Our rating of services stayed the same. We rated it them as good because:

• Records were clear, up-to-date and available to all staff providing care. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
• The services prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
• The services provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Information about the outcomes of patients’ care and treatment was routinely collected and compared against national data. Information was monitored in different meetings to identify areas for improvement. The maternity service used safety monitoring results well.
• Staff gave patients enough food and drink to meet their needs and improve their health.
• There was good evidence of multi-disciplinary team work to make sure patients were transferred / discharged to the appropriate location at the right time and with the support and involvement of carers and relatives. The newly developed frailty service was starting to reduce patient admissions and reduce re-attendances. The mental health liaison team facilitated communication with the community mental health teams and home-based treatment team, enabling people to be discharged from hospital with more intensive mental health support.
• In the main, services made sure staff were competent for their roles, although some improvements were required with competency re-training in maternity services. Managers appraised staff’s work performance to provide support and monitor the effectiveness of the service. However, appraisal rates were variable across the service.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Privacy and dignity was maintained. We saw staff reassuring patients who were anxious or upset, with specialist support available if this was needed. The Friends and Family test had a good response rate for medical care services which demonstrated a high percentage of people would recommend these services.
• The services were planned and provided in a way that met the needs of the local people. The medicine and emergency care division recognised the needs of the local population and used various sources of data such as public engagement and the use of local data and statistics to design and plan the services provided.
• Services had a vision for what they wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
• Services had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• Managers across the hospital promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• Services used a systematic approach to continually improve quality and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• Services had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• Services engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
• Services were committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

However;

• We observed failure to follow infection prevention and control procedures on a number of occasions across wards and departments. There was also a lack of adequate assurance of compliance with infection prevention and control procedures.
• Nursing vacancy, turnover and sickness rates were all above the trust targets in medical care services, as was the use of bank staff. Some services did not always have enough staff with the right qualifications, skills, training and experience to provide care and treatment. Including the requirement for registered children’s nurses in urgent and emergency care services and limited flexibility in numbers of midwives to cope with increased capacity and demand, or short notice sickness and absence.
• Completion levels of mandatory training for some subjects, particularly level 3 safeguarding children were variable in all the services we inspected.
• Maintenance and safe storage of equipment in maternity and medical care services was not at satisfactory levels. We saw sluice rooms unlocked in several wards, with cleaning solutions accessible to patients and visitors.
• Patient risk assessments were not completed consistently including a lack of risk assessments relating to patients’ mental health needs or behaviour; the World Health Organisations five steps to safer surgery maternity safety checklist was not completed fully in theatre and patients attending the emergency department were not routinely assessed for venous thromboembolism in line with best practice guidance.
• Staff did not understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. We found there was an inconsistent approach for assessing the needs of patients who lacked capacity.
• Not all services were provided seven days a week. For example, at weekends consultant review of medical and stroke patients was limited to only new patients although the staff could request review for other patients, or regarding concerns. Physiotherapy and occupational therapy services were available for stroke patients Monday to Friday, however only new stroke patients were seen at weekends due to more limited availability of therapy services.
• We were not fully assured that all patients received timely pain relief in the emergency department. Children attending the department via the waiting room were not always assessed, prioritised or given pain relief at this point of care.
• Delayed discharges were an ongoing challenge for medical services. There was a backlog of dispatch of discharge letters on the acute medical unit some up to six weeks. Specialist leaders identified concerns in delays for follow up appointments particularly in rheumatology.
• The trust did not always meet the national standards for access to services. As at the last inspection we found the service did not always meet national standards to admit, transfer or discharge patients within four hours.
• Complaints were not always responded to in a timely manner which meant they did not meet the trust targets for closure of complaints. Although, concerns and complaints were treated seriously, investigated and learned lessons.
• Whilst the systems and processes were in place to support leaders of medical care services, the capacity to deliver change was limited by continuing operational pressures and challenges in recruiting and retaining staff. There was an overall lack of pace in achieving stability and sustainable improvement in the service.

