A summary of our findings about this location appears in the overall summary

The Royal Albert Edward Infirmary is a large district general hospital operated by Wrightington, Wigan and Leigh NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, general medicine (including elderly care), surgery, neonatal care, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services. The hospital has 513 beds.

Urgent and emergency services and children and young people’s services at Royal Albert Edward Infirmary were previously inspected in December 2015. Urgent and emergency services were rated as ‘good’ and children and young people’s services were rated as ‘requires improvement’.

In March 2017, we carried out an unannounced inspection of these services to review specific areas of care including the assessment and observation of patients, record keeping, pathways of care for discharging or transferring patients, staff training and staffing levels.

The inspection was in response to concerns that were raised about the safety of services provided to patients. The inspection therefore focused solely on the safety of services provided. We inspected the hospital during the evening/night of 17 March 2017, visiting the following areas:

• Paediatric Emergency Care Centre (PECC)
• Emergency Care Centre (ECC)
• Rainbow Ward

We found that these services required improvement for safety. This was because the systems and processes for recognising risks and escalating the deteriorating patient were not always adhered to, records were not always completed correctly and compliance levels in some areas of training, such as safeguarding level three, were lower than the trust target.

Our key findings were as follows:

• Records were not always completed fully by medical and nursing staff. This meant there was limited evidence of the care provided to patients.

• Despite tools being available to help staff manage risks to patients, they were not always used effectively. For example, in some records we reviewed we saw no evidence of clinical observations, early warning scores and risk assessments. We also had concerns that some of the guidance relating to managing risk was unclear. For example, one piece of guidance instructed staff to complete ‘routine’ observations, without clarifying the specific frequency.

• Mandatory training figures for staff did not always reach the trust target of 95%. Training for safeguarding was particularly low. This posed a risk that staff may not have the necessary training to enable them to care for patients appropriately.

• Dispensers storing sanitising gel were empty in the main reception area in the emergency care centre. This limited people’s ability to clean their hands effectively prior to entering the department.

• A room in the emergency care centre storing major incident and chemical decontamination equipment was also used occasionally to take blood samples from patients. The room was a less than ideal environment with large items of equipment next to the trolley where patients sat to provide their samples.

• Duty of candour was not fully documented in the investigation report following the never event on Rainbow ward.

• Appropriate action was not always taken following completion of the Paediatric Early Warning Score (PEWS) on Rainbow ward.

  However:

• Following our inspection in December 2015, the trust had improved the levels of training for nurses on Rainbow ward, with higher compliance in advanced paediatric life support and tracheostomy care.

• Staffing levels on Rainbow ward were also improved, with greater numbers of staff available to care for children at all times.

• Staff in the Emergency Care Centre were able to explain their actions during major incidents or incidents involving hazardous substances.

In areas of poor practice the trust needs to make improvements.

Importantly, the trust must:

• Ensure staff complete mandatory safeguarding children training appropriate to their role.
• Ensure staff complete other mandatory training to maintain compliance in line with the trust target.
• Ensure that tools to manage risk are used and recorded such as completing risk assessments and observations and taking appropriate action when triggering Paediatric Early Warning Scores (PEWS).
• Ensure that patient records are accurate and complete.

In addition the trust should:

In relation to children and young people services:

• Ensure duty of candour is documented following a notifiable safety incident.
• Ensure cleaning schedules are consistently completed in all areas.
• Ensure the expiry date is legible on all controlled drugs.
• Ensure the medicine fridge thermometer is reset in line with trust policy and action taken is documented when the fridge temperature deviates from the acceptable range.
• Ensure the refrigerator in the milk room is available and fit for use.
• Ensure current guidelines for the management of paediatric sepsis are available for staff.

