Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust

Wrightington, Wigan and Leigh NHS Foundation Trust is a medium sized acute Trust providing district hospital services for a population of around 320,000 people in and around Wigan and Leigh and Specialist Orthopaedics Services to a wider regional, national and international population. The trust has 696 beds in total of which 646 are general and acute; 37 are maternity and there are 13critical care beds.

There were 4250 whole time equivalent (wte) staff overall with 447 (wte) being medical staff, 1210 (wte) being nursing staff and 2593 (wte) from other staff groups

We inspected the trust as part of the comprehensive inspection programme between 8 and 11 December 2015. We visited the Royal Albert Edward Infirmary, Leigh Infirmary, Wrightington Hospital, the Thomas Linaker Centre and Boston House.

We rated the trust overall as good and found there were areas of excellent practice.

Our key findings were as follows:

Leadership and Culture

The trust was led and managed by a stable and visible executive team. The team were well known to staff and were seen as accessible and approachable. The Chief Executive Officer (CEO) had been on secondment for 12 months and the Deputy CEO had covered in their absence. The CEO had very recently returned to the trust at the time of the inspection.

The trust had a well-developed approach to vision and strategy with clearly articulated aims and objectives. The trust’s vision, values and priorities were shared and understood by staff who were aware and positive about their role in achieving them.

There was a very positive attitude throughout the trust based on a culture of continuous improvement and striving for excellence. Staff felt supported, able suggest improvements and develop professionally. Staff were proud of their services and proud of the trust.

The trust had been nationally recognised for its staff engagement programme. The trust had won the HSJ awards for Provider Trust of the Year and Patient Safety (Quality Champions Programme) in December 2014. At WWL staff engagement was paramount and supported by the award winning ‘WWL Way’ programme that promoted ‘Happy Staff, Happy Patients’. As a result the trust was ranked as the second best Acute Trust in the NHS as a place to work.

Nurse staffing

Nurse staffing across the trust was in the main well managed and in most services there were sufficient numbers of suitably qualified staff to meet the needs of patients appropriately. However there were some areas where nurse staffing required improvement particularly in the paediatric services.

Our particular concerns related to the paediatric department where nurse staffing was not calculated using a recognised dependency tool and did not take in to account the ages of the children on the ward or the acuity in and use of, the High Dependency unit.

Nurses within the ward were highly committed and were covering shifts through the trust bank but this was having a significant effect on their ability to provide high quality, safe care.

Medical Staffing

Medical staffing was good across the trust with only a small number of vacancies and the trust were considering alternative ways to address this shortfall. The staff skill mix showed the proportion of consultants and junior grades was higher than the England average. There was a positive culture amongst all grades of medical staff who felt supported by managers and their seniors.

Training and competencies

Safeguarding, mental capacity act (2005) and deprivation of liberty safeguards were robust and supported by adequate uptake of subject specific training. The specific e-learning programme for MCA and DOLS was launched in September 2015 and had previously been included in mandatory safeguarding training (compliance was 96.3% at the time of the inspection). However, not all staff had completed the new e-learning programme at the time of our inspection, however, it was envisaged that all staff would have taken up the e-learning programme at the end of September 2016.

At the time of our inspection there were 5 ST doctors trained in APLS working within Paediatrics and at least 1 speciality doctor working in A&E who was trained in PLS. In addition there were 10 anaesthetists trained in APLS plus 3 Speciality Trainees in Royal Albert Edward Infirmary (RAEI) trained in PLS or APLS, however, a misinterpretation of the national guidance in relation to the requirement for at least one trained nurse per shift with this qualification had resulted in only one member of the paediatric nursing staff having the qualification. We raised this with the trust and immediate action was taken to mitigate associated risks and address the competency shortfall.

In addition, nursing staff on the paediatric ward were also not trained in the care required by children with tracheostomies. Again we raised this with the trust who planned action to address the shortfall.