• Following the inspection, we raised the concerns regarding infection control procedures and capacity to consent procedures with the trust and requested assurance that improvements would be made. The trust provided us with evidence that action had been taken and was being monitored to ensure sustained improvement and adherence to standards. We reviewed the action taken in May 2018 when we returned to the trust to carry out our well-led inspection. We found that whilst some improvements had been made, these were still not fully embedded and a review of the consent policy was required to ensure it met the requirements of the Mental Capacity Act 2005.

At our previous inspection we found that improvements were needed in the way medicines were recorded in the hospital. We found that action had been taken to correct this issue and the trust was carrying out checks (audits) to make sure that improvements were sustained. We talked to patients, members of the pharmacy team and nurses on the wards. Most patients were very happy with the care they received and said they were well informed about their treatment, including medicines. One person told us that they had not been given adequate pain relief during their first few hours in the hospital. Nurses told us that the pharmacy service was good, and pharmacy staff were helpful. However, they said that patients sometimes had to wait several hours, or rarely overnight, for their 'take home' medicines before leaving hospital.

At our previous inspection we found that improvements were needed in the way medicines were managed in the hospital. We carried out this inspection to check on the progress made with the actions the Trust told us it was taking, and found significant improvements in the arrangements for managing medicines. However, the arrangements were not consistently followed on two of the three wards we visited. We talked to two patients, a relative, and to staff on the wards. Both patients told us that they were kept informed about their treatment.

When we carried out our unannounced visit to Leighton Hospital we mainly visited Wards 2 and 21b.

All the patients to whom we spoke were complimentary about the care that they were being given. One said “Service is good, nurses are good and they can’t do enough for you. They keep checking to make sure you are alright”. Another said “these professionals are a credit to their profession”.

When we observed care on the wards we saw patients were treated properly and when we asked patients about this they told us they were treated with dignity and respect.

We examined a sample of patients’ records and found that they were properly assessed and planned to needs of the patients on the wards. We also saw that arrangements for people’s discharge was done in conjunction with staff from the local authority’s other NHS trusts and voluntary bodies.

We discussed the arrangements for the safeguarding of vulnerable adults and while they met the requirements of regulations we noted The Trust had plans to improve training for staff.

We looked at the management of drugs on three wards and found that arrangements for the handling and recording of medicines were not consistently adhered to.

We asked about the Trust’s arrangements for monitoring it’s quality of care through ward level audit and examination of mortality figures and found they were working well.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

When we visited Leighton Hospital on 4 May 2011 we spoke to seven older patients who were accommodated on wards four and fifteen. Ward four is a general medical ward and fifteen a surgical trauma ward.

All patients told us they were happy with the way staff treated them and that they were treated with respect and dignity. Most patients understood why they were on the ward although some seemed unaware and relied on their relatives to explain to them. Almost all patients had been asked how they liked to be addressed and this name was used. Most patients understood how to raise concerns although a few seemed unaware, despite having been given information packs that explained this to them.

A few patients said staff did not respond quickly enough although most found it to be fine and some commented that they realised staff needed to prioritise between patients.

We spoke to seven patients on the two wards about the hospital food and most told us that staff had discussed what they liked to eat and that staff checked that they had eaten enough. No patient had missed a meal for a reason other than personal choice.

Most patients seemed satisfied with the quality of the food and commented that it arrived hot. There were specific comments from individuals about their own taste in food was not always met but no theme to the concerns.

Those patients who said they needed help with their meals said that they always got it.

Leighton Hospital is one of three locations providing care as part of Mid Cheshire Hospitals NHS Foundation Trust. It provides a full range of hospital services including emergency care critical care, coronary care, general medicine including elderly care, general surgery, orthopaedics, anaesthetics, stroke rehabilitation, paediatrics and midwifery-led maternity care. The trust also provides outpatient services and a minor injuries unit at Victoria Infirmary and intermediate care services at Elmhurst Intermediate Care Centre.