In relation to urgent and emergency services:

• Ensure trust guidance is consistent throughout all departments in relation to the use of early warning scores, clinical observations and general monitoring of patients, and that where required, categories and frequency of monitoring is stipulated to ensure clarity.
• Ensure that all staff use the same guidance relating to the frequency of observations
• Ensure that sanitising gel is available in all dispensers
• Review the suitability of the room used to store major incident equipment in relation to taking blood samples from patients
• The trust should review the entrance and exit door to the paediatric emergency care centre with a view to ensuring the risk of children or young people exiting the department is as low as practicable.
• Consider amending the checklists used on resuscitation trolleys to ensure any action to replace missing items can be documented to avoid potential confusion.
• Consider introducing checklists to record that defibrillators have been checked rather than relying on printed strips stored in no particular order.
• Obtain assurance and ensure that staff involved in assessing patients are aware of, or appropriately prompted to consider female genital mutilation
• Ensure that guidance about conditions requiring senior medical review covers occasions when consultants are not on site and available only on an on call basis.
• Ensure that the care pathway for caring for patients with a blood borne virus is up to date and that the latest version is displayed on the relevant noticeboard in the emergency care centre.
• Only store equipment in appropriate packaging and remove equipment that is not stored in this way.

Professor Ted Baker

Chief Inspector of Hospitals

We inspected the hospital in November 2012 and again in April 2013. At both of these inspections we found that the hospital was not meeting the standards required for the management of medicines. We issued a Warning Notice after our inspection April 2013 and asked the hospital to make improvements. We issue Warning Notices to a registered person [in NHS Trusts this person is the Chief Executive Officer(CEO)] where the quality of the care they are responsible for falls below what is legally required.

After our inspection in April 2013, the provider (the hospital senior managers) wrote to us and told us about the changes that had made and those that they were planning to make. When we visited in July 2013 we found that that many improvements had been made. Patients told that they had no concerns about their medicines. One patient told us “You can see the nurses checking your medicines before they give them to you. This makes me feel safe.” We found that the hospital was now meeting the standards for the management of medicines.

We looked at the systems in place for checking that medicines were managed safely within the hospital. This is sometimes referred to as a quality assurance system. We found that significant improvements had been made and that the hospital was now meeting this standard too.

This was a follow up inspection to the one that we carried in November 2012. At that inspection we found that there were concerns about the timeliness with which patients received fluids, the level of privacy and dignity and arrangements in place regarding the management of medicines for patients administering their own medication whilst in hospital. We were also concerned as there were not always plans in place to achieve full compliance with guidelines issued by the National Institute for Health and Clinical Excellence (NICE).

At this inspection we visited five wards and did not find any concerns about patients’ care. We spoke with nine patients who told us that they were well looked after. Patients’ comments included “Everything is fine. They have kept me informed about what is happening.”; “I had a long wait in A&E but staff were very busy. My experience has been OK” and “There are lovely staff. They have been very good to me.”

Most patients said that there were no issues with their medicines. However when we checked patients’ records we found that patients were not always receiving the medicines that they should. There were systems in place to check that patients had been given the correct medicines at the correct time but the problems identified had not been followed up with actions.

We visited the hospital because we had concerns about some serious incidents that had happened within the operating theatres at Royal Albert Edward Infirmary (Wigan Infirmary) and also at Wrightington Hospital. These incidents occurred because internationally recommended checklists were not being completely followed on some occasions. We found that systems had improved within the operating theatres where the serious incidents had taken place. However, some theatre staff told us that they did not always get the required level of support from some of the surgeons.

Some patients told us they were very happy with the care that they received and we heard comments such as “The doctors explain everything, nothing is too much trouble." On one ward of the five we visited we heard mixed feedback from patients about the care they received. Two patients told us that they had not received pain relief. We were also concerned about the timeliness with which patients received fluids, the level of privacy and dignity and arrangements in place regarding the management of medicines.

We spoke with 15 staff who all told us that they received sufficient training for their roles and that they were supported in their jobs.

There were systems in place to monitor the quality of care being delivered. However, it is a concern that there were not always plans in place to achieve full compliance with guidelines issued by the National Institute for Health and Clinical Excellence.

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.

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.
• 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 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.

Importantly, the trust must:

In Emergency Department:

• Ensure that there are sufficient numbers of staff who are trained to resuscitate children at all times.

In Medicine:

• Deploy sufficient staff with the appropriate skills on wards.
• Ensure that all staff receive appraisals and complete mandatory training to enable them to carry out the duties they are employed to perform.
• Ensure that records are kept secure at all times so that they are only accessed by authorised people.

In Children and Young People:

• Ensure staffing levels are maintained in accordance with National professional standards.
• Ensure that there is one nurse on duty on Rainbow ward trained in Advanced Paediatric Life Support each shift.
• Ensure that staff are trained and competent to deliver the care required by patients with a tracheostomy.
• Ensure that risk rating and escalation is robust to ensure mitigating actions are taken in a timely way.
• Ensure the ward manager has sufficient time to perform the managerial tasks associated with the role.
• Ensure the senior leaders of the service are cited on the risks and actions being taken.

In addition the trust should:

In Emergency Department:

• Improve incident reporting by ensuring all staff are aware of the types of incidents they should report.
• Improve the reviewing of risk assessments to manage and mitigate them in a continuous and timely way.
• Improve documentation in patient records to ensure it is accurate and fully completed.
• Take action to improve performance in the monitoring of vital signs for children.
• Take action to improve the provision of leaflets in different languages to reflect the needs of the local population.
• Improve the screening for infectious diseases, such as Ebola, across the department.
• Review the compliance with policies and procedures relating to the time patients should spend in the clinical decision unit (CDU).
• Review compliance with the cleaning regime in the children’s emergency department (PECC).

In Medicine:

• Improve the timeliness of discharge when patients are fit to do so.
• Reduce the moves between wards that patients are experiencing and the number of patients receiving care on a ward not specific to their needs.
• Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.
• Review the gaining of consent for the use of bedrails and the application of the Mental Capacity Act (2005) principals where appropriate. Supported by procedures and relevant mental capacity act training.
• Review the prescribing of oxygen for patients when required.
• Maintain patients’ privacy and dignity at all times in the discharge lounge.

In Surgery:

• Maintain that trolleys containing patient’s notes are kept locked.
• Maintain that records are fully completed with name and designation always clearly recorded and printed.
• Display dated green ‘I am clean’ stickers on all equipment.

In Maternity:

• Review and maintain that emergency equipment and medicines are checked in line with trust policies and procedures and that a record is held.
• Review and maintain that equipment is checked and records are kept to ensure equipment is maintained and fit for purpose.
• Review accessibility procedures into the maternity unit.
• Review procedures related to temporary staff and ensure that there are robust monitoring arrangements in place.
• Review and maintain that guidelines are up to date and include evidence of the use of latest recognised publications.
• Review communication methods used to deliver key messages to midwifery staff.
• Review the on-going problems with the drainage problem on the maternity unit to seek resolution.
• Review and maintain that there are robust systems in place to ensure the security of both the postnatal ward and delivery suite.

In Children and Young People:

• Consider the provision of accredited Newborn Life Support training for junior Doctors working on Rainbow ward and the neonatal unit.
• Take steps to ensure that resuscitation equipment is available and fit for use.
• Record the maximum and minimum fridge temperatures for each medication fridge.
• Maintain equipment within the required timeframes.
• Review the checking of controlled medicines is in line with trust policy.
• Develop a current Female Genital Mutilation policy which includes the mandatory reporting requirements and a domestic abuse policy and training that includes modern slavery, human trafficking and domestic violence prevention orders.
• Identify staff learning needs through the trusts appraisal process.
• Consider employing a  Registered Mental Health Nurse to care for children requiring Child and Adolescent Mental Health Services.
• Ensure shower facilities for parents staying with their children are in good working order.

In End of Life:

• The service should improve their compliance with the regional DNACPR standards particularly with regards to the use of MCA and best interest decisions.
• The service should consider improving access to medical devices out of hours. At the time of our inspection syringe drivers which may be required at the weekend were kept in a loan store in the basement. 
• The service should improve the review and updating of the risk register in a timely manner, with target dates for actions, to ensure all risks are being managed effectively and are not left on the register without being addressed for an extended time.

In Outpatient:

• Consider improving outpatient facilities such having drinking water available and children’s facilities in the outpatient waiting area.
• Consider the implementation of the use of the Safety Checklist for Interventional Radiology.
• Review the outpatient area in proximity to the reception desk to explore options for improving privacy for patients.

Professor Sir Mike Richards

Chief Inspector of Hospitals