The Care Quality Commission
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Liverpool University Hospitals NHS Foundation Trust Also known as Aintree University Hospital NHS Foundation Trust - formerly

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

Overall: Requires improvement read more about inspection ratings

All Inspections

29 June to 26 July 2021

During a routine inspection

Liverpool University Hospitals NHS Foundation Trust was formerly called Aintree University Hospital NHS Foundation Trust. It changed its name on 1 October 2019 when it acquired Royal Liverpool and Broadgreen Hospitals NHS Trust.

The trust has four hospitals – University Hospital Aintree, Royal Liverpool University Hospital, Liverpool University Dental Hospital and Broadgreen Hospital – which provide a full range of acute services, including acute medicine, urgent and emergency care, acute frailty units, rehabilitation services, dental services and surgical services, to a population of approximately 630,000 people.

When a trust acquires another trust in order to improve the quality and safety of care we do not aggregate ratings from the previously separate trust at trust level for up to two years.

The ratings for the trust in this report are therefore based only on the ratings for University Hospital Aintree and our rating of leadership at the trust level.

Our normal practice following an acquisition would be to inspect all services run by the enlarged trust. However, our usual inspection work has been curtailed by the COVID-19 pandemic.

At Royal Liverpool University Hospital we inspected only those services where we were aware of current risks. We did not rate the hospital overall.

In our ratings tables starting on page 30 we show all ratings for services run by the trust, including those from earlier inspections and from those hospitals we did not inspect this time.

We carried out an unannounced inspection of Urgent and Emergency Services, Surgery, and Medical care at University Hospital Aintree and Royal Liverpool University Hospital because of continuing concerns about the quality and safety of some services.

We also inspected the well-led key question for the trust overall.

Overall, we rated the trust as requires improvement.

Following this inspection, due to the concerns we had identified in Urgent and Emergency Services at University Hospital Aintree and Royal Liverpool University Hospital, and Medical Care at University Hospital Aintree, we wrote to the trust under Section 31 of the Health and Social Care Act 2008, in a Letter of Intent to take urgent action. Following this we received limited assurance and therefore issued urgent conditions requiring the trust to take urgent action.

Safe

  • Mandatory training compliance was low for medical staff in urgent and emergency services
  • Patients in emergency departments did not always receive appropriate care and treatment in a timely way, exposing them to the risk of harm.
  • There were not always sufficient medical and nursing staff with the right qualifications, skills, training and experience to keep patients safe in emergency departments and medical wards.
  • Staff did not always have the correct level of training on how to recognise and report abuse and not all staff at the trust had completed safeguarding children level three training.
  • Staff did not always adhere to trust and national infection prevention and control guidance in urgent and emergency and medical care services at Royal Liverpool University Hospital.
  • The service did not always use systems and processes to safely prescribe, administer, record and store medicines in line with requirements.
  • Staff did not always recognise and report incidents and near misses in the emergency department at Royal Liverpool University Hospital, and medical care and surgery at University Hospital Aintree. Services did not always manage patient safety incidents well and did not always share lessons learned with the whole team.

However:

  • In surgery there was enough staff to care for patients and keep them safe. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well.
  • The emergency department at Royal Liverpool University Hospital was well designed in the major’s area with individual rooms with glass sliding doors.

Effective

  • Staff did not always provide care and treatment based on national guidance and evidence-based practice and in urgent and emergency departments and medical care fluid documentation was not always accurate and complete.
  • Staff did not always assess and monitor patients regularly to see if they were in pain and gave pain relief in a timely way.
  • Services did not always make sure staff were competent for their roles.
  • Key services in medical care were not available seven days a week.

However:

  • Staff provided good care and treatment, gave patients enough to eat and drink. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.

Caring

  • The trust did not always maintain patients’ privacy and dignity, specifically when needing to be cared for in a corridor in the urgent and emergency department.

However:

  • Staff treated patients with compassion and kindness and took account of their individual needs and helped them understand their conditions. They provided emotional support to patients, families and carers.

Responsive

  • The trust did not always manage the access and flow of patients, in the urgent and emergency care department and in medical care services; with patients spending long periods waiting for an in-patient bed.
  • Surgery services performed worse than the national average for the percentage of cancer patients treated within 62 days. The average length of patient stay was worse than the national average.
  • Provision for patients who had a diagnosis of dementia was not well developed and there was variation in appropriate care to meet individual needs for these patients.

However:

  • The trust planned care to meet the needs of local people and made it easy for people to give feedback.

Well-led

  • Although the trust had an overall vision and strategies, the trust strategy was due to launch and was not yet embedded. Not all services had their own vision and strategy.
  • Staff were supported by local leadership, but some did not always feel respected, supported and valued. Senior managers were not always visible in services.
  • Trust governance processes were not robust or always effective. Risks were not always identified correctly with appropriate mitigations put in place.
  • However:
  • Staff were focused on the needs of patients receiving care. Most staff were clear about their roles and accountabilities. The trust engaged with patients and the community to plan and manage services and all staff were committed to improving services continually.
  • The trust had been a lead participant in several COVID-19 research programmes.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection

8 to 17 Sept 2020

During an inspection looking at part of the service

Liverpool University Hospitals NHS Foundation Trust came into operation on 01 October 2019. The trust has four hospitals – Aintree University Hospital, Royal Liverpool Hospital, Liverpool Dental Hospital and Broadgreen Hospital – which provide a full range of acute services, including acute medicine, accident and emergency, acute frailty units, rehabilitation services, dental services and surgical services, to a population of approximately 630,000 people.