Mid Cheshire Hospitals NHS Foundation Trust provides services to a population of approximately 300,000 living in and around Alsager, Crewe, Congleton, Knutsford, Middlewich, Nantwich, Northwich, Sandbach and Winsford.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of Leighton Hospital between 8 and 10 October 2014. We also carried out an announced inspection of the Victoria Infirmary. In addition an unannounced inspection was carried out between 5pm and 8.30pm on 24 October 2014 at Leighton Hospital only. As part of the unannounced visit we looked at the management of medical admissions out of hours.

Due to the size and nature of services provided at the Victoria Infirmary we have included our findings for this service within the core service reports for outpatients and emergency & urgent care services.

Overall we rated Leighton Hospital as ‘good’. We have judged the service as ‘good’ for safe, caring, effective and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs.

Our key findings were as follows:

Access and patient flow

• Due to the numbers of emergency admissions there was continual pressure on the availability of beds at the hospital. This meant that some patients were not placed in the area best suited to their needs. As a result the management of patient access and flow across the hospital was of concern and remained a significant challenge for managers. The hospital had made sound arrangements to ensure the timely medical review of patients. However, some of the areas used for escalation beds, especially the primary assessment area, did not provide an appropriate environment for the care of patients overnight. The trust had implemented the Golden Patient initiative to ensure that patients did not spend more than 23 hours in this area and were moved to a setting more suited to their needs at the earliest opportunity.
• There were occasions when patients were moved from ward to ward, sometimes at night due to pressures on bed availability.
• There were also pressures placed on bed capacity by the number of delayed discharges.
• Patient discharge letters were not always issued to GPs in a timely way. In addition the quality of information included in the letters varied considerably. This was of concern as poor communication with GPs and others can lead to delays and confusion in managing patients’ care going forward.

Cleanliness and infection prevention and control

• Patients received care in a clean, hygienic and suitably maintained environment.
• Appropriate equipment was in good supply and was clean and well maintained.
• Staff were aware of and applied infection prevention and control guidelines.
• We observed good practices in relation to hand hygiene, ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• However, there were not always enough medical staff to provide timely treatment and review of patients, particularly during out of hours.
• Shortages of medical staff also meant that some patients waited for long periods in outpatients as medical staff were sometimes called to the wards or emergency department to see patients whose condition had deteriorated.
• The trust was working hard to recruit and retain consultants. It had a number of initiatives in place including cross working with neighbouring trusts and recruiting medical staff from overseas. These initiatives were helping to address medical shortfalls. Nevertheless, the shortage of medical staff meant that patients sometimes waited for extended periods of time to be seen by a consultant.
• There was also a shortage of trainee doctors. This was being taken forward by the Medical Director with the regional training schools, with a view to the trust being allocated a full complement of trainee doctors. This would alleviate pressures on the existing team and free up more senior colleagues so they could see patients quickly.
• The pressures on the medical workforce had also led to delays in discharge letters to GPs. There were also concerns about the quality and content of the discharge letters as they were of variable quality and clarity. The lack of clarity had the potential to lead to confusion about who was responsible for the ongoing care of patients. The trust had recognised this as an issue and had begun to pay medical staff overtime to reduce the backlog. However, there were a number of wards and departments that were still struggling to send out this important information in a timely way.

Nursing staff

• Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services. However nurse staffing levels, although improved, remained a challenge. The trust was actively recruiting nursing staff from overseas to try and improve staffing levels.
• Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short notice sickness and absence.
• Nurse staffing on the critical care unit did not always meet best practice requirements.

Mortality rates

• Our intelligent monitoring report highlighted the trust as being an elevated risk for mortality rates. The medical director took the lead for addressing this and implemented an action plan that appears to be effective. The plan included partnership working with community providers and commissioners and is reducing HSMR and SHMI rates.
• The trust showed insight in understanding the mortality data and identifying any potential improvement areas for patient safety or the patient pathway. In addition, work had been undertaken with the coding team and the medical staff to improve the coding information. Changes in coding practice had been made and the trust was confident that its mortality data quality had improved and would continue to do so.
• Mortality and morbidity meetings were held weekly and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for every patient who had died in the hospital within the previous week. Any learning identified was shared and applied.
• While we were carrying out our inspection the latest SHMI data became available. This indicated that the trust was moving nearer to expected levels at 104, continuing the positive downward trend. The trust stated its intention to remain proactive and vigilant in understanding and improving its mortality rates.

