when to be open and transparent with people who used the services at the trust.

  • There was a clear vision and strategy across the trust and services were planned and delivered to meet the needs of patients. The trust had an aim to be an inclusive and accessible place for all to visit and work and had implemented actions to meet this aim. There was increased clinical engagement since the last inspection.

  • The trust was involved in a number of innovation and improvement areas and had been recognised nationally and internationally for the work they were doing.

We saw several areas of outstanding practice including:

  • Each ward had their own dedicated pharmacist and medication was accessed by fingerprint technology this ensured that medication was secured and stock levels were adequately controlled.

  • There was a chef allocated to each ward and all food was prepared on the ward.

  • A hybrid theatre had recently been opened and a small number of operations had been undertaken using this facility. This was the first paediatric hybrid theatre to be opened in Europe.

  • The hospital innovation team had worked collaboratively with a local university to develop ‘virtual surgery’ and to use high definition 3D printing so that organs can be viewed in much more detail. This allowed staff to ‘virtually walk around’ organs.

  • The child and adolescent mental health (CAMHS) community service was part of a network of statutory and voluntary services. It was piloting ways to make it easier for people to contact services, so they could be either referred to the child and adolescent mental health services, or signposted elsewhere.

  • The CAMHS community service followed best practice by using the choice and partnership approach, which emphasised collaborative working with children and young people and their families. The service had recently introduced the “THRIVE” model, which aims to provide better outcomes for children and young people, and reduce waiting times.

  • The hospital had an international health partnership with a hospital in Kathmandu and many specialities were engaged in quality improvement work including the emergency department for resuscitation training.

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

Importantly, the trust must:

  • Ensure that all serious incidents are reported in line with the trust policy and initial investigations are carried out in a timely way so that any immediate actions to mitigate risk are identified.

  • Ensure all children and young people receive treatment in relation to sepsis within appropriate timeframes and have a process to monitor adherence to policy for patient’s treated for sepsis..

  • Ensure that robust arrangements are in place to govern the fit and proper person’s process.

At Alder Hey Hospital

  • Take action to ensure all staff who are involved with assessing, planning, and evaluating care for children and young people are trained to safeguarding level three in line with the safeguarding children and young people: roles and competencies for health care staff Intercollegiate Document (2014).

  • Ensure that there is a member of staff trained in advanced paediatric life support available in every department at all times as outlined in the Royal College of Nursing guidelines

  • Ensure that compliance with mandatory training is improved, particularly for medical staff.

  • Ensure that formal risk assessments are undertaken in all departments and all identified risks are captured on the risk register where needed.

Child and Adolescent Mental Health Services (CAMHS) – Community

  • Ensure that lone working practices are implemented, to ensure the safety of staff and others.
  • Ensure that the confidentiality of patient information is maintained, and that patient records are only accessible to authorised staff.

Professor Ted Baker 

Chief Inspector of Hospitals

19-20 April 2017

During an inspection of Specialist community mental health services for children and young people

We rated specialist community mental health services for children and young people as requires improvement overall because:

  • The practices for lone working were not consistently implemented, so did not protect staff. There was no direct way of calling for urgent assistance from inside the therapy rooms.

  • At Sefton CAMHS, confidential information about children and young people was left in an unlocked office on a corridor shared with amixture of NHS and non-NHS businesses. This meant unauthorised people could potentially see patients’ records.

  • Morale among some staff was low.

  • Some staff did not feel able to raise concerns.

  • The service employed adequate numbers of staff, but there were staff shortages caused by staff absences which included long term sickness, maternity leave, and training.

  • Risk assessments and care plans were not always clearly recorded, or easy to find in the care records.

  • The service was provided from two office buildings, one in Liverpool and one in Sefton. There were therapy rooms on each site. They were not purpose-built and the décor was generally tired and worn. Attempts had been made to make them more child and young person friendly, particularly in the waiting areas. This had been designed with input from children and young people.

  • There were internal waits for access to therapies and to see a consultant psychiatrist.

  • There were a large amount of clinical records waiting to be scanned and archived. These were not for current patients, and the trust had implemented a plan to address this over time.

However:

  • The service was provided by a multidisciplinary team of staff, who had training in working with children and young people. Across the service staff had training and experience of a variety of psychological therapies. Staff had completed their mandatory training, received regular clinical supervision and had an annual appraisal.

  • Children, young people and their parents were mostly positive about the service they received. Staff were caring and responsive to their needs. Children and young people and their families were able to raise their concerns. Complaints were responded to appropriately.

