Arrowe Park Hospital is an acute hospital that is part of a number of services operated by Wirral University Teaching Hospital NHS Trust. The hospital serves a local population of around 330,000. From November 2017 to October 2018 the emergency department saw 96,668 attendances, of which 20,884 were children. Total attendances had decreased by 3% from the previous year. During this period 33% of patients arrived by ambulance and the admission rate was 29%, which was a decrease of 3% from the previous year. In October 2018, no patients left the department without being seen and 6% of patients reattended within seven days of discharge.

This was an unannounced, focused inspection to review the safety of the emergency department as part of a focussed winter inspection programme. It took place between 1pm and 9pm on Monday 4 March 2019.

We did not inspect the whole core service therefore there are no ratings associated with this inspection. Our key findings were:

Our key findings were

• The emergency department (ED) was not always responsive to patients who presented with a high level of risk and we saw delays to assessment sometimes resulted in clinical deterioration.
• Staffing levels of paediatric-trained nurses overnight did not meet the minimum standards recommended by the Royal College of Paediatrics and Child Health (RCPCH).
• There were significant delays in most aspects of the service, including triage delays of over two hours and delays in awaiting specialist review of over 14 hours.
• Flow from the ED to the rest of the hospital did not meet demand and there was limited input from acute medical physicians. This reflected a culture in which not all specialty teams worked well together for the improvement of patient experience.
• Patients were regularly accommodated in corridors for extensive periods. This included elderly patients, those living with dementia and patients with mental health needs. Staff did not have the resources or facilities to deliver care with privacy and dignity.
• Overnight medical cover was often restricted to one doctor with higher specialist training at grade ST4 (specialist trainee) with one doctor at basic specialty trainee level (ST3). The service relied substantially on locum doctors, who formed 40% of the establishment. Staff said it applied substantial stress to the team.
• The ambulatory care unit was operating significantly above the capacity at which staff could effectively deliver safe care and delays in medical reviews exceeded six hours during our inspection.
• There were gaps in fire safety practice and training. We observed multiple examples of obstructed escape routes and partially blocked fire exits. Staff demonstrated highly variable knowledge of emergency procedures and described standards of training as poor.
• There was variable compliance with the Control of Substances Hazardous to Health (COSHH) Regulations (2002) and chemicals were not always stored safely and securely.
• Access to clinical areas was not controlled, including to the paediatric ED. This presented a safeguarding and security vulnerability to patients and staff.
• The ambulatory care unit (ACU) and acute medical unit (AMU) operated in a constant state of escalation, which placed additional pressures on staffing.
• Staff in paediatrics dedicated ED did not ensure that the audio-visual security system was routinely used.

• The trust had failed to act on an action plan issued in August 2018 to address several issues we found were on-going, including delays in decision to admit processes and security of the paediatric ED.
• The resuscitation unit operated effectively with senior decision-makers and senior nurses always present.
• There was effective clinical collaboration between the consultant in charge and the nurse in charge and it was notable that staff systematically did their best in challenging circumstances.
• Staff demonstrated resilience and compassion when trying to help patients who experienced significant delays and expressed frustration. This included when they faced aggression and verbal abuse.
• The security team had wide-ranging responsibilities and provided considerable support, including in safeguarding and child protection circumstances.
• Leadership in the ED, ACU and AMU was consistently good and shift-leading nurses demonstrated supportive practice and well-developed competencies in reducing delays.
• The working culture empowered staff and promoted peer challenge as a strategy to deliver high standards of care and a strong work ethic. Although this was an overall finding the team in EDRU did not feel listened to or fully supported by the trust.