We carried out a short notice announced focused inspection of elements of the safe and well-led domains in urgent and emergency care services, surgical services and medical care services, on both the Royal Liverpool Hospital and Aintree University Hospital sites. We did not rate the core services because this was a focused, short notice inspection in response to specific areas of concern.

We inspected safety and governance processes in urgent and emergency care, surgery and medical care services. We also looked at the wider oversight and management of risk, governance and safety of patients across the trust.

During our inspection, we found significant concerns relating to the management of medicines. We put our concerns formally in writing to the trust and asked for urgent action to mitigate the risks to patients. The trust provided a detailed response including improvement actions already taken or planned, all actions were due for completion by November 2020. This provided assurance that sufficient action had been taken to mitigate any immediate risks to patient safety. We will continue to monitor this information through our routine engagement with the trust.

We found:

  • The leadership, governance and culture did not always support the delivery of high-quality person-centred care.
  • The statement of its vision and guiding values was incomplete and had not been developed into deliverable strategies.
  • The trust’s strategic approach was underdeveloped and did not fully reflect the health economy in which the service operated.
  • The governance arrangements and their purpose were unclear, and there was a lack of clarity and maturity regarding the implementation of the trusts board assurance framework.
  • The arrangements for governance and performance management were not always clear and did not operate effectively.
  • Risks, issues and poor performance were not always known or escalated appropriately, and actions lacked pace and urgency to address the concerns.
  • The trust had inconsistent systems to ensure staff knew about safety alerts and incidents across the locations we inspected. We found an issue where there had been insufficient action to mitigate risks.
  • Following the inspection, the trust acted to make improvements and had implemented a new trust-wide safety bulletin.
  • We found a lack of clarity and proactivity regarding discharge planning, we raised this at the time of inspection and were given assurances from senior leaders that this would be addressed as part of the trust’s winter planning.
  • There was limited evidence of learning and reflective practice among leaders.
  • There were limited processes to review key items such as the strategy, training objectives, implementation plans or the governance framework.
  • Clinical engagement was variable. Medical staff reported that channels of communication were not always effective and appeared to be blocked at middle manager level.
  • The pharmacy department and responsibilities for medicines management and governance sat within the clinical support division. Trust reconfiguration had initially resulted in limited representation from the pharmacy team at trust board level.

However:

  • There was a varied mix of skills and experience across the non-executive directors and a considered approach to the skill set requirements when new non-executive directors were recruited.
  • Staff and leaders recognised the workforce as being loyal to the city, local community, and the trust. Leaders also recognised that staff were hard working and committed to providing high quality patient care.
  • The trust had recently undertaken a series of quality improvement idea sessions with staff from different service areas in the trust.
  • During the first wave of the pandemic, the trust had implemented a number of initiatives to support employee wellbeing, including free accommodation to keep staff and their families safe, provision of free food and car parking, and a ‘Support Our Staff’ appeal that had raised £500,000, which was being used to support improvements for staff break areas.

14 May to 20 Jun 2019

During a routine inspection

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

We rated the trust as requires improvement for safe, and effective, caring, responsive and well led as good.

We rated well-led at the trust level as good.

We rated the hospital as requires improvement for safe and well led. We rated effective, caring and responsive as good. We rated two of the trust’s services at this inspection. In rating the trust, we took into account the current ratings of the services not inspected this time.

The trust was rated as requires improvement for Use of resources.

Our decisions on overall ratings take into account, for example, the relative size of services and

we use our professional judgement to reach a fair and balanced rating.

Our full Inspection report summarising what we found and the supporting evidence appendix containing detailed evidence and data about the trust is available on our website – .

16 January 2018

During an inspection looking at part of the service

Our rating of the trust stayed the same. We rated it as requires improvement .

We did not rate the trust following this inspection as it was a focused inspection and only looked at certain aspects of the effective and well led domain in medical care services. Therefore the inspection had no impact on the previous ratings or overall findings for the trust.

We found:

  • There had been improvements in the identification and assessment of those persons who lacked capacity to consent to their care and treatment.

However:

  • There were still areas that required further improvement. We found that the trust was not fully compliant with the requirements in the enforcement action we took. We have taken further action to ensure that the provider is complaint with the relevant regulation. We will regularly monitor the trust with any actions they put in place to ensure they are fully implemented.

To see information from our earlier inspection of this trust please see our previous report (7 March 2018).

6 March 2014

During a routine inspection

Aintree University Hospital NHS Foundation Trust is a large teaching hospital in Liverpool with 706 inpatient beds, serving a population of around 330,000 in North Liverpool, South Sefton and Kirkby. The trust provides services to some of the most deprived areas in England

The trust is one of the largest employers locally with more than 4,000 whole time equivalent staff. The trust gained foundation trust status in 2006 (one of the first trusts in Merseyside to do so) and has more than 13,000 public and staff foundation trust members.

Currently, the trust has one location, Aintree University Hospital, actively registered with the Care Quality Commission. The hospital provides general acute services and also works with partners to provide a range of services in community settings including rheumatology, ophthalmology and alcohol services. Other tertiary services provided by the trust include respiratory medicine, rheumatology, maxillofacial and liver surgery.

The hospital is well supported by the local community and has over 800 volunteers. The Volunteer Department provides a well-respected service with local and national recognition, particularly for its positive contribution to the patient journey and development opportunities for the local population.

All the patients we spoke with were positive about their care and treatment at the hospital. Patients felt that they were well cared for and staff treated them with dignity and respect. However, there were three questions in the A&E Patient Survey 2012 where the results were worse than expected: they concerned length of time patients waited in A&E, waiting to be examined by a nurse or doctor and information concerning how long the patient would have to wait to be examined.

There were effective systems in place to prevent patients suffering pressure ulcers, falls, blood clots and hospital acquired infections.

Staff were trained in identifying abuse and neglect and knew how to report concerns of this nature.

Operating theatre staff were undertaking the ‘five steps to safer surgery’ procedures, and used the World Health Organization (WHO) checklist. However, we found examples of the WHO safer surgery checklist not being completed appropriately in theatres and we have asked the trust to take action to correct this.

Staffing

All the wards and departments we inspected were adequately staffed, and staff had access to training and development opportunities to improve their knowledge and skills to develop professionally.

Staff were committed and enthusiastic about their work and worked hard to ensure that patients were given the best care and treatment possible. There were good examples of policy and practice being changed as a result of learning from patient experiences. Staff were well supported by their managers and felt confident in raising concerns with them.

There were a number of initiatives in place to engage staff in developing future plans for the hospital. The Chief Executive was highly visible and staff were encouraged to share their ideas and suggestions for improvement. Staff sickness rates were below the national average.

Cleanliness and infection control

The hospital was clean throughout and there was good practice in the control and prevention of infection. Practice in this area was supported by training and a trust-wide control of infection team. The hospital infection rates for C.difficile and MRSA infections lie within an acceptable range for a trust of this size

Medicines management

There were good systems in place to manage medicines and ensure that patients’ medicines were provided in a timely way.

Governance and risk management

On 29 September 2013, we carried out a scheduled unannounced inspection of the trust and we found that the trust had systems and processes in place for governance and risk management. However, the implementation and quality of the systems was variable. Risk management was a particularly poor area at all levels of the organisation, as was the timeliness to put in place risk reduction measures to prevent serious incidents reoccurring. We judged that this was a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and that this had a major impact on people who use the hospital. Consequently we served a notice warning the trust it must take action to secure improvement.

We followed up the warning notice and the actions the trust had taken as part of this inspection.

We found that the trust had made significant progress and met the requirements of the notice at the time of our inspection. We will continue to monitor the trust closely to ensure that the improvements are embedded and sustained.

However, there was still work for the trust to do to understand the discrepancy in its mortality data. We have told the trust that this must be addressed as a matter of priority

Prior to our inspection we were also aware of the concerns of Monitor (the foundation trust regulator). Monitor’s concerns about the trust’s C.difficile, MRSA, A&E four-hour waiting time and referral to treatment targets raised concerns about governance at the trust. We looked at these issues as part of our inspection found that the trust had improved its performance in these areas.

In addition, the NHS Staff Survey 2012 indicated that there were a number of concerns raised by staff, for example, staff witnessing potentially harmful errors, near miss incidents, and physical violence from patients/relative and staff, staff also experienced pressure to attend work when unwell, lack of appraisals, support from managers and lack of job satisfaction. We looked at these issues as part of our inspection and found that incident reporting had increased and the trust was responding to incidents in a more timely way. The trust was continuing its work to provide timely feedback to staff when incidents are reported.

The NHS staff survey for 2013 indicated that there had been a significant improvement in staff receiving

‘Support from immediate managers’ and the trusts performance is better than average compared to other acute trusts nationally.

The trust scored in the top 20% of acute trusts for the following two indicators:

  • Percentage of staff witnessing potentially harmful errors, near misses or incidents in last month.
  • Percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months

However, the trust scored in the bottom 20% of acute trusts for the following four indicators:

  • The percentage of staff appraised in the last 12 months
  • The percentage of staff having well-structured appraisals in the last 12 months
  • The percentage of staff receiving health and safety training in the last 12 months
  • The percentage of staff suffering work related stress in the last 12 months

The trust has acknowledged that it still has work to do in these key areas and has plans in place to improve its performance over the coming months.

Complaints management

When we carried out this inspection we worked with colleagues from the Patients Association and looked again at how complaints were managed in the trust as we had identified concerns about complaints management in our previous inspection in September. It was evident that considerable work has been carried out to date to make improvements and that more patients were now receiving timely and well considered responses to their complaints. However, this work needs to continue with pace and vigour so that the trust can be assured that complaints are managed effectively on a consistent basis.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

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.