  • Children and young people were involved in the development of the service. This was under the banner of “FRESH”, which was used on the trust’s website and in printed information. There were regular patients’ forums and participation groups where developments of the service were discussed.

  • At the last CQC inspection waiting lists were found to be over 18 weeks, and the trust did not monitor them effectively. At this inspection we found that the waiting lists and the time people wait had reduced. The waiting lists and times were monitored, and reviewed at a weekly meeting. Average waiting times were within the trust’s target of 12 weeks from referral to treatment, and within 18 weeks from referral to treatment.

  • The service followed best practice by using the choice and partnership approach, which emphasised collaborative working with children and young people and their families. The service had recently introduced the “THRIVE” model, which aims to provide better outcomes for children and young people, and reduce waiting times.

  • All children and young people had an assessment carried out, and were offered choices about further partnership working with the child and adolescent service, signposted to other services, or given information and advice on self-help and care.

  • Staff were knowledgeable in the assessment of capacity and consent, and how it applied to children and young people. Children and young people understood who their information was shared with.

  • Incidents were reported, investigated, and action was taken to reduce the risk of them happening again.

  • The service was part of a number of pilots and initiatives that aimed to improve access and outcomes for children, young people and their families. Many of these involved working with other organisations.

22 September 2015

During an inspection looking at part of the service

Alder Hey Children’s NHS Foundation Trust is one of the busiest children’s hospitals in Europe and provides care for more than 270,000 children, young people and their families every year. The trust provides a range of services from the main Alder Hey Hospital site and leads research into children’s medicines, infection, inflammation and oncology. The trust is due to move into a new build hospital in October 2015, which is a purpose built, state of the art hospital. This new build named ‘Alder Hey in the park’ has been built adjacent to the existing site. The new build contains 16 operating theatres and 260 inpatient beds, 48 of which are in intensive care, high dependency and the burns unit.

We last inspected this trust in June 2015 and we rated the provider as ‘good’ overall. The focus of this inspection was to inspect the new build prior to its opening.

We carried out our focused inspection on 22nd September 2015 to review the building, environment and process for transfer into the new hospital. We focussed our inspection on the most appropriate elements of the safe and well-led domains and reviewed several areas including the intensive care unit, neonatal unit, accident and emergency department, theatres, radiology and a selection of wards. We also reviewed data supplied by the trust.

Our key findings were as follows:

  • A big move plan was developed in October 2014 to ensure a robust strategy was in place for the move. This plan was reviewed and found to be comprehensive covering all areas to assist in a smooth transition to the new build. In addition each clinical area had developed business continuity plans incorporating pertinent issues for their area.
  • Building control (local authority) and the local fire authority had approved fire regulations. Assurance was given that all fire regulation signage would be completed prior to the hospital opening.
  • Schedule 12 “the building certificate” was due to be completed and signed off prior to the building being handed over to the trust on 30th September 2015. The production of the “building certificate” is the culmination and sign off of a process which involves the completion of 76 service / sub certificates of which each in turn have many commissioning test and validation certificates witnessed and signed off. A random selection of test certificates was reviewed and was found to be satisfactory.
  • The safety and resilience of services and infrastructure and its testing was found to be satisfactory.
  • New and existing medical and non-medical devices and equipment were being transferred and installed through a managed process to ensure it was safe and fit for use.
  • The location was suitably equipped and supported to implement the trust’s policies and procedures for hygiene and the prevention of health care acquired infections.
  • The new build was found to be compliant with the disability discrimination act with disabled toilets, wide corridors and doorways for wheelchair and lift access.

We saw several areas of outstanding practice including:

  • The children and young people’s design group, which was made up of current and former patients aged 10-22, had input on everything from the colour of the rooms, to the artwork displayed in the new hospital and what their wards should look like.

Professor Sir Mike Richards

Chief Inspector of Hospitals

15 - 16 June 2015

During an inspection looking at part of the service

Alder Hey Children’s NHS Foundation Trust is one of the busiest children’s hospitals in Europe and provides care for more than 270,000 children, young people and their families every year. The trust provides a range of services from the main Alder Hey Hospital site and leads research into children’s medicines, infection, inflammation and oncology. The trust also provides an inpatient and community Child and Adolescent Mental Health Service (CAMHS) to support young people between the ages of 5 and 14 years. A new Alder Hey Children’s Hospital is currently being built adjacent to the existing site and is set to open in 2015.

We last inspected this trust in May 2014 and we rated the provider as ‘requires improvement’ overall. In reaching our judgement, we told the trust that they must make improvements to:

  • Ensure nurse staffing levels were appropriate in all areas, without substantive staff feeling obligated to work excessive hours or additional shifts.
  • Provide effective medical leadership on the High Dependency Unit.
  • Ensure that clinical records are available in the outpatients department for patient consultations
  • Ensure that nurses are following the trust’s policy regarding the safe administration of medicines.
  • Address the shortfalls in governance and risk management systems.
  • Improve the timely completion of investigation of incidents and Never Events (serious harm that is wholly preventable) so that learning can be systematically applied to avoid recurrence.

Before carrying out this inspection, we reviewed a range of information we held, and asked other organisations to share what they knew about the hospital. These included clinical commissioning groups (CCGs); Monitor and the local Healthwatch.

We carried out our focused inspection on 15 and 16 June 2015 to check whether improvements had been made. As part of this inspection, we also inspected the community and inpatient Child and Adolescent Mental Health Services’ (CAMHS), which had not previously been inspected using our comprehensive inspection methodology.

It was evident that the trust had made a very positive response to the findings of our last inspection and improvements had been made in all of the areas we identified. The trust had also improved in a number of areas where we indicated it should make improvements with particular reference to the services for young people transitioning in to adult services and in the engagement and inclusion of staff in the change agenda for the transfer in to a new purpose built hospital in October 2015.

Our key findings were as follows:

Leadership and Culture

The trust was led and managed by a stable and visible executive team. The senior team were now well known to staff and were more frequent visitors to the wards and departments. It was evident that the senior team had made considerable efforts to engage and include staff in the change agenda through a variety of staff fora and engagement events. Staff were more positive about the visibility and accessibility of the senior team as well as the improvements made since our last inspection.

There was a positive culture throughout the trust. Staff were very proud of the work they did and proud of Alder Hey. There was a mix of excitement and anxiety regarding the move to the new hospital. Overall staff morale had improved and staff were well sighted on the transformation and change agenda. However, this was less evident in the Outpatients and Diagnostic Departments where some staff still felt remote from managers and communication with staff required improvement.

Nurse Staffing

The trust had worked hard to recruit additional nursing staff and the numbers of nurses employed had significantly increased. Over 80 additional nurses had been recruited and the trust remained active in securing nursing staff on an ongoing basis. All the wards and departments we inspected were adequately staffed to meet the needs of patients. There was an escalation process in place that nurses used to alert managers to staffing shortages (often as a result of unplanned absence). Managers responded by securing additional resources where possible to maintain appropriate staffing levels and skill mix. There were occasions when managers were unable to secure additional resources, however such events were infrequent and there was no evidence that this had compromised patient safety at the time of our inspection.

Medical staffing

Medical support for the High Dependency Unit (HDU) had significantly improved since our last inspection and it was evident that the trust had taken action to provide a longer-term solution for strong medical leadership and support within the unit until the transfer to the new hospital in October 2015. A consultant intensivist had been allocated to the HDU for 50% of their working time. This arrangement would remain in place until the transfer to the new hospital and meant that medical cover for the unit was now sufficient to provide clinical leadership and support for the care of children and young people requiring high dependency care.

Records availability

The outpatients department has made considerable progress since our last inspection in managing medical records and making them available for clinics. The trust had undertaken a lot of work to ensure that 95% of records were available for each of the clinics and effective systems were now in place to ensure the availability of records within the department.

The trust was due to go live with a new electronic medical records system at the time of our inspection. It was anticipated that the new system would secure further improvement. Staff had received training in the use of the new system and were confident in using it.

Transition Services for Young People

There has been a significant amount of progress in transitional services since we last inspected and we have been impressed by the trust's response in this area. There was now a clear overarching vision, framework and strategy for transitional care. The trust had a designated medical and nurse lead for transition who hadrecently led a review of transition services for young people into adult services, focusing on those young people with complex needs.

The team could clearly identify challenges in transitioning into adult services and had formulated clear aims and objectives to improve transition arrangements for young people.

A transition strategy was in place for young people with complex needs and there were arrangements in place to identify gaps in provision and escalate externally to providers and commissioners alike.

The trust had introduced a named executive lead for transition who chaired the transition steering group and there were arrangements in place for escalation of concerns to the board through the executive lead.

Young people in transition were benefitting from these improvements and were well supported in accessing appropriate support services as they moved in to adulthood.

Child and Adolescent Mental Health Service (CAMHS)

Inpatient services were good overall, with caring rated as outstanding. The care was centred on the child and delivered safely and effectively.  Community services provided good care; however, there were areas where improvements were needed. Vacancies within the service meant that staff were carrying high caseloads and there were delays of up to 18 weeks for assessment following referral to the service.  When children and young people were accepted for service, care was good.

Lone working arrangements for staff need to be consistently applied to ensure safe practice. The monitoring of environmental risks in community settings also needs to be embedded to ensure that people are kept safe.

Governance and Risk Management

A recent review of the actions undertaken to improve the trust’s overall quality governance score was provided to us as part of our inspection. The score in July 2014 was 4.5; this had reduced to 3 in May 2015 and indicated positive improvements. (A score 4 or below is required for aspirant foundation trusts).

The trust had undertaken a great deal of activity to improve its risk management arrangements. This had included seeking the help of an external risk management consultant, implementing actions in response to internal audit reviews of risk management and included a risk maturity review of the internal audit programme.

The corporate risk register was much improved when compared with the register at the last inspection. The risk register template now includes clear sections for the risk description, causes and consequences to prompt risk owners to consider all potential causes and consequences of the risk condition. There is a section for existing controls but not for gaps in these controls. However, an assessment as to the effectiveness of the controls was still required. In the outpatient and diagnostic imaging departments, we found departmental risk registers were not kept up to date with little or no evidence that they were reviewed on a regular basis. Nevertheless there was evidence of improvement overall.

We saw that the compassionate care being delivered by staff on the critical care unit and the child and adolescent mental health (inpatients) service was outstanding.

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

Importantly, the trust must:

  • Ensure that robust arrangements are in place to govern the fit and proper persons process.

The trust should:

  • Provide adult safeguarding training for staff across all services.

At Alder Hey Hospital

The trust must:

  • Ensure that departmental risk registers are kept up to date and reviewed appropriately.
  • Improve its risk management processes in the outpatient and diagnostic imaging departments and provide appropriate training for those delegated to manage risk.
  • Ensure there is an appropriate process in place for checking and recording pregnancy status in adolescent female patients.
  • Ensure that learning from incidents and complaints is shared with staff to prevent recurrent issues.
  • Ensure that processes are robust and effective in relation to patient emergencies in the radiology department and that first aid and resuscitation equipment is suitably available and checks completed and documented regularly.
  • Ensure that correct hand hygiene measures are in place and that people are aware of and using the correct techniques.

In addition the trust should:

  • Improve staff compliance with mandatory training.
  • Improve staff compliance with safeguarding training.
  • Provide adult safeguarding training for staff across all services.
  • Continue to recruit nursing and medical staff to address shortfalls across the surgical and critical care services.
  • Improve patient access and flow across critical care services.
  • Ensure that people’s medicines are given in the necessary quantities at all times and that the records reflect what has been administered to prevent the risks associated with medicines that are not administered as prescribed.
  • Ensure that outstanding actions on the risk register are reviewed and updated across all departments.
  • Ensure that adequate signage is displayed in relation to entering areas in the radiology department.
  • Seek to fill vacancies on medical wards and reduce the need for locum cover.
  • Continue to recruit nursing and medical staff to address shortfalls across the surgical services.
  • Maintain staffing levels in the Neonatal Unit according to nationally recognised guidance.
  • Implement policies and procedures relating to transition, to ensure there are trust-wide policies and procedures for staff to refer to when dealing with young people that are; or, should be considered for transitional pathways.
  • Ensure that work undertaken in the learning disabilities steering group and the transition steering group are linked so that information is shared and used to benefit both of these vulnerable groups of children and young people.
  • Continue to develop relationships with adult health and social care providers to ensure the safe and effective transition of care for young people.
  • Ensure that appropriate systems are in place for patients or those close to them to raise an alarm if they require assistance whilst in outpatient changing areas.
  • Undertake a review of staffing within each area of the outpatients department to ensure that there is an appropriate system in place to determine staffing requirements.
  • Improve communication with people for whom English is not their first language.

Child and Adolescent Mental Health Services (CAMHS) – Community

The trust must:

  • Take action to improve the overall waiting time from referral to assessment to intervention and to ensure that there are effective systems in place to monitor the risk of people waiting to be seen.

The trust should:

  • Ensure that risk assessments are correctly recorded on the patient record system.
  • Ensure that there is an effective system in place to keep staff safe when visiting people in the community.
  • Ensure that there are suitable alarm systems in place in community offices where people are seen.
  • Ensure that staff are receiving mandatory training.
  • Ensure that staff know what action to take in case of fire.
  • Ensure that there is an effective system in place to monitor the safe storage and use of FP10 prescription pads.