We told the trust they must:

• Improve performance in the national 15-minute triage recommendation, ensure triage processes meet national best practice guidance.
• Ensure adequate risk controls are in place for patients who wait extended periods for triage.
• Improve the effectiveness of internal professional standards for patients who need a specialist review and reduce delays in decision to admit times.
• Improve specialist review times.
• Improve standards of privacy and dignity for patients cared for in ED corridors and in the EDRU.
• Ensure fire safety controls and standards are fit for purpose in the ED, ACU and AMU.
• Ensure staff have adequate training and confidence in non-medical emergency procedures, including in evacuation plans.
• Ensure hazardous products and chemicals are stored in line with the Control of Substances Hazardous to Health (COSHH) Regulations (2002).
• Ensure patient’s records are always stored securely and restrict access to electronic records to authorised staff.
• Staff in the paediatrics-dedicated ED must ensure that the audio-visual security system is routinely used.

In addition, the trust should:

• Improve governance processes andgovernance oversight of the streaming process to improve safety and reduce risk at the front end of the ED.
• Ensure there are enough suitably qualified doctors available in the ED overnight to meet patient need.
• Ensure the availability of paediatric-trained nurses in the ED complies with RCPCH recommended staffing levels.
• Ensure staff in EDRU have the competencies and ability to communicate appropriately with the relatives of patients.

There were also areas of outstanding practice:

• The responsiveness of the lead nurse in ED to surge situations resulted in a rapid reduction of triage delays in the department. For example, by redeploying existing staff they reduced the triage time from two hours to 17 minutes within a two-hour period.
• Staff were proactive in identifying opportunities for improved practice for patients with complex needs, including the use of multidisciplinary social care assessment pathways.

Professor Edward Baker

Chief Inspector of Hospitals

A summary of services at this hospital appears in the overall summary above.

We spoke with nine patients about their medicines. All were very positive about their stay and nobody raised any concerns about the way their medicines were handled.

We visited Arrowe Park Hospital and spoke to patients and relatives. Patients told us they felt they were well cared for and were well looked after. Comments made included:

“Everything is great, I have no complaints”, “I am very well cared for”, “They are very good and the staff are very nice”, “The care is good and so is the food”.

Patients told us the staff treated them with dignity and respect and the food was very nice with good choices. We were told they usually answered the call bell in a timely manner, however on occasions they had to wait as staff were busy with other patients.

Relatives of patients told us they were pleased with the care as their relatives had told them they were well looked after. Two of the relatives we spoke with felt communication between the ward staff and they should have been better. They said they were disappointed in having to ask for information regarding their relatives on a number of occasions before the information was forthcoming. Other family members felt they were kept informed as their relative had told them what was happening and gave them the information they needed.

We spoke with five patients about their medicines. None of them raised any direct concerns about the way their medicines were handled. One patient said they were looking after their own medicines and they were ‘’pleased’’ that they could do this as it helped them retain some of their independence. They also said this meant they could take them when they wanted to and so they didn’t have to wait for nursing staff to give them.

Other patients said that they had been given information regarding their new medicines and said they had been well looked after and the new medicines had helped.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

Arrowe Park Hospital is one of two hospital sites managed by Wirral University Teaching Hospitals NHS Foundation Trust. The hospital is the main site and provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity and gynaecology services and a range of outpatient and diagnostic imaging services.

The hospital is located on the Wirral peninsula in the North West of England and serves the people of Wirral and neighbouring areas.

Wirral University Teaching Hospitals NHS Foundation Trust became a Foundation Trust on 1 July 2007. The trust provides services for around 400,000 people across Wirral, Ellesmere Port, Neston, North Wales and the wider North West footprint with 855 beds trust-wide, including 749 at Arrowe Park Hospital.

We previously inspected this hospital in May 2015 as part of a responsive unannounced inspection and found that there were shortages of nursing staff on some medical wards which we told the trust to address.

We carried out an announced inspection of Arrowe Park Hospital on 16 – 18 September 2015 as part of our comprehensive inspection of Wirral University Teaching Hospitals NHS Foundation Trust and we checked to make sure staffing levels had improved.

