Staff could not demonstrate that they monitored the effectiveness of care and treatment. There were gaps in management and support arrangements for staff, such as appraisal and supervision. The service did not always plan and provide care and treatment in a timely way that met the needs of local people and the communities served.
The service did not always work with others in the wider system and local organisations to plan care. Ineffective access and flow processes were creating and contributing to significant delays in admissions to the wards.
Waiting times were not in line with national standards. Senior leaders did not always have a clear understanding of the risks, issues and challenges in the service. We were not assured local leaders and staff understood the vision and knew how to apply and monitor its progress.
Staff did not always feel respected, supported and valued by the wider hospital and senior managers. The service did not always have an open culture where patients, their families and staff could raise concerns without fear. Leaders did not always operate effective governance processes, throughout the service, across both sites and with partner organisations.
Leaders did not always use systems to manage performance effectively. The service used multiple clinical systems which were impacting on patient safety and effective care. The information systems were not integrated. Leaders and staff did not always actively and openly engage with patients, staff, equality groups, the public and local organisations to plan and manage services.
They did not always collaborate with partner organisations to help improve services for patients. The service controlled infection risk well and kept equipment and the premises visibly clean. The service managed patient safety incidents well. Staff recognised and reported incidents and near misses and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Staff protected the rights of patients subject to the Mental Health Act Staff gave patients enough food and drink to meet their needs and improve their health.
Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients.
They supported each other to provide good care. Staff supported patients to make informed decisions about their care and treatment. Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients' personal, cultural and religious needs.
Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Staff made reasonable adjustments to help patients access services.
They coordinated care with other services and providers. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint. Frontline nursing and medical leaders were visible and approachable within the service. Staff were focused on the needs of patients receiving care. There were plans to cope with major incidents.
Medical care We rated this service as requires improvement because:. The service did not have enough staff to care for patients and keep them safe. Staff did not always have training in key skills or manage safety well. The service did not control infection risk well. Staff did not always assess risks to patients, act on them or keep good care records. They did not always manage medicines well. The service did not always learn lessons from safety incidents.
Staff did not always give pain relief when people needed it. Managers did not always monitor the effectiveness of the service or make sure staff were competent. Staff did not always have access to good information. Key services were not always available seven days a week. People could not always access the service when they needed it. Leaders did not always run services well using reliable information systems and did not consistently support staff to develop their skills. Staff did not always feel respected, supported and valued.
The service did not engage with the community to plan and manage services. Staff understood how to protect patients from abuse. Staff collected some safety information and used it to improve the service. They gave patients enough to eat and drink. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions.
They provided emotional support to patients. Staff were clear about their roles and accountabilities. They were focused on the needs of patients receiving care. Surgery services We rated it as requires improvement because:. The service did not always manage patient safety incidents well. Whilst managers investigated never events, lessons learned were not always shared with the whole team and remedial actions taken did not minimise the risk of reoccurrence.
We were not assured that the service had effective systems in place for identifying and reporting never events. Not all patients could access the service when they needed it and receive the right care promptly. The services performed worse than the national average for the percentage of cancer patients treated within 62 days.
The average length of patient stay was worse than the national average. The total number of patients on the waiting list continued to increase since January Whilst the service did not achieve national standards for waiting times from referral to treatment; they performed better than the average when compared with other trusts in the region.
Mandatory training compliance was below trust targets for a number of training modules, such as paediatric life support and higher level resuscitation training.
Complaints were not always responded to within the timescales specified in the trust complaints policy. An effective work culture focused on patient safety had not been fully embedded across the surgical teams in theatres. The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
They provided emotional support to patients, families and carers. Local leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued by their line managers. During the week in which this inspection took place Merseyside was in a Tier 3 COVID area and therefore facing higher community infection rates which would impact on the activity of the trust.
We carried out a focused, responsive inspection at Royal Liverpool University Hospitals on 28 and 29 October to review the processes, procedures and practices within the medical care core service. We looked at parts of the safe, effective, caring and well-led key questions. We did not rate services because this was a focused, short notice inspection in response to specific areas of concern.
We observed care and treatment and specific documentation in eight patient records, including do not attempt cardiopulmonary resuscitation DNACPR , mental capacity assessment, care plans and intentional rounding documentation. We also interviewed key members of staff, medical staff and the senior management team who were responsible for leadership and oversight of the service. We spoke with 18 members of staff. We did not speak with any patients during this focused inspection however we conducted a short observational framework for inspection SOFI , observed patient care, the environment within wards and safety briefings to capture patient experience.
Over a three-week period in October , CQC had received a number of enquiries from patients, relatives and staff which related to poor patient care and experience.
These concerns related to nutrition and hydration, hygiene needs; staff being unable to provide care; infection prevention and control and staffing concerns.
We heard from patients, relatives and staff that:. We also heard concerns that a patient at risk of falls had sustained an injury during admission after falling from their bed due to mitigating actions not being taken.
Immediately prior to the inspection we received further enquiry concerns from patients and relatives that:. These concerns were mainly related to medical wards at both Royal Liverpool Hospital and University Hospital Aintree and specifically to wards 22 and 25 at University Hospital Aintree. In accordance with CQC procedures, due to the significant concerns raised, enquiries were also referred to local authority safeguarding services.
We initially raised the concerns with senior leaders and asked for information of how the trust was assured of patient safety at the point of delivery. The trust provided details of their assurances about nurse staffing, senior nurse review of clinical areas, including the environment, patient experience, and infection prevention and control. There was lack of clarity regarding any continued actions to ensure risk assessments were completed and reviewed in a timely way in response to changing patient needs.
We carried out a focused, short notice inspection in response to the specific areas of concern. We inspected medical care core services at Aintree University Hospital on 28 and 29 October and our findings are summarised below.
We did not inspect all the key lines of enquiry or domains and therefore have insufficient evidence to change the ratings. We found evidence to support the serious concerns that had been raised regarding patient care, as follows:.
The service did not always control infection risk well. Senior managers did not have clear oversight of infection control relating to bed spacing. The systems in place to manage infection prevention and control were not always followed by staff.
There was no evidence of leaders taking action to ensure compliance and mitigate these risks, which meant patients could be exposed to the risk of harm. We observed doors to side rooms and bays on some wards were not consistently kept closed. Staff inconsistently completed and updated risk assessments for each patient and action to remove or minimise risks was unclear.
Staff did not always maintain accurate records to confirm how frequently patients required care. Although managers regularly reviewed and adjusted staffing levels and skill mix the service did not always have enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
We saw this particularly affected ward 25, services for stroke patients, and ward 24 at night. We were not assured that patient acuity and dependency, or staff experience was always taken into consideration and this impacted on their ability to manage frail patients requiring additional support.
The stroke ward had a high sickness rate following positive screening of COVID with a number of staff who were required to isolate in line with government guidance. Records were not stored securely on all wards that we visited, and staff used different documents in ward areas within the same hospital. The service used systems and processes to prescribe, administer, record and store medicines.
However, we saw that medicines were not always administered on time and controlled drugs were not always checked in line with trust standard operating procedures.
Agency staff did not always have access to the electronic patient medication system. Not all patients requiring dietetic review received this in a timely way, including some with significant nutritional needs. However, from our observations on ward 20 during inspection we saw staff gave patients enough food and drink to meet their needs; but patients requiring one-to-one supervision on other wards did not always receive adequate support for nutrition and hydration needs.
Staff cared for patients with compassion and dignity; however, we observed a number of call bells were not always answered in a timely manner due to the high number of patients and low levels of staff on all wards inspected. During the inspection we noted delays in responding to patient call bells in different ward areas. Local leaders were not always visible and approachable in the service for staff.
Although local leaders were supported by Trustwide quality matrons who completed regular walkarounds there was a lack of senior leadership oversight in the service.
Leaders did not always operate effective governance processes throughout the service and with partner organisations. Ward based quality information boards were inconsistently completed and no action had been taken to address this. Leaders and teams did not always identify and escalate relevant risks and issues or identify actions to reduce their impact.
The design and maintenance of facilities kept people safe and most areas had enough equipment for staff to carry out their role. We observed staff working extremely hard to provide treatment and care under difficult circumstances during the current COVID - 19 pandemic, which had impacted on the numbers of patients and their acuity. We spoke with senior leaders on the day of inspection about our concerns and to request that the trust took action to ensure immediate patient safety.
The trust identified immediate actions in response to the concerns identified. Following the inspection, we reviewed information the trust had provided to CQC before the inspection and our evidence gathered during our onsite inspection.
We found there was a lack of robust systems and processes to monitor the quality of the care patients received at both hospital sites in the medical core service. We formally wrote to the trust following our inspection and clearly identified the significant patient safety concerns we had found with regards to nutrition and hydration; infection prevention and control; staffing; assessment of health needs, implementation of care and documentation and operational oversight and governance.
We asked the trust to take urgent action and provide a detailed response with action plans to mitigate the risks to patients. The merging of the two organisations was integral to regional NHS plans to deliver improved quality of care and to make changes in existing care models.
The merger provides an opportunity to reconfigure services in a way that provides the best healthcare services to the city and improves the quality of care and health outcomes that patients experience. It serves a core population of around , people across Merseyside as well as providing a range of highly specialist services to a catchment area of more than two million people in the North West region and beyond. It also has a successful Volunteers scheme, with more than volunteers providing support in a variety of roles.
Aintree Hospital is located in Fazakerley, in the north of the city. Broadgreen Hospital, which is co-located in south Liverpool with Liverpool Heart and Chest Hospital NHS Foundation Trust, is home to a number of elective surgical, diagnostic and treatment services, together with specialist rehabilitation. It supports dental teaching and provides emergency care and a range of specialist dental services including restorative dentistry, paediatric dentistry, orthodontics, oral surgery and medicine and a Consultant-led Dental Sedation Unit.
Patient support services The unit is supported by a multi-denominational chaplaincy department. Facilities The Critical Care Department contains an 11 bed intensive care unit and a 12 bed high dependency unit. Referral information Referrals to Critical Care are made by any of the doctors or nurses in the hospital when they are concerned about a patient.
The Team The Critical Care Department is staffed by a highly skilled and experienced multi professional team that includes critical care trained nurses and doctors trained in intensive care medicine.
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