Nutrition and hydration

• Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.
• There was a period over mealtimes when all activities on the wards stopped, if it was safe for them to do so. This meant that staff were available to help serve food and assist those patients who needed help. There was a coloured tray system in place so that patients who needed assistance with eating and drinking could be easily identified and offered appropriate and discreet support.

Medicines management

• Medicines were provided, stored and administered in a safe and timely way.
• Anticipatory end of life care medication was appropriately prescribed. Patients who had moved into the community on an end of life pathway were sent home with prescriptions including a signed prescription chart. This was good practice as it enabled community nurses to give symptomatic relief without delay from the time the patient arrived home.

We saw several areas of outstanding practice including:

• In medical care, the trust had introduced an electronic handover tool (e-handover) for which they had received a Health Service Journal Award. Medical staff at the trust had developed documentation for the care of patients on an alcohol detox pathway.
• The new critical care unit had been designed in accordance with the latest best practice guidance with the aim of reducing delirium and the problems associated with sensory deprivation. For example the rooms on one side of the unit benefitted from full length windows incorporating an electronic blind so that natural light was visible. In addition the unit made use of sky ceiling photo panels above patient beds, which displayed realistic images of blue skies, white clouds and blossom trees.
• The end of life care service had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medication.
• The hospital had a rapid discharge pathway to enable patients to be discharged from the acute hospital to home in the last hours /days of their lives. An audit in March 2014 showed that the preferred place of care (PPC) was achieved for 84% of patients seen by the specialist palliative care team (SPCT) and PPC wishes were met for 96% of the patients seen by the team.

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

Importantly, the trust must:

• Ensure that medical staffing is sufficient to provide appropriate and timely treatment and review of patients at all times including out of hours.
• Ensure that medical staffing is appropriate at all times including medical trainees, long-term locums, middle-grade doctors and consultants.

• Improve patient flow throughout the hospital to reduce the number of patient bed moves and patients’ length of stay – particularly in the medical division.

• Take action to clear the backlog of discharge letters, and implement an effective system for managing discharge letters so that GPs receive accurate and robust information about their patients in a timely way

• Ensure that escalation areas are appropriate environments for the care of patients and provide them with ready access to bathing and toilet facilities.

In addition the trust should:

• Consider improving arrangements for clinical supervision to ensure they are appropriate and support staff to effectively carry out their responsibilities, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.
• Ensure that, where patients are deemed not to have capacity to consent, staff are establishing and acting in accordance with the best interests of the patient and that this is appropriately documented.

In emergency & urgent care services:

• Ensure that all staff complete their mandatory training in a timely manner.
• Consider updating the sudden death checklist for paediatrics to include a “do not leave child alone with parents” step.
• Ensure they have a list of appropriate staff that have been trained with the required scene safety and awareness training.

In medical care services:

• Ensure timely access to treatment for upper gastrointestinal bleeds and stroke thrombolysis, including out of hours.
• Ensure action is taken to improve outcomes for patients with diabetes or who have had a stroke.

In surgery services:

• Ensure that appropriate action is taken to reduce the number of elective surgical patients that are readmitted to hospital following discharge.
• Continue to monitor and fully implement the proposed actions in order to reduce the number of cancelled operations and improve theatre utilisation.

In maternity & gynaecology services:

• Review and improve the provision of consultant anaesthetic sessions for elective caesarean sections to provide a more responsive service for women.

In services for children & young people:

• Consider reviewing safeguarding children training to ensure that the format, content and duration is in line with best practice guidance, in particular the provision of inter-agency training, and that the time allowed for level 3 training is appropriate to support the learning needs of staff
• Ensure that safeguarding concerns are reported via the incident reporting systems to make sure that incidents are fully investigated, and provide assurance that all relevant staff are aware of lessons learned.

In outpatients and diagnostic imaging services:

• The trust should take action to ensure that waiting times for outpatient clinics are improved and that clinics do not over run leading to cancellation of appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals