Liverpool Women's NHS Foundation Trust

Liverpool Women’s NHS Foundation Trust provides a range of specialist services for women including inpatient and community maternity services that deliver approximately 8,000 babies a year, a neonatal service to support newborn babies needing specialist care, obstetrics, gynaecology, gynaecology oncology, termination of pregnancy and a unique emergency room for patients who have urgent gynaecological problems or for women with problems in early pregnancy (at fewer than 16 weeks). The trust is also a major obstetrics, gynaecology and neonatology research hospital, one of only two specialist trusts in the UK, and the largest women’s hospital of its kind in Europe.

Liverpool Women’s NHS Foundation Trust serves more than 30,000 patients from Liverpool, the surrounding areas and across the UK.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of the trust on 18 and 19 February 2015, and we undertook an unannounced inspection between 4pm and 7pm on 4 March 2015. As part of the unannounced visit, we looked at maternity and surgical services.

We rated Liverpool Women’s NHS Foundation Trust as good overall, although we found that the community midwifery service required improvement. The trust was developing plans to reconfigure and integrate the community service at the time of our inspection.

The trust had a vision ‘To be the recognised leader in healthcare for women, babies and their families’. This vision underpinned all the trust’s strategies and plans. The vision and values were well known throughout the organisation. The values were represented in all key documents and strategies as well as being embedded in the staff appraisal process. The trust had recently reviewed its quality strategy and the revised strategy had received board approval in February 2015. All agreed priorities had clear and measurable indicators for success that were subject to regular monitoring and review.

All staff were aware of the trust’s priorities and challenges, and understood the plans and actions needed to address them.

After our previous inspections in April and September 2014, the trust made significant improvements to its governance and risk management systems. Governance and risk management systems were more robust and provide good information and assurance in respect of performance and risks.

The senior team was visible and accessible to staff, and managers were seen by staff as supportive and approachable. There were some concerns about the leadership style on the labour ward that managers were committed to exploring and addressing.

Staff were committed and passionate about their work. They were keen to learn and continuously improve the services they offered to patients.

There was a positive and enthusiastic culture throughout the trust. Staff were proud of the services they offered and the work they did.

The trust was open about its financial challenges and was working with commissioners and other key stakeholders to seek solutions that would improve its financial position and secure the future sustainability of services.

Cleanliness and infection prevention and control

• Patients received care in a visibly clean and suitably maintained environment. There was a high standard of cleanliness throughout the trust. Staff were aware of current infection prevention and control guidelines. They were supported by staff training and the adequate provision of facilities and equipment to manage infection risks.
• There were good rates of compliance recorded in hygiene audits across all services provided by the trust.
• Infection rates were low, and staff were proactive and vigilant in the prevention and control of infection.

Incident reporting

• There were established systems for reporting incidents and ‘near misses’. Staff had received training and were confident in the use of the incident reporting system. The latest national reporting and learning system (NRLS) data (September 2014) stated that the organisation had a reporting rate of 68.48 per 1000 bed days, which was higher than the median of 35.92 for the cluster of acute specialist trusts. The trust were in the highest 25% of reporters. The trust was however slow to upload incidents to the NRLS system with 50% of incidents submitted more than 41 days after the incident had occurred.
• The reporting culture had improved from the previous reporting period. The trust had worked with its staff teams to address this issue and to encourage and support staff to report all incidents appropriately. Managers realised that a low patient safety incident reporting culture could hinder staff in identifying risks and the trust in taking action to prevent avoidable harm to patients.

Safeguarding

• The systems, policies and procedures for safeguarding children were robust, well understood and supported by staff training. All relevant staff had received child safeguarding training. There were good examples of staff acting promptly and appropriately to secure the safety and welfare of children.
• However, the trust had identified that adult safeguarding was less well developed. In response, a comprehensive staff training programme for the safeguarding of vulnerable adults had recently been introduced. Staff were developing their understanding, competency and knowledge in this area at the time of our inspection. Staff training figures indicated that, by March 2015, 95% of relevant staff would have received adult safeguarding training.
• Safeguarding practice was supported by a trust-wide safeguarding team that staff could access for advice and support. However, at the time of our inspection there appeared to be an over-reliance on these key individuals as opposed to sustainable systems and processes to safeguard adults. Also, we found some examples in the surgical service indicating that the approach to the safeguarding of adults needed further development.
• The trust acknowledged at board level that the adult safeguarding systems were not yet robust, and it increased the level of risk on the board assurance framework in relation to safeguarding in December 2014.
• The trust had developed comprehensive plans to address the identified gaps in training and practice.

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Nurse and Midwifery staffing

• Nurses and midwives were caring and compassionate. They treated patients and those close to them with dignity and respect, and they were committed to giving patients a high standard of care and treatment. Appropriate staffing levels were calculated using a recognised tool and regularly reviewed.

• Since our last inspection, there had been a significant increase in the numbers of nurses and midwives employed, and there were now sufficient numbers to meet the needs of patients in all the core services we inspected. There were plans to increase the number of neonatal nurses to meet the British Association of Perinatal Medicine (BAPM) standards. At the time of our inspection, staffing was sufficient to meet the needs of babies being cared for because current neonatal staff were working extra hours to fill gaps in the staffing rota.

• The neonatal service had introduced the Advanced Neonatal Nurse Practitioner (ANNP) role. The ANNPs were having a positive effect in supporting high-quality care for babies needing specialist neonatal support. However, it was acknowledged that more work was required to fully embed and integrate this key role within the service.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff. There were excellent examples of senior doctors providing strong leadership and being actively engaged in the design and development of services.

• There were sufficient numbers of consultants and middle grade doctors to provide good quality care and treatment for patients; however, in maternity – inpatient services, the consultant cover was only 77 hours, which was lower than the 98 hours minimum recommended by the Royal College of Obstetrics and Gynaecology for a unit this size. Junior medical staff were well supported and provided with excellent teaching and learning opportunities.

• The tier 1/middle-grade staffing levels were acceptable in terms of establishment but the neonatal unit often operated below the required level. In response to this, the service had introduced an ANNP role to help junior doctors working in the unit.

Mandatory training

• The trust had set targets of 95% and 90% for mandatory training and appraisals, respectively. These targets were not yet being achieved at the time of our inspection. The overall compliance figures reported to the trust board in January 2015 was 91% for mandatory training and 86% for appraisals. There were plans to increase completion rates by the end of the performance year.

Nutrition and hydration

• Patients’ religious and cultural needs were considered and food was provided in accordance with their requirements. Staff gave appropriate and discreet support to those patients who needed help with eating and drinking. Specialist dietary support was available to patients whose condition indicated or required a specialist diet.
• The trust had a team of midwives, support workers and infant feeding advisers who helped women to feed their babies. The maternity and neonatal teams were supported by Liverpool Babies & Mums Breastfeeding Information and Support (BAMBIS), a team of peer supporters who offered breastfeeding support and information to pregnant women, breastfeeding mothers and their families.

Outcomes and evidence-based care

• Care and treatment were delivered throughout the trust in accordance with evidence-based guidelines. The trust had a system for receiving, recording, assessing and monitoring compliance with guidance from the National Institute for Health and Care Excellence (NICE). Quarterly reports were provided for commissioners as part of the quality contract requirements, with internal mechanisms monitoring compliance at divisional and trust-wide levels. When guidance could not be implemented in full (for example, if other healthcare providers were involved as part of the patient pathway), this was risk assessed for inclusion on the risk register and in the monitoring reports.
• Maternity outcomes were monitored using a local maternity dashboard and Royal College of Obstetrics and Gynaecology indicators. These monitored key outcomes, such as methods of delivery, still-birth and neonatal death, epidural rates and the number of women receiving-one-to one care during labour. Clinical outcomes in Maternity services were comparable with or better than, those of similar services.

• In gynaecology services senior staff took part in national and local audits to ensure that they were providing care in line with recognised standards. These included the national menorrhagia audit and a local audit to investigate the recurrence rate of infections with Bartholin’s gland surgery. The results were comparable with other similar organisations.

• Surgical site infection rates were compared with a peer trust for the 12-month period up to December 2014; the trust was better than or equal to the peer trust on all but one type of infection.
• Care for end of life patients was based on the National Institute for Health and Care Excellence (NICE) guidance. The trust had reviewed its own processes in response to the national review of the Liverpool Care Pathway and produced end of life care guidance for staff
• The neonatal services used a combination of guidelines from National Institute for Health and Care Excellence (NICE), British Association of Perinatal Medicine (BAPM) and Royal Colleges’ to determine the care and treatment provided.

• The service benchmarked patient outcomes against similar units in the UK and the USA. Outcomes compared well with other neonatal services. There was also benchmarking against similar units for mortality and morbidity rates. There was evidence that mortality rates were within acceptable ranges and were continuing to decline. Infection rates had also declined and compared well to similar units.

Access to services

• The trust consistently met most of the access targets. These included referral to treatment times in all specialties, booking midwife visits before 12 weeks and foetal anomaly scans between 18 and 20 weeks, and the cancer targets of 31 and 62 days.
• The trust did not always achieve the 60 minute targets for treatment in its emergency gynaecology service; however, the trust consistently achieved the national 4 hourly access target for emergency departments. Managers were of the opinion that the target for all acute emergency departments was not necessarily the best measure for a specialist department of this nature.

Governance risk and management and quality measurement

• After our previous inspections in April and September 2014, the trust made significant improvements to its governance and risk management systems. The board assurance framework was now a live document that was well understood by the board. The framework was set out under the trust’s strategic aims, and had good risk descriptions with clear details of the risk, cause, effect and impact. There was good alignment with the risk register. In addition, controls were appropriate and there were good examples of assurance sources.
• The newly approved quality strategy detailed the quality governance arrangements for the trust and the new arrangements were being implemented at the time of our inspection. The trust had recently introduced a ‘patient experience senate’ as part of its quality governance arrangements, and it had plans to introduce senates for patient safety and clinical effectiveness. All committee activity related to quality governance ultimately reported to the governance and clinical assurance committee that in turn reported to the trust board. Attendance at some of the committees, such as the corporate risk committee, could have been improved: some members had only attended 4 of the past 9 committee meetings.

• The trust had been an outlier in for its data quality on a number of occasions (CQC ‘Intelligent Monitoring’ reports). A dedicated data quality committee was now in place to provide challenge and assurance in this regard. A ‘gatekeeping’ policy had been introduced for secondary uses (SUS) data to ensure that all data was validated before leaving the organisation. We were unable to ascertain the impact of this work at the time of our inspection; however, the trust was confident that data quality would improve as a result of the actions taken.

Innovation, improvement and sustainability

• The trust was a major obstetrics, gynaecology and neonatology research hospital and there was a wide range of ongoing research projects at the time of our inspection.
• There were examples of innovative and outstanding practice for example; the neonatal unit was the first unit in the country to put the HeRo System in practice. This was a monitoring system that monitored the variability in babies heartbeats that helped with the early diagnosis of infections and other complications.
• The trust acknowledged that it was not financially sustainable in its current structure. It was working with partners in ‘Healthy Liverpool’ (a system wide project with aims to provide a new health and social care system to transform the health of Liverpool citizens). to discuss proposals for the future and how service provision can be developed and sustained.

We saw several areas of outstanding practice including:

• The implementation of the HeRo system. The neonatal unit was the first in the country to put this system into practice.
• The neonatal unit’s benchmarking of its practice and outcomes against other units in the UK and the USA.

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

Importantly, the trust must:

• Improve the way in which medicines are managed and stored.
• Check the folder of medication data sheets in each room within the neonatal unit at more regular intervals; and confirm with a signature that they have been checked and are valid.
• Store the portable box containing emergency medicines in the high dependency unit securely.
• Provide appropriate neonatal resuscitation equipment in the maternity assessment unit.
• Provide effective controls to prevent the abduction of infants from the labour ward and the Catharine Medical Centre.
• Ensure that risks regarding the storage of formula milk are appropriately assessed, and effective controls implemented to manage those risks.
• Provide operating department practitioners or suitably qualified midwives in theatre recovery outside normal working hours.
• Ensure that the telephone triage line is staffed at all times.
• Ensure that, when restraint is necessary, it is undertaken in accordance with the relevant regulations and legislation.
• Ensure that paper medical records are of an adequate standard and provide accurate, up-to-date records of the consent, care and treatment provided.
• Ensure that all staff are able to safeguard adults appropriately.

In addition the trust should:

• Review the number of hours of consultant cover in maternity, which were lower than the recommended minimum from the Royal College of Obstetrics and Gynaecology for a unit this size.
• Ensure that issues identified during audits are addressed.
• Review the numbers of incidents reported in all services.
• Ensure that domestic violence referrals from the police are reviewed within agreed timescales.
• Review practice with regard to the artificial rupture of membranes during induction of labour.
• Improve the response rates for the NHS Friends and Family Test.
• Consider including emergency appointments in the induction suite diary.
• Ensure that there is an effective system in place for testing portable electrical appliances.
• Allocate a non-executive director with responsibility for termination of pregnancy services.
• Review the timing of resuscitation decisions so that discussions are initiated with patients at a time when they are well enough to fully consider their wishes.
• Initiate work on advanced care planning with patients at a time when they are well enough to fully consider their wishes.
• Monitor the quality of care planning on the wards against patients’ assessed needs.
• Provide dementia training for ward staff.
• Address the leadership issues and staff morale within the intrapartum areas.
• Address the role of the advanced neo-natal practitioners (ANNPs) so they are clear how it fits within the service and take steps to involve them in developments in the neonatal service.
• Consider the provision of newborn life support training for community midwives.
• Consider auditing the availability of patient records.

Professor Sir Mike Richards

Chief Inspector of Hospitals