Child and Adolescent Mental Health Services (CAMHS) – Inpatient

The trust should:

  • Ensure adequate medicines management oversight, and improve day to day medicines management practices, for example, recording dates of opening of medicines.
  • Ensure that a patient’s medication is verified by a pharmacist or pharmacist technician upon admission.
  • Ensure that medicines management practices are audited frequently in line with good practice.
  • Ensure full compliance with the Mental Health Act and Code of Practice including records management, treatment certificates, consideration of, and decisions around consent to treatment, and good and timely access to mental health act support.
  • Consider improving the identification of key information in care records such as whether the child is on the child protection register or whether the child is looked after.

Professor Sir Mike Richards

Chief Inspector of Hospitals

15 and 16 June 2015

During an inspection of Child and adolescent mental health wards

We gave an overall rating for child and adolescent mental health inpatient wards of good because:

  • The ward and facilities were safe, clean and adequately maintained. Ligature points were managed adequately. Staff observed blind spots at all times.
  • Multi-disciplinary team meetings were highly effective and included representation from a wide range of disciplines.
  • There was a holistic approach to assessing, planning and delivering care and treatment to patients, which commenced prior to admission. The unit’s pre-admission process included comprehensive assessments and structured education, therapy and activity plans.
  • There was a team around the child approach with the patient being at the centre of the assessment, care planning and recovery process. There was a strong, visible person-centred culture. Staff were highly motivated and provided care that promoted people’s dignity.
  • There were effective staff training, supervision and appraisal structures in place to support staff at all levels. Staff were fully aware of their own service’s objectives but felt disconnected from the main trust.

Although the facilities promoted recovery, comfort and dignity, there was insufficient outdoor space on the site for activities such as ball games and physical exercise. There were some poor medicines management practices and no pharmacy service provided to the unit.

15 & 16 June 2015

During an inspection of Specialist community mental health services for children and young people

  • We rated specialist community mental health services for children and young people as requires improvement because:
  • There were waiting times for non urgent referrals with a small number of young  people waiting up to 21 weeks to be seen for a 'Choice' appointment which is a combination of assessment and treatment. Nationally, this placed the service at 22 out of 47 trust providing this service.
  • There was a lack of effective system to monitor people who were waiting to access the service.
  • There were a large number of vacancies which the trust were struggling to recruit into.
  • Mandatory training rates were below 75% for a number of subjects including fire training and safeguarding level 3 training.
  • Staff were not always protected from risks with a lack of alarms in offices and for community visits.
  • Environmental and fire risks were not being effectively addressed at Seymour House.
  • Patient records were regularly not available at Seymour House due to connectivity issues.

Staff had the skills to carry out their roles within the trust. There were comprehensive assessments of needs. Care was delivered in line with best practice and outcome measures were used. Staff training, supervision and appraisal structures were set up to support staff at all levels.

21-22 May 2014

During a routine inspection

The Care Quality Commission (CQC) carried out this comprehensive inspection because the Alder Hey Children’s NHS Foundation Trust had been flagged as a potential risk on the CQC’s intelligent monitoring system (which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations). Alder Hey Hospital has been inspected three times since its registration with CQC. The most recent inspection took place in December 2013. This was a responsive inspection focusing on the operating theatres as we had been made aware of concerns in this area. The inspection found that trust was not meeting the following essential standards:

  • Care and welfare of people who use services
  • Staffing
  • Supporting workers
  • Assessing and monitoring the quality of service provision.

The inspection took place between 20 and 22 May 2014, and an unannounced visit took place between 6am and 11am on Sunday 1 June 2014.

We followed up the outstanding compliance issues as part of this inspection.

Overall, this trust required improvement, although we rated it ‘good’ in terms of having effective and caring services.

Our key findings were as follows:

Nurse staffing

Nursing staff were caring and compassionate and treated children and young people with dignity and respect.

Staff were highly committed to giving children and young people a high standard of care and treatment. Nurse staffing levels on most wards within the medical division were calculated using a recognised dependency tool. However, some services had nursing vacancies. While the trust was actively recruiting to these vacancies, some areas did not provide the minimum staffing levels required, mainly at night. The trust had a system for escalating staffing shortages; however, requests for additional bank (overtime) or agency staff were not always filled, or were filled with staff that did not have the necessary expertise in a particular specialist area.  When possible beds were closed to maintain safe staff to patient ratios, however, this was not always achievable in cases of unplanned absence and meant that there were times when wards were short staffed. This was a particular concern in the medical and surgical wards. The trust had already addressed the shortfall in the accident and emergency (A&E) department by providing an additional nurse for the night shift seven days per week.

Medical staffing

The hospital was staffed by highly skilled, competent and well-supervised doctors. Medical staff were universally committed to the care and treatment of children and young people. Consultants were present or accessible 24 hours a day and carried out daily ward rounds. Middle grade and junior doctors were on site 24 hours a day. However, the model of care in the high dependency unit (HDU) meant that there were clinical risks associated with a lack of overall medical leadership, clinical accountability and timely clinical decision making. The trust was aware of the risks associated with the HDU and had developed some solutions for the short and medium term, prior to the planned move to the new hospital. However, we were not assured that the arrangements were always promoting the safety of children and young people on the unit and we requested that immediate remedial action be taken by the trust to mitigate the risks. On the unannounced visit, it was clear that immediate steps had been taken to improve the level of medical support on the HDU and an intensive care consultant had been allocated to the unit for 50% of their working time.

Patient mortality

The trust had a well-established mortality review process. The aims were for departments and services to undertake a mortality review within two months of the patient’s death with a further review by the Hospital Mortality Review Group within four months to check the findings. The review did not always occur within the four-month timescale, largely due to clinical workloads. There were minimal variances in the findings. Both reviews identify any elements of the patient journey where harm and/or death was avoidable. Root cause analysis investigations are completed where this can add additional learning and action plans are generated and implemented.

Infection control

The hospital was clean throughout and there was good practice in the control and prevention of infection.

There had been positive changes made in the neonatal surgical unit (NSU) following an infection outbreak in 2013.

Staff applied good practice guidance, supported by training and dedicated staff for control of infection.

Some infection risks were related to the age and fabric relating to the 100-year-old hospital building. However, the trust was responding well to the challenge and managing the physical environment well until the planned move to a new hospital in 2015.

The hospital infection rates for Clostridium difficile (C.difficile) and MRSA infections were within an acceptable range for a hospital of this size.

Nutrition and hydration

There was a range of specialist support to ensure that children and young people’s nutritional needs were met. Dietary and nutritional requirements were considered as part of the care planning process. Specialist support was available for a range of conditions, including children who had diabetes and coeliac disease.

The oncology unit had a designated chef onsite to support young people’s nutritional needs.

On the NSU a dietician visited and reviewed all babies on a daily basis.

A new initiative on the NSU was ‘Promoting transition to breastfeeding’, a pathway for promoting breastfeeding and the health benefits for babies.

Fluid charts were completed, and recorded inputs and outputs. If babies were having total parenteral nutrition (nutrition administered intravenously) their daily weight was monitored to ensure that their nutritional and hydration needs were met.

Children and young people were complimentary overall about the food provided.

Improvements were required to ensure that food and drink was more readily available in the A&E department. There was a vending machine available for drinks and snacks, with a wider choice of food available in the canteen, however, children and young people (and their parents and carers) were reluctant to leave the department in case they missed their ‘turn’. Staff told us that they would provide a drink and toast to children and young people who had been waiting in the department for a long time if asked.

Nevertheless, there was no formal system to ensure that nutritional and hydration needs were met for children and their families waiting for long periods in the A&E department.

Medicines management

The trust had medicines governance and incident reporting structures. The policies and procedures for medicines handling were robust and the relevant guidelines were followed.

The pharmacy department provided a good service to most of the wards in the hospital but, due to staff shortages, could only provide a partial service to some wards. The staff shortages impacted on the ability of pharmacists to complete medicines reconciliation for each patient within the first 24 hours of their admission (recommended to reduce preventable medication errors).

Nurses and parents said there were no delays in children being discharged home as there was an effective system for ensuring that discharge medication was available in a timely manner. However, we observed that there were often delays with people being attended to by pharmacy staff when they had an outpatient’s prescription to be dispensed.

Pharmacy staff undertook training and competency assessments prior to visiting wards to ensure their practice was safe.

A review of the drug charts on the wards showed that nurses were not following the trust’s policy regarding the safe administration of medicines, which stated that two nurses must prepare and administer medicines to each child.

We found on two wards that nurses were not completing the records about the administration of medicines in line with NMC guidelines because they did not make an immediate record of the medicines administered. We saw that, on one of the wards, all medicines were signed for before any medication was given, and nurses told us this was usual practice.

Medicines were stored on the wards in lockable cupboards and fridges in dedicated clinical rooms. Entry to the rooms was by means of keypads. On a number of wards, we found that the fridges were unlocked. Nurses told us the key codes were not changed regularly, and we observed on one ward that people who were not authorised to have access to the room had access to the key code. This could allow unauthorised access which may lead to drug tampering.

