Wrightington, Wigan and Leigh NHS Foundation Trust Royal Albert Edward Infirmary Quality Report The Elms, Royal Albert Edward Infirmary Wigan Lane Wigan Greater Manchester WN1 2NN Tel: 01942 778858 Date of inspection visit: 8-11 December 2015 Website: [email protected] Date of publication: 22/06/2016 This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this hospital Requires improvement ––– Urgent and emergency services Good ––– Medical care (including older people’s care) Good ––– Surgery Good ––– Critical care Good ––– Maternity and gynaecology Requires improvement ––– Services for children and young people Requires improvement ––– End of life care Outstanding – 1 Royal Albert Edward Infirmary Quality Report 22/06/2016 Summary of findings Outpatients and diagnostic imaging Good ––– 2 Royal Albert Edward Infirmary Quality Report 22/06/2016 Summary of findings Letter from the Chief Inspector of Hospitals The Royal Albert Edward Infirmary is one of three locations providing care as part of Wrightington, Wigan and Leigh NHS Foundation Trust. It 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 services and a range of outpatient and diagnostic imaging services. Wrightington, Wigan and Leigh NHS Foundation Trust provides services for around 320,000 people in and around Wigan and Leigh with 696 beds. In total, the Royal Albert Edward Infirmary had 497 beds. We carried out an announced inspection of the Royal Albert Edward Infirmary on 8–11 December 2015 as part of our comprehensive inspection of Wrightington, Wigan and Leigh NHS Foundation Trust. Overall, we rated the Royal Albert Edward Infirmary as ‘Requires Improvement’. 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. • We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care. • ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use. • Overall, patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines. Nurse staffing • Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services. • Nurse staffing within the paediatric services was inadequate. Nurse staffing levels on rainbow ward did not reflect Royal College of Nursing (RCN) standards and on the neonatal unit did not always meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM). Also staffing rotas on Rainbow ward did not identify an appropriately trained member of staff for the High Dependency Unit (HDU) for each shift. • There were no paediatric trained nursing staff available in the department between 1.30am and 7:30am. Across the department only 18% of staff were trained in paediatric life support (PLS) and 13% in advanced paediatric life support (APLS) which meant that it could not be guaranteed that there would be a sufficient number of staff trained to resuscitate a child when the CED was closed. • On the medical wards we found there were occasions where nurse staffing levels were not overall sufficient to meet the needs of patients. Staff vacancies had been identified on the departmental risk register. • Current long-term sickness and interim staffing requirements within maternity, during recruitment processes, were being covered by bank staff. The trust target for bank nurses was less than 5%, however 14% were employed in November 2015 and 8.9% in December 2015. Leadership and Management • The senior team, in the majority of core services, were visible and accessible and well known to the staff. • Midwives were not clear about the trust vision and strategy.There were regular senior meetings that were cascaded to staff but staff felt that meetings with them needed to be more formal. 3 Royal Albert Edward Infirmary Quality Report 22/06/2016 Summary of findings • Clinical cabinet meetings took place monthly and were well attended by a managers and clinicians. • Within children and young peoples services there was a corporate and a divisional risk register in place. However managers were not fully aware of all the risks in their department. Risks regarding nurse staffing levels had been recognised by managers in September 2015; however this was not recorded on the risk register. It was recognised again on a leadership ‘walk around’ on 1 December 2015 but no immediate action was taken. • Lack of coherence between the executive team, service managers and staff meant identified risks were not clearly escalated, documented or robust actions taken to mitigate them within children and young people’s services. There was also a lack of proactive action in the case of nurse staffing on Rainbow ward. The lack of protected management time for the ward manager limited their ability to address managerial duties including addressing the staffing concerns. Access and Flow • Between April 2015 and September 2015, the trust exceeded the 90% standard for the proportion of patients waiting 18 weeks or less from referral to treatment. The latest figures for October 2015 showed the trust’s performance was at 92%, with the exception of general and oral surgery. WWL is in the top 10% nationally for RTT performance as at October 2015, ranking 5th out of 139 Acute Trusts. • General surgery and trauma/orthopaedic wards had medical outliers (medical patients that were not nursed on a medical ward due to bed shortages) each month between January 2015 and August 2015. The number of patient outliers for June 2015 was 141. Staff reported daily review of these patients by medical staff. • Between March 2015 and the time of inspection, the departments performance in meeting the Department of Health target for 95% of patients to be seen, treated, discharged or admitted within 4 hours was mixed. The service met the target in six of the nine months. However, performance was consistently better than the national average in that time. • National targets to achieve 92% for referral to treatment for patients on incomplete pathways between April 2015 and October 2015 were achieved overall within the paediatric specialities. Individually two specialities missed the target on one occasion in this period but this accounted for a total of two children only. • Children referred to child and adolescent mental health services (CAMHS) were usually seen within 24 hours however staff reported long delays to access specialist inpatient beds. Between 17 August 2014 and 16 August 2015 the trust had 178 admissions receiving care from the CAMHS team. • Within outpatients, the 18-week referral to treatment performance between January 2015 and October 2015 showed the trust had exceeded the trust’s 95% target and was better than the England average and standard with an overall average of 98%. We saw several areas of outstanding practice including: • The end of life service had a visible person-centred culture. are was provided by compassionate, caring staff who were sensitive to the needs of seriously ill patients. People were respected and valued as individuals, and staff throughout the service demonstrated a commitment to recognising the needs of the patients at end of life, and of their families. There were systems in place to support this, including the use of the swan logo. The use of the logo was seen to be identified universally and promoted high quality care to patients at the end of life and their families. • The emergency 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 to the department. 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 flex 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 Hospital 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 4 Royal Albert Edward Infirmary Quality Report 22/06/2016 Summary of findings 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. However, there were also areas of poor practice where the trust needs to make improvements.