Mortality and morbidity

The Trust’s SHMI was above expected range when deaths 30 days post discharge was included. Between April 2014 and March 2015 the SHMI score for Wrightington, Wigan and Leigh NHS Foundation Trust was 112.57. (Reported at 108.4 for October 13-September 14 in the August 2015 Trust Board Performance Report).

Incident reporting

The number of incidents reported by the trust was consistent with the England average for a trust of this size, indicating a healthy reporting culture. For the reporting period Apr 2014 to Sept 2014 the trust reported 35.11 incidents per 1000 bed days against a median of 35.1. For the reporting period Oct 2014 – Mar 2015 the Trust reported 41.3 incidents per 1000 bed days against a median of 35.34.

The Trust commissioned an external review that focussed on five of the incidents reported as Never Events since October 2012. The review concluded that three should be de-escalated to serious incidents and the remaining two events did not indicate any systematic concerns although recommendations for learning and improvement had been made as a result of the review.

Cleanliness and infection control

Patients received their care in a clean and suitably maintained environment. In the recent PLACE assessments the trust scored 100%, making the Trust’s hospitals the cleanest in the NHS for the second year running. Infection rates were within acceptable limits.

Nutrition and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team. There was a system in place that identified patients who needed assistance with eating and drinking. Support with eating and drinking was given to patients in a sensitive and discreet way.

Patient Outcomes

The trust participated in national audits and performed as expected or better in many areas including myocardial ischaemia national audit project; Bowel Cancer Audit (2014); Hip Fracture audit, National Paediatric Diabetes Audit and the ICNARC audit.

However, there were some areas for improvement including angiography, national neonatal audit and there was a mixed performance in the National Emergency Laparotomy audit. However, the stroke rating had improved to D.

Between January 2014 to December 2014, hospital episode statistics (HES) showed that the average length of stay for elective medicine at the hospital was 7.3 days, which was longer (worse) than the England average of 4.5 days. For non-elective medicine it was 5.4 days, which was shorter (better) than the England average of 6.8 days. However it should be noted that a large amount of the Trust’s elective medicine work is undertaken as day cases (96.1% at WWL compared with a national average of 91%). For January – December 2014, WWL ranked 20th out of 137 trusts for % age day case rates, however 122nd out of 137 Trusts for 0 Length of stay.

Access and flow

Patient access and flow across the trust was good overall, although the urgent care department failed to meet national targets for ambulance turnaround times of 30 minutes on around 40% of occasions in 2014, this rose to around 50% during 2015. Patient Referral to Treatment Times (RTT) were consistently above the national average with the trust performing in the top 10% nationally for RTT performance (October 2015).

However there had been a number of cancelled operations for which the patient had not received their operation within 28 days of the cancellation.

Bed occupancy rates had been lower than the England average however, the number of patients who were cared for on wards of a speciality different to that of the patient needs (Outliers) was significant and moves at night of patients receiving medical care were not uncommon.

Providing responsive services

Services were planned to meet the needs of the local population. The trust was part of the Greater Manchester health and social care devolution programme to provide a partnership approach to care and the healthier together programme. This was to reconfigure services across Greater Manchester into a small number of specialist centres to help meet the needs of patients. Adjustments for patients with specific needs were in place. Identification/ flagging systems were robust except in the case of patients with learning disabilities. Assessments were robust and there were staff with specialist roles to support these vulnerable patients. There were strong systems and processes for dealing with complaints and sharing learning.

Vision and Strategy

The trust had a mission statement, vision and values and behaviours which were known widely across the trust. These were supported by service level strategies although there was no strategy in the paediatric service. They had a new model of care with five key areas of focus which supported the trust being part of the Greater Manchester health and social care devolution programme to provide a partnership approach to care and the healthier together programme. The trust was recognised for its staff engagement programme. The trust had an ambitious culture driven by the trust vision to be in the top ten percent in all aspects of performance and care .This was supported by the executive team’s emphasis on an open and collaborative approach.

Fit and Proper Persons

There were formal procedures in place including a template to record compliance with the Fit and Proper Persons regulation. We reviewed the personnel records of 6 relevant staff and found they contained the relevant and appropriate information to meet the requirements.