Some medicines were not administered in accordance with safe medicine practice and there were no robust systems to ensure best practice.  Interventions by pharmacists to improve patient safety were not reported as incidents and, unless they were deemed to be significant, no notes were made to support learning. We saw examples where had the Pharmacist not intervened then it would have resulted in an error. We saw that the pharmacist did not record the errors in patients’ notes or in any communications with the ward staff or managers or doctors. Nurses told us that no discussions took place about errors that Pharmacists found on the patient’s drug charts and that doctors were not formally informed of the changes made.

There was an incident reporting system in the trust and staff said they understood how and when to make reports. However, information received from the trust, together with our findings showed that incidents were under-reported, limiting the opportunity for learning and reducing the risk of harm.

We spoke with patients and their parents who all told us they were happy with the levels of information they had about their medicines and felt they understood what medicines were prescribed for and how to take them. However, only one parent told us that the side effects of the medication had been explained.

Safeguarding

Staff had a good knowledge and understanding of safeguarding procedures and knew how to contact the hospital safeguarding team, should this be necessary.

The electronic system within the hospital identified children and young people with a child protection plan.

Training records indicated that only 61% of staff across all divisions in the trust had received level 1 (the lowest level) safeguarding training or a safeguarding update within the last year. There were initiatives in place to increase the level 1 safeguarding training, including increased use of e-learning and workbooks. This work should continue as a matter of priority so that all staff have received current training in identifying issues of abuse and neglect and are able to escalate their concerns appropriately.

Meeting the needs of young people

Managers and frontline staff were not aware of the Department of Health’s 2011 standard ‘You’re Welcome’ quality criteria for young people friendly health services. We were advised that the You’re Welcome accreditation will be through the Healthy Liverpool Integrated Care Delivery (Children) programme.

New hospital plans identified a 75% single-room occupancy per ward with pull-out beds for families. The plans showed designated lounge areas for young people within ward settings.

Young people’s groups had been actively involved in decision making on the future of the trust. Examples of these were the Children and Young People’s Forum, medicines group and new hospital build group.

As part of the new tender process, young people were invited to influence the decision of the final choice of hospital design.

We found excellent examples of evidence that young people were involved in the new build, which included choice of fabric and furnishings and challenging the choice of IT services.

The trust had a wide range of activities aimed at young people – for example, music, performing arts, and photography.

We identified that there was no trust lead to support young people with learning disabilities. We spoke with staff that were unclear on who coordinated services for young people with learning disabilities.

Young patient experience data was collected at the trust and reported to the board. This information demonstrated that children and young were happy with how they were treated by staff and included in decision making about their care. They also reported that they were less happy with information they received when they were discharged from hospital

Mandatory training

The trust has set itself a target of 90% compliance with all mandatory training. This has not been met in any identified mandatory training area. The highest rate of completion was fraud, complaints, infection control (non-clinical), health & safety and manual handling – all of which were 80% or above. Compliance below 80% was: fire – 70%; equality & diversity – 62%; information governance – 58%; infection control (non-clinical, clinical areas) – 69%; infection control (clinical) – 79%; resuscitation – 41%; practical manual handling – 30%; major incidents – 66%; conflict resolution – 41%; medicines management – 43%; transfusion e-learning – 69%.

Work to increase the levels of mandatory training should be a priority for the trust so that it can be assured that staff maintain their competency in these key areas.

We also found

  • National guidelines were used to treat children and young people and care pathways reflected national guidelines. Standards were monitored and outcomes were good when compared with other children’s hospitals.
  • The trust had a well-established mortality review process.
  • In the surgical service, the recovery rates for children and young people were favourable when compared to similar hospitals.
  • In the medical wards, care was planned and delivered in a way that took children and young people’s wishes into account.
  • Access to advice and information was good for children and young people, their families and carers, both during the hospital stay and after discharge.
  • Some children and young people were concerned that they had to wait for long periods of time in the A&E department and did not always realise that they had been admitted to the observation unit.
  • In the paediatric intensive care unit there was evidence of strong medical and nursing leadership.
  • Strong professional nurse leadership on the HDU.
  • The specialist palliative care team provided a safe, effective and responsive service to children and young people with life-limiting illness. Children and young people were appropriately referred and assessed by the specialist palliative care team.
  • A bereavement service supported families’ emotional needs at the end of life and afterwards.
  • Counselling support was available through the Alder Centre.
  • In transitional services, we found examples of excellent pathways for young people transitioning to adult services with specific long-term health needs. However, we found that there was no overall responsibility or leadership for transitional services within the trust.
  • In the outpatients department, there were concerns regarding long waiting times and the availability of case notes and records.