Overall, we rated Arrowe Park Hospital as ‘Requires Improvement’. We have judged the hospital as ‘good’ for caring. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe, effective, well led and responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

• The trust had infection prevention and control policies in place which were accessible to staff.
• Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures. However, in the critical care unit not all staff followed ‘bare below the elbows’ guidance and there was mixed levels of compliance with hand hygiene protocols.
• ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
• There had been no cases of methicillin resistant staphylococcus aureus (MRSA) bacteraemia infections or clostridium difficile infections identified in surgical services across the trust between March 2015 and August 2015. However, across the same period, medical care services reported 21 cases of clostridium difficile infections, two cases of MRSA and six cases of MSSA. The data could not be split so as to separate cases that specifically occurred at Arrowe Park Hospital.
• According to the submitted and verified intensive care national audit and research centre data (ICNARC), the critical care unit performed as well and sometimes better than similar units for unit acquired MRSA and clostridium difficile infection rates.
• Side rooms were used where possible as isolation rooms for patients at increased risk of cross infection. There was clear signage outside the rooms so that staff were aware of the increased precautions they must take when entering and leaving the room.
• We observed that the disposal of sharps, such as needle sticks followed good practice guidance. Sharps containers were dated and signed upon assembling them and the temporary closure was used when sharps containers were not in use.
• Patient-led assessments of the care environment (PLACE) audits for 2013 and 2014 scored higher than the national average for cleanliness across the trust, specific data for Arrowe Park Hospital was not available.

Nurse staffing

• We previously inspected this hospital in May 2015 as part of a responsive unannounced inspection and found that there were shortages of nursing staff on some medical wards which we told the trust to address.
• The trust had responded positively to our last inspection and had actively recruited nursing staff in a variety of ways to improve staffing levels. However, there were still staffing shortfalls across the hospital.
• To attempt to address shortfalls in staffing, matrons met each day to discuss nurse staffing levels across the divisions to ensure that there was good allocation of staff and skills were appropriately deployed and shared across all wards. In July 2015 there were still 70 nursing vacancies in medical and acute services across the trust.
• The trust had a high vacancy rate for nursing staff in medical services trust wide, which was 13% at the time of the inspection. The turnover of nursing staff was 9.7%.
• The vacancy rate for nurses in surgical services was below 3% for the five month period prior to the inspection. At the time of the inspection the vacancy rate for nurses across surgical services trust-wide was 2.4%.
• There was no recognised acuity tool in use to determine staffing numbers on paediatric wards. A band 6 nurse devised the staff rota and the skill mix of each shift was based on their knowledge of individual staff competencies.
• The staffing and skill mix on surgical ward areas and in theatre areas was sufficient, with some periods of reduced staffing in areas because of last minute sickness and unexpected events. However, there was a lack of surgical staff trained in paediatric life support. This training was not mandatory for staff, despite them regularly working with children.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• The information we reviewed showed that medical staffing was generally sufficient at the time of the inspection.
• The trust had identified areas, such as the emergency department and medical specialties, where medical staff shortages presented a risk to patient care and treatment and were working hard to recruit and retain consultants.
• The vacancy rate for medical staff was 12.4% and the turnover of medical staff in medical services trust wide was 18% at the time of the inspection.
• The total number of shifts covered by locum medical staff in medical services trust wide, between April 2015 and September 2015, was 1,428. This was for a number of reasons including vacancies, extra staffing over and above the normal levels and extra ward rounds. Locums were either trust staff working extra shifts or from an agency.
• The number of palliative care consultants was below the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance.
• There were 57.4 whole time equivalent (WTE) vacancies across all staffing in the diagnostics and imaging services as of August 2015.

Mortality rates

• Monthly governance meetings were in place where mortality, incidents and actions were discussed. Information was then cascaded to senior staff via email to enable sharing with other staff. However, in medical services it was unclear if any actions for improvement were agreed at the meeting.
• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. Between October 2013 and September 2014 the trust score was 97.