We saw several areas of outstanding practice including:

• The A&E department is one of the top performing in the country, consistently achieving the national 95% standard. The Trust has been number one in Greater Manchester since April 2015 and is currently fourth in the country. The Ambulatory Assessment Area ensures patients receive timely assessment and aids patient flow throughout the hospital forming an integral part of the trusts approach to 7 Day Service initiative.

• The urgent care department used an electronic dashboard (A&E APP) that constantly monitored flow through the department. It used predictive information based upon seasonal variances and data from previous years to generate likely numbers of attendees. The system also used live data of ambulances on route to the department. Where demand was strong at particular times of the day the department was able to flexibly use staff from other areas to ensure response rates were maintained.Meetings were held several times per day to discuss flow throughout the hospital to avoid delays in patients moving through the system.

• The trust recognised that an important element of achieving high quality care was to ensure that the staff had the capacity and capability to deliver improvement. The trust had set up a ‘Quality Champion’ programme to support the delivery of service improvement and recognise the achievements of the staff.

• All Quality Champions who had completed the training programme and commenced an improvement project were awarded a bronze badge. Silver and gold badges were awarded to those Champions who sustained their improvements and disseminated them to other organisations. The department had a number of staff of various grades who were quality champions, and had identified staff who were about to start the programme.

• Within radiology there was effecting in-sourcing of staff to cover shortfalls.

• Staff were supported to undertake a counselling qualification in order to improve the staff support network.

• The use of the swan logo, symbolising dignity in death, included some outstanding practice. The swan logo identified patients at the end of life and bereaved families, enabling staff to treat them accordingly and the initiative included open visiting, relatives staying on the ward, free designated car parking, comfort packs and bereavement trays for relatives. These facilities and systems in place were intended to minimise stress for families staying with their relatives and allowed them to spend as much time as they wished together in their last days and hours.

• Access to support for relatives from a bereavement specialist nurse following the death of a loved one was particularly noteworthy. The specialist nurse would attend inquests or visit at home if required.

• Within Maternity, the development of the ‘sim man’ as part of the ‘skills and drills’ mandatory training was part of the poster presentation at a conference last year.

• The urology department aspired to offering one stop clinics for haematuria patients. These meant patients attending initial appointments could have biopsies done at the time of their initial consultation rather than having to return for a second appointment.
• A trust ‘pioneering staff engagement’ programme was in place across a multi-disciplinary team with a number of innovating programmes in progress. The service had received several awards over the past two years.
• The achievements of the breast team deserve particular recognition. The staff achieved screening targets above national average and managed a large catchment area of patients. The specialist nurses ensured a holistic patient approach and considered psychosocial aspects of women having breast surgery by offering a complete service. There is evidence of continuous learning and participation in audits.

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

Importantly, the trust must:

At Royal Albert Edward Infirmary

• The trust must ensure that there are sufficient numbers of staff who are trained to resuscitate children at all times in the emergency department.

• The trust must deploy sufficient staff with the appropriate skills on the medical wards.

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

• The service must ensure staffing levels in the paediatric service are maintained in accordance with National professional standards.

• The service must ensure that there is one nurse on duty on Rainbow ward trained in Advanced Paediatric Life Support each shift.

• The service must ensure that staff are trained and competent to deliver the care required by paediatric patients with a tracheostomy.

• The service must ensure that risk rating and escalation is robust to ensure mitigating actions are taken in a timely way.

• The service must ensure the paediatric ward manager has sufficient time to perform the managerial tasks associated with the role.

• The service must ensure the senior leaders of the paediatric service are cited on the risks and actions being taken.

At Leigh Infirmary

• Ensure safeguarding, mental capacity act (2005) and deprivation of liberty safeguards are in place and followed to ensure patients safety at all times. Processes must be clearly defined, understood and followed by staff.
• Ensure that there is adequate space on the wards for patients to receive safe and effective care.
• Ensure that there are adequate facilities to store clinical waste safely.
• Ensure care is delivered as per evidence based guidance

Professor Sir Mike RichardsChief Inspector of Hospitals