Three Compliance Inspectors and a specialist nurse advisor visited David Ferrier Ward, Lady Anne Allerton Ward, Molly Lane Fox, a Neuro-oncology unit and Bernard Sunley Ward. We also visited two outpatient clinics.

During our inspection we spoke with 26 patients, six relatives and 15 members of staff. We looked at 17 sets of patient records.

Speaking with patients across all wards the feedback we received was positive. One person on Bernard Sunley Ward told us that the “staff are very patient” a relative said “staff are very warm”.

Another patient on the ward said it was “Fantastic, couldn’t ask for more, staff are very knowledgeable” and that staff “sit and chat with you”

One person on Lady Anne Allerton Ward said the “nurses are very good, come when you need them”. Other patient feedback we received included that staff "come promptly” and that the ward was “exceptionally clean”. A visiting relative told us care was "always good, never had concerns, there are enough staff and they are nice staff”.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Care plans were detailed and any new nurse would be able to be guided to deliver the appropriate care.

We found that there were enough qualified, skilled and experienced staff to meet people’s needs and that staff felt supported and were supported to meet the needs of the people who use the service.

As part of the inspection an unannounced visit was undertaken by three compliance inspectors from the Care Quality Commission and an external specialist advisor on 12 November 2012. We visited the Neuromedical Intensive Care Unit (MICU), the Neurosurgical Intensive Care Unit (SICU), the High Dependency Unit (HDU), Lady Anne Allerton ward (LAAW), David Ferrier ward (DFW) and the Outpatients department.

We spoke with patients, their relatives and staff from a range of medical, nursing, and therapy backgrounds. In general, the patients we spoke with were positive about their experiences at the hospital. We received the following comments from patients:

“I can’t say a bad word about the place.”

“They stop to explain everything.”

“The staff have been very helpful.”

“It is gold star. Ten out of ten.”

“It is spotless.”

“The referral process is difficult. It took me a long time to get [the referral] here.”

We found that people received care that met their needs and respected their privacy, dignity and independence. Adequate staffing was available to meet patients’ needs, although there were a high number of staff vacancies on DFW. We found that when patients did not have the capacity to consent, the provider acted in accordance with the Mental Capacity Act, although some staff were not fully aware of their responsibilities. The procedures for restraint were still being developed and the reasons for using restrictions were not always being recorded.

This was the first time we have rated this location.

We rated the hospital as good because:

• We rated effective, caring, responsive and well-led as good, and safe as requires improvement.
• We rated all services inspected as good.
• The hospital managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Learning from incidents was discussed in departmental and governance meetings and action was taken to follow up on the results of investigations. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Staff understood how to protect patients from abuse and there were effective systems in place to protect people from harm. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff provided evidence based care and treatment in line with national guidelines and local policies. There was a program of national and local audits to improve patient care. Patient outcomes were better than the national average. The hospital was involved in the development of national professional guidelines.
• There was effective multidisciplinary team working. Relevant professionals were involved in the assessment, planning and delivery of patient care. New admissions were discussed at the multidisciplinary admissions meeting for the hospital which was supported by medical, nursing occupational therapy and physiotherapy staff, social care and continuing health care representatives.
• Staff had opportunities for further development. Staff could apply for additional training if it was relevant to their role. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
• Feedback from patients confirmed that staff generally treated them with respect and with kindness and our observations of interactions between staff and patients and relatives showed staff were sensitive and respectful. Most patients we spoke with said they felt involved in their care and had the opportunity to ask questions.
• Services were developed to meet the needs of patients. The service was undergoing a redevelopment programme to expand the service and improve patient experience.
• The service took account of patients’ individual needs. Staff used flags on the electronic patient wards boards to indicate if a patient was at risk of falling, was living with dementia, had a risk of developing pressure ulcers or needed assistance at meal times. This helped improve care by making sure patients got the attention and support they needed.
• Staff felt valued, were supported in their role and had access to opportunities for learning and development.
• The leadership team had a clear vision and strategy and there were action plans in place to achieve this. Staff were committed to delivering the vision of being a leading hospital for neurological disorders and were aware of how their role contributed to the broader vision and strategy of the hospital.
• The hospital was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation. The service provided multiple examples of their leading role in world leading research projects.
• The trust’s exemplar ward accreditation programme focused on improving patient experience, safety and quality and efficiency and was led by frontline staff.
• The service had extensive engagement with patients via focus groups held by hospital specialities and events hosted by charities and other organisations. This engagement was used to drive improvement and innovation in the hospital services.

However:

• Medical staffing in critical care was not in line with professional standards. Pharmacy and therapy staffing levels were also below the recommended guidelines.
• There were high nursing vacancies at the time of inspection. The vacancy rate was 18.4%, much higher than the trust target of 6.5%. However, there were recruitment plans in place and new staff were expected to start later in 2018.
• There were two different charts in place for identification and escalation of deteriorating patients, albeit for different purposes, which some staff reported as confusing.
• Mandatory training in key skills for medical staff, including safeguarding training, fell below the trust’s target for compliance.
• Whilst we saw many examples of good practice in relation to medicines management, the trust’s policies for safe storage and management of medicines were not always followed consistently.
• Although the service generally controlled infection risk well, we observed staff did not always comply with hand hygiene protocols.
• Resuscitation equipment was not always checked on a regular basis.
• Fluid balance management was not consistent. We found in some records there were gaps in recording and the patient’s total fluid intake had not been monitored.
• Patients told us about communication issues. Patients were not always informed of clinic delays, instructions from staff were at times unclear and letters to themselves or GPs were not always received.
• Reception staff across some of the areas we visited did not always appear welcoming to patients and at times ignored patients or reacted in a discourteous manner. However, we also saw other examples of where staff treated patients with respect and kindness.
• Patients discharged from the intensive therapy units did not have access to a specific ITU follow up clinic contrary to best practice.