Nutrition and hydration

• The majority of patients we spoke with said they were happy with the standard and choice of food available.
• In the CQC accident and emergency patient survey 2014, patients gave the emergency department a score of seven out of ten for being able to access suitable food or drink whilst in the department.
• Staff in surgical services managed the nutrition and hydration needs of patient’s well, both pre and post operatively. Patients were given information in the form of leaflets about their surgery and told how long they would need to fast pre-operatively.
• In all the records we reviewed, a nutritional risk assessment had been completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.
• A coloured tray system was in place to highlight which patients needed assistance with eating and drinking. The trust had an internal target to ensure that 75% of patients got assistance with eating when they required it. Information provided by the trust showed that they were not meeting this target in medical specialties.
• Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.
• The trust was awarded UNICEF baby friendly accreditation in July 2014 for work related to supporting breastfeeding and parent infant relationships.

We saw areas of outstanding practice including:

• Senior clinicians on the emergency surgical assessment unit had recognised that fluid balance monitoring could be improved and introduced a training programme for health care support workers to achieve this aim. Health care support workers told us they felt empowered by the training and saw fluid balance monitoring as an integral part of their role after it. Audits showed that the completion of fluid balance charts had improved since the training and senior clinicians reported that there had been a significant reduction in the number of patients developing acute kidney injuries (a condition associated with dehydration).

• The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘A’ which was an improvement from the previous audit results when the trust was rated as a grade ‘B’. Since October 2014 the trust had either been ranked first or second regionally in the SSNAP audit.

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

Importantly, the hospital must:

Urgent and emergency care

• Ensure call bells are available in every bay and placed with patients.
• Staffing continues to remain a focus and that shifts are adequately staffed to meet the needs of patients.
• Ensure that risks are always managed and mitigated in a timely way.

Medical care (including older people’s care)

• The trust must ensure that robust information is collected and analysed to support improvements in clinical and operational practice.
• The trust must ensure that care and treatment is only provided with the consent of the relevant person and if a patient lacks capacity to consent, the Mental Capacity Act (2005) principles are adhered to. This must be supported by staff receiving training in consent and the principles of the 2005 act.
• The trust must deploy sufficient staff with the appropriate skills on wards, especially on the medical short stay ward and on ward 16 at night.
• The trust must ensure that learning is shared across all service areas and the reasons for any changes made clear to all staff.
• The trust must ensure that records are kept secure at all times so that they are only accessed and amended by authorised people.

Surgery

• The trust must ensure that there are adequate numbers of suitably qualified staff in theatre recovery areas to ensure safe patient care.
• The trust must ensure that all staff involved with the care and treatment of children receive adequate life support training.
• The trust must ensure that all staff receive are appropriately trained and able to use the incident reporting system.

Critical care

• The trust must address the governance shortfalls in critical care and make sure that the systems and processes in place for assessing, monitoring and mitigating local risk are managed effectively.
• The trust must ensure that all staff understand the thresholds for reporting incidents and are encouraged to use the electronic reporting system.
• The trust must make sure that all staff understand and comply with the best practice in infection prevention and control. This includes appropriate use of handwashing and the use of antiseptic hand gels.

Maternity and gynaecology

• Review the management of the electronic rostering system to ensure it does not allow staff to be rostered on different wards at the same time.
• The provider must deploy sufficient clinical and midwifery staff with the appropriate skills at all times of the day and night to meet the needs of women following the trust risk assessment and escalation procedures.
• The provider must ensure that there is a detailed overview of the types and seriousness of incidents and learning is shared across all service areas and the reasons for any changes made clear to all staff.
• The provider must make sure individual care records are always accurate and completed contemporaneously.
• The provider must make sure community midwives have easy access to the emergency medication and equipment detailed in best practice guidance. The equipment must be checked and items provided within the use by date.

Children and young people’s services

• Resuscitation trolleys must be appropriately checked and the log book must be signed to confirm all items are in working order. The trolley must include a defibrillator at all times.
• Must ensure that there is a robust system to determine staffing numbers which takes into account the acuity of patients and skill mix of staff.

• Information must be collected and analysed to support developments in clinical and operational practice.

• Must review the children’s safeguarding training to ensure it meets Royal College of Paediatrics and Child Health (RCPCH) guidelines 2014.