We saw several areas of good practice, including:

  • The medical division participated in research at local, national and international levels. The trust is the first Investing in Children accredited hospital in the UK.
  • Alder Hey Children’s Hospital has a gait laboratory to assess walking for children with neuromuscular disorders, such as cerebral palsy, which is not available elsewhere in North West England. The service therefore receives referrals from all over the North West.
  • Trust physiotherapists have linked with the community physiotherapists to provide appropriate postoperative care and a trust audit demonstrated that this has translated into improved outcomes for children and young people.
  • The surgical department received a significant research grant to coordinate a national trial aimed at reducing the rate of infection following shunt operations for children with hydrocephalus (build-up of fluid on the brain). The results of this project will be used to produce good practice guidance to improve the care and treatment for children nationally and internationally.
  • When babies were admitted to the NSU, parents were taught correct hand-washing techniques.  The unit was developing infection control safety cards for parents.

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

Importantly, the trust must:

  • Continue to address staffing shortfalls. Nurse staffing levels must also be appropriate in all areas, without substantive staff feeling obligated to work excessive hours or additional shifts.
  • Provide a longer-term solution for the medical leadership on the HDU.
  • Ensure that children and young people who require one-to-one support in the isolation pods on the HDU receive it.
  • Take action to ensure there are sufficient levels of nursing staff across the HDU.
  •  Continue to take action to ensure that clinical records are available in the outpatients department.
  • Take action to ensure that nurses are following the trust’s policy regarding the safe administration of medicines.
  • Review the resuscitation equipment on each surgical ward to ensure that this meets the minimum equipment and drugs required for paediatric cardio-pulmonary resuscitation as outlined in the Resuscitation Council (UK) 2013 guidance.
  • Address the shortfalls in governance and risk management systems.
  • Improve the timely completion of investigation of incidents and Never Events (serious harm that is largely preventable) so that learning can be systematically applied to avoid recurrence.

In addition the trust should:

  • Review its pharmacy arrangements to improve support to wards out of hours and at weekends.
  • Ensure that the A&E department clarifies its use of the observation ward as a CDU and make it clear to children and young people and their parents when they have been transferred to the CDU rather than being in A&E.
  • Ensure that the A&E department reviews its arrangements for providing food and drinks in the waiting areas, and make it clear that hot and cold drinks and food are available on request.
  • Ensure that children, young people and their parents using A&E services are aware of the trust’s complaints procedure and are supported in using it where necessary.
  • Review the provision of isolation cubicles within the hospital to isolate children and young people who may represent an infection risk to others.
  • Consider changing open storage units to closed ones in the surgical wards to reduce the risk of cross-infection, especially in areas where clinical procedures take place, such as the treatment rooms.
  • Consider removing the bin in the children’s play area on Ward K3.
  • Consider reviewing the risk assessment for the fire escapes in the surgical wards to make sure they are secure enough to prevent children and young people leaving unnoticed and protect against people entering unobserved.
  • Consider the provision of a dedicated health play specialist and psychology resource to the critical care areas.
  • Ensure that the arrangements stated in the board papers received by the inspection chair on 22 May 2014 concerning the medical cover in HDU are monitored.
  • Ensure that staff report incidents on the NSU.
  • Ensure that staff effectively check and sign resuscitation equipment on the NSU.
  • Ensure that drug charts are appropriately completed on the NSU.
  • Review the learning disability service provision to ascertain roles and responsibilities of both nurses and doctors for adolescents and young people in transition.
  • Consider the Trust’s overall strategy, board reporting mechanisms and leadership responsibilities related to transitional care.
  • Take action to implement risk assessments in the outpatients department. The risk assessments would ensure the safety of children, young people, relatives and staff within the department.
  • Ensure staff in the outpatients department have the opportunity to receive clinical supervision via a Trust wide model.
  • Improve systems to ensure children and young people and their relatives and carers can make appointments in the outpatients department.
  • Ensure letters sent to children and young people and their parents and carers are in the appropriate community language for those people who do not speak English as a first language.
  • Ensure that staff in the outpatients department are effectively engaged in the development of the service.
  • Improve staff engagement across all services and improve the visibility of the board and senior team.
  • Improve the communication with staff to demonstrate a listening and responsive senior team.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.