We undertook this inspection in response to concerns that were raised with us about poor staffing and patient safety on ward 25. Following these concerns being raised, the trust were unable to provide us with sufficient assurances that patient safety was being maintained and that there were sufficient arrangements to monitor the services provided on ward 25.

On 12 February 2019 we carried out a focussed unannounced inspection of ward 25.

As this was a focused inspection we did not inspect all domains therefore, this inspection had no impact on the overall rating of the trust from the previous inspection in October 2018 when we rated it as requires improvement.

Medical care (including older people’s care)

We did not rate the service following this inspection, therefore the rating of requires improvement for medical care services following the previous inspection in October 2018 remained the same.

During this inspection we found the following areas that required improvement;

• Although the service had controlled infection risk well on most occasions, we found that daily cleaning checks had not always been completed, particularly for the cleaning of commodes. This meant that there was an increased risk that infection would be spread.

• Although the service had suitable premises and equipment, they had not always looked after them well. This was because controlled substances that are hazardous to health had not always been locked away and sharps had not always been managed safely.

• The service had staff with the right qualifications, skills and training to keep people safe from avoidable harm. However, there had not always been enough staff care and treatment. Records between the 1 January 2019 and 12 February 2019 indicated that the planned establishment for registered nurses had not been met on 63% of occasions during the day.

• Although controlled drugs had been managed in line with trust policy and legislation, general medicines had sometimes been left unsecured in patient areas.

• The service had not always promoted a culture that had supported and valued staff. Some staff informed us that although they had raised concerns about topics such as patient acuity or staffing, they were unaware if any action had been taken to make improvements.

• The service had not always used a systematic approach to continually improve the quality of its services. Meetings that had been held by the clinical business unit had not been minuted, meaning that it was unclear what had been discussed or what action had been taken to make improvements to areas of poor compliance.

• The service had not always collected, analysed, managed and used information well to support all its activities. We saw limited documented evidence of how information about ward 25 had been collected. We did not see documented evidence at any level of discussion about the performance of ward 25.

However, we also found the following areas of good practice;

• The service had managed patient safety incidents well. We found that all reported incidents had been investigated in a timely manner and that actions had been implemented to reduce the risk of a similar incident happening again.

• Patient risk assessments and patient observations had been undertaken in a timely manner on most occasions, in line with trust policy. For example, the majority of falls risk assessments had been completed correctly.

• Staff had kept detailed records of patient’s care and treatment.

• There was a clear leadership structure in place to oversee the management of ward 25.

• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

Professor Ted Baker

Chief Inspector of Hospitals

Our rating of services stayed the same. We rated it as requires improvement. This inspection was not rated and therefore did not have an impact on the overall rating for the hospital.

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

Aintree University Hospital NHS Foundation Trust (the trust) is a large teaching hospital in Liverpool.

There are 706 inpatient beds, serving a population of around 330,000 in North Liverpool, South Sefton and Kirkby. The hospital provides care and treatment for people living in some of the most deprived areas in England.

The hospital provides a full range of acute services which include: acute medicine, accident and emergency, acute frailty unit, surgical services. In addition to these services, the trust provides specialist services for Merseyside, Cheshire, South Lancashire, and North Wales. These specialist services include: major trauma, complex obesity, head and neck surgery, upper gastrointestinal cancer, hepatobiliary, endocrine services, respiratory medicine, rheumatology, ophthalmology, and alcohol services.

The hospital is one of the largest employers locally with more than 4,000 whole time equivalent staff. The trust gained foundation trust status in 2006 and was one of the first hospitals in Merseyside to do so.

Urgent and emergency services at Aintree University Hospital were previously inspected in March 2014 and were rated as ‘good’.We carried out an unannounced responsive inspection of urgent and emergency services to review pathways of care when patients attended the service were receiving treatment from the service, and when they were transferred out of the service at Aintree University Hospital. The inspection was in response to concerns that were raised with us about the safety and quality of the service provided to patients. This inspection focused predominantly on the safety of the urgent and emergency services provided; however, where inspectors observed practice in other areas we have included this information in our report.

We inspected the hospital during the afternoon and evening of 1 April 2016. We visited the following areas:

• Accident and emergency (A&E);

• Observation Unit ;

• Acute medical unit;

• Wards 30 and 31 (which included the frailty unit);

• The bereavement centre to review records.

We found that urgent and emergency care services required improvement for safety. This was because the systems and processes for recognising and escalating the deteriorating patient were not always adhered to, to keep people safe.

We reported our findings to senior staff at the trust at the time of the inspection and actions were put in place to address the concerns.

Our key findings were as follows:

• Nurse staffing levels were not always filled to the safe staffing establishment, and staffing was below the safer staffing establishment on the SAU, ward 31 and in the accident and emergency department at the time of our inspection. There were periods of understaffing against the establishment over a number of days prior and post inspection and we saw evidence that staff had raised staffing concerns using the incident reporting process. The trust was taking action to address the nurse vacancy rate, but it remained evident that the wards were not always staffed to establishment.

• Staff were using a national Modified Early Warning Score (MEWS) tool to help monitor a patient's condition and identify signs of deterioration in their condition. However, we found examples where these were not completed in line with the trust’s MEWS Standard Operating Procedure. This included: MEWS not correctly calculated and repeated observations not being performed in line with the timeframes identified in the trust’s MEWS Standard Operating Procedure. We were concerned that this may not appropriately identify patients who were deteriorating.

• We found there was poor staff compliance with the trust’s mandatory training target. The trust had a plan in place to reach 85% compliance by March 2017. However, patients could be at risk if staff were not adequately trained in a timely manner.

• There was generally good practice with regard to infection control.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure staff undertake and record patient observations consistently and accurately.

• Ensure that staff adhere to the modified early warning score (MEWS) Standard Operating Procedure and the sepsis clinical guidance document that the trust has in place to minimise risk of harm to patients.

• Ensure that staff perform out repeat observations in line with the clinically indicated MEWS trigger.

• Ensure that staff are trained and competent to identify and escalate the deteriorating patient.

• Improve staff compliance with mandatory training in a timely way.

• Ensure that staffing levels in all areas adhere to the safer staffing requirements.

• Ensure that patient records are completed contemporaneously and reflect the care provided to patients.

In addition, the trust should:

• Put in place robust audit processes to identify any areas where performance or practice requires improvement.
• Consider how lessons from incidents are shared and audited to identify if learning has been applied and is embedded throughout the trust.
• Have robust procedures to replace equipment on resuscitation trolleys in a timely manner across the trust to reduce the potential risk to patients who experience a cardiac or respiratory arrest.
• Review areas used for escalation purposes to ensure they are suitable for the service provided, based on patient need.
• Consider options to improve the privacy and dignity for patients during times when the trust is utilising the escalation policy due to periods of increased demand on the services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Aintree University Hospital 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 hospital provides care and treatment for people living in some of the most deprived areas in England.

The hospital provides a full range of acute services and also works with partners to provide a range of services in community settings including rheumatology, ophthalmology and alcohol services. Tertiary services provided by the trust include respiratory medicine, rheumatology, maxillofacial and liver surgery.

The hospital 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 hospitals in Merseyside) and has more than 13,000 public and staff foundation trust members.

The hospital is well supported by the local community and has more than 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.

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 safer surgery checklist not being completed appropriately in all theatres and have asked the hospital to take action to correct this.

Staffing

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

Staff sickness rates were below the national average.

Staff were well led at both a local and trust wide level. 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.

Cleanliness and infection control.

The hospital was clean throughout and there was good practice in the control and prevention of infection. Practice was supported by staff training and a hospital wide control of infection team.

The hospital infection rates for C.difficile and MRSA infections lie within an acceptable range for a hospital 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.

Complaints management

When we carried out this inspection we worked with colleagues from the Patients Association and looked 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 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.

Many patients did not know how to make a complaint and there was a lack of accessible information about making a complaint in many of the wards and departments we inspected.

We spoke with many patients during this inspection. Most of them and their relatives spoke positively about their experience and the care they received. They provided positive comments such as:

"My Dad couldn't have been given better care."

“I was seen quite quick when I arrived and then taken to x ray, I am just waiting now to see what’s happening.”

We found that all patients when admitted were assessed and a plan of care was put into place. As the care plans were standardised we found that sometimes they appeared inflexible when needs outside of the standard assessment tools were identified. This was particularly so for patients with dementia care needs. We observed felt that patients who had a diagnosis of dementia were not supported with a comprehensive assessment and care plan to adequately meet their needs and their safety at times had increased because of this.

We looked at care and welfare of patients within the Accident and Emergency department. Despite the smooth running of the department we found the area to be under significant pressure as the hospital did not have any empty beds to transfer patients to an inpatient area. We were very concerned to find this resulted in a considerable delay in admitting patients to the hospital.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage them.

People were cared for in a clean, hygienic environment and patients received care, treatment and support from staff that were competent to carry out their roles and responsibilities.

Overall the Trust had systems and processes in place for governance and risk management. However, the implementation and quality of these was variable. Risk Management was a particularly poor area at all levels of the organisation. We found complaints management required improvements.

Prior to our visit a number of concerns were reported to us relating to the assessment, planning and delivery of care and treatment and support experienced by patients and their relatives.

During our inspection we spoke with a large number of patients in two busy ward areas. We asked them about the care and support they were given during this hospital admission. Mostly patients told us they were well cared for and their needs were fully met. They said that on admission, medical and nursing staff had undertaken a thorough assessment and in particular they ‘had been asked about their likes and dislikes’. Many patients were aware they had a care plan, they knew care staff looked at these each day, but they did not fully understand what this was. Patients told us that staff respect their dignity and privacy and curtains were always pulled around for this purpose. We were told that staff generally respond to call bells promptly and one relative commented that they ‘had no concerns, it was a very nice ward’.

We had mixed comments made by patients and relatives for the communication opportunities with staff. Some relatives told us it was difficult speaking with medical and senior staff and poor communication had made them more ‘anxious’ about their relatives care. Other relatives told us communication with more junior staff was good.

We had mixed feedback for the quality of the food. One patient reported positive comments but mostly negative views were expressed to us. The concerns raised were that food had been served cold, it was of a poor quality and patients were disappointed that soup was not available as a food choice. Some patients who had regular admission to the hospital stated that there had been a ‘steady decrease’ in the overall quality of food provided. One patient told us she was not allowed certain soft foods because these were only available to patients with special dietary requirements.

Patients told us that they did not have any concerns about staff training, nurses were always very competent and patients were ‘well cared for’. A number told us communication with staff could be better, and some commented that staff attitude at times was ‘poor’.

Our rating of services went down. We rated it them as requires improvement.

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