End of life

• Ensure that any complaint received is investigated and necessary and proportionate action is taken in response to any failures identified by the complaint or investigation.
• Seek and act on feedback from relevant persons and staff teams, for the purpose of continually evaluating and improving services.
• Evaluate and improve their practice in respect of the processing of information relating to the quality of people’s experience.
• Ensure there is a robust vision and strategy for end of life services and all staff are aware of them.
• Ensure that there is an appropriate replacement care plan in place across the trust following the withdrawal of the Liverpool Care Pathway.
• Ensure that all risks associated with end of life services are recorded and monitored with appropriate actions taken to mitigate them.

Outpatients and diagnostics

• The trust must take action to reduce the delay in referral to reporting times of urgent diagnostic investigations.
• The trust must resume radiation safety committee meetings and hold them at least annually.
• The trust must take steps to fill vacancies to ensure compliance against their current staffing establishment.

In addition the trust should:

Urgent and emergency care

• Review and introduce regular audits of patient records to ensure all relevant details are correctly sourced and recorded.
• Review and evaluate the outcomes from use of the potential sepsis warning tool.
• Take action to address waiting times and the access and flow through the hospital.

Medical care (including older people’s care)

• The trust should ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.
• The trust should ensure that the acuity of patients on the coronary care unit is regularly assessed to ensure there is an appropriate skill mix of staff.
• The trust should ensure that trolleys used to store records and sharp instruments are kept secure when not being used.
• The trust should ensure those patients are discharged as soon as they are fit to do so.
• The trust should ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
• The trust should ensure that patients’ views are sought to help inform changes to services provided.
• The trust should ensure that actions to improve standards of medicines management are identified in a timely way.
• The trust must consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

• The trust should ensure that the emergency surgical assessment unit is not used for medical outliers.
• The trust should ensure that patients are not kept in theatre recovery areas for long periods of time or overnight.

Critical care

• The trust should ensure that all equipment is regularly serviced, maintained and remains fit for purpose.
• The trust should ensure that all patient records are accurate and fit for purpose.
• The trust should ensure that any delayed discharges from critical care do not result in a breach of the government’s single sex standard.
• The trust should consider developing to plans to indicate when facilities will be upgraded to comply with the current HBN 04-02. It is imperative that critical care is delivered in facilities designed for that purpose.
• The trust should consider how it is going to improve performance in reducing the number of delayed and out of hours discharges of patients from critical care.
• The trust should consider articulating a vision and strategy for the critical care service and communicating this to its staff.

Maternity and gynaecology

• The provider should ensure women and babies who are subject to safeguarding or child protection concerns have their needs reviewed before they are discharged from the maternity service.
• The provider should consider making it possible for all staff to be able to complete incidents directly onto the system
• The provider should make sure the arrangements for managing medicines and medical gases keep people safe and meet the relevant best practice guidance.
• The provider should ensure the general public are given opportunities to comment on their strategic plans.
• The provider should consider providing written information in different languages.
• The provider should consider maternity and gynaecology working more closely together so that effective systems can be shared.
• The provider should consider ways of improving staff satisfaction with working for maternity services at Arrowe Park Hospital.

Children and young people’s services

• The patient electronic system in the emergency department should include a safeguarding identifier to inform staff of known safeguarding concerns.
• The trust should consider adding a paediatric nurse to the trust wide safeguarding team.
• A robust development plan should be in place to improve staff skills.
• The cot space on the neonatal ward should meet British Association of Perinatal Medicine (BAPM) standards.
• There should be more integrated working between the wards and the children’s assessment unit.
• All equipment in all areas of the children ward, neonatal unit and the children’s assessment unit should be tested for electrical safety and all plug sockets should have safety plugs.
• There should be an active board level representative for children and young people’s services.

End of life

• Ensure policies and protocols are reviewed and monitored regularly to ensure their effectiveness and implementation is consistent across the trust.

Outpatients and diagnostics

• The trust should take steps to ensure that equipment is available and fit for use with minimal disruption to the service.
• The trust should ensure that medication is not left unattended when not in use.

Professor Sir Mike Richards

Chief Inspector of Hospitals