Warrington and Halton NHS Foundation Trust serves a population of 330,000. The majority of emergency care and complex surgical care is based at Warrington Hospital.

We carried out an unannounced focused inspection of the emergency department at Warrington Hospital on 18 February 2019. The purpose of the inspection was to review the safety of the emergency department as part of a focused winter inspection programme. At the time of our inspection the department was under adverse operational pressure.

We did not inspect any other core service or wards at this hospital or any other locations provided by Warrington and Halton NHS Trust. We did visit the GP assessment unit and the ambulatory emergency care unit. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry. We did not rate this service at this inspection.

The trust has one emergency department which provides a 24-hour, seven day a week service. It is a designated trauma unit but patients with major trauma are usually taken directly to the neighbouring major trauma centre.

Our key findings were as follows,

• There were not enough available beds in the hospital to allow emergency patients to be admitted to a ward as soon as this was required. This had resulted in a crowded emergency department with patients receiving care and treatment in corridors. One patient spent 18 hours in the department. Another was nursed in the corridor for six hours.
• Initial clinical assessment (triage) of patients did not take place according to guidance produced by the Royal College of Emergency Medicine and the Royal College of Nursing. Patients (including those arriving by ambulance) sometimes waited for two hours to be triaged. There was a risk that serious medical conditions could remain undetected with a consequent delay in treatment.
• Early warning scores were not always calculated as often as they needed to be to detect patients who were at risk of deterioration.
• There were not enough nurses and doctors with the right skills and experience to treat all the patients who attended the emergency department.
• Ambulance crews sometimes had to wait in the emergency department because they could not handover their patients to hospital staff. This meant that they were not able to leave the hospital to respond to new 999 calls.
• On-call specialist doctors were often slow to respond when emergency patients were referred to them.
• There was a lack of awareness of performance standards such as ambulance handover times, response times from on-call teams, time taken to perform urgent brain scans, or average time between the decision to admit and admission taking place

However;

• Once identified, critically ill patients were seen quickly by a senior emergency department doctor and were treated according to national guidance.
• There was a supportive and friendly culture within the department which was centred on the needs of patients.
• Junior doctors felt well supported and were positive about the training they received in the department.
• Staff of all disciplines and seniority spoke positively about working in the emergency department.
• The emergency department had an energetic, cohesive and well-motivated leadership team.

Professor Edward Baker

Chief Inspector of Hospitals

We visited Warrington Hospital on 28th January 2014 and went to the Accident and Emergency Department (A&E), elderly care wards A2, A3, A8 and A9. We also spoke with staff on the wards and departments we visited, observed care being delivered and spoke with patients and family members. We also spoke with members of the Dementia Care Team in the Trust including the medical lead and a dementia specialist nurse. We received further information from the Trust during the inspection. We looked at treatment records for patients and spoke with staff who worked in discharge planning and the hospital social work team.

We looked specifically at the care and treatment of people who were admitted to hospital and had either diagnosed dementias or identified cognitive impairments who may have been admitted to the hospital for a number of reasons.

Most people we spoke with told us that they were happy with the service they received in the hospital. One person told us: “The staff seem very jolly with my relative, and chat with her whilst they make sure she is alright”; “The staff have been very caring and informative about the medical condition and treatment for this” and ‘The staff have been great with him all the time he has been here.” Most care we observed was delivered by nursing staff in a kind and responsive manner. We saw that family members were involved in discussions about their relatives by looking in the notes and by speaking with family members.

We also reviewed comment cards which we had left on the wards mentioned above, the majority of which were positive about the service.

We saw that the hospital had a process to ensure that people with dementia who had different support needs were identified on admission and provided with care and treatment which met their individual needs. We tracked four patient’s pathways through the hospital and found that this was effective. The trust used ‘This is me’ a document which can be filled out and given to staff when a person with dementia goes into hospital and provides a 'snapshot' of the person behind the dementia. The leaflet will help hospital staff to learn about the person's habits, hobbies, likes and dislikes; however there was some variation in the quality and detail of information about people’s social histories and preferences.

Most of the staff we spoke with had received a minimum of one day training specifically related to dementia care and they all spoke positively about this.

There were systems put in place by the provider on a ward and trust-wide level to monitor the quality of dementia care provided.

We spoke with professionals who frequently used the services of the microbiology laboratory and they said they were more than happy with the service that was provided. They said that they were informed by the lab staff of the test results (as soon as these were available) to help plan the patient care pathway. They found lab staff approachable and supportive.

One person said “Very good, cant think of any mishaps”, “ the turn around time is good“, “there is always someone on the end of the phone to give advice and support”.

There were no serious untoward incidents in the last 12 months, providing assurance of good laboratory practice.

Staff spoken with said that they had adequate staff to meet the needs of the service.

Staff spoken with said “I like the job and people it is a good team”, “ we get good training on the job”, “I am quite happy in my work”, “ this is a nice place to work.”

On examination of documents requested and interviews with some users and staff, it appeared that good laboratory processes were in place and that the laboratory offered a high quality and safe service

During our inspection we spoke with 18 people including patients, relatives and other visitors in various wards and departments. Most of the feedback we received was positive. We heard comments such as “the staff are brilliant, nothing is too much trouble for them”; “I give them 90%”; and staff are marvellous and “staff have been good.” We received very few negative comments about the services. One person felt they had a long wait in the accident and emergency department and another person stated that their food was not always as hot as they liked it.”

Patients we spoke with told us they were always asked for their permission before care or treatment was given. We found that the hospital had robust procedures in place to ensure that the rights of patient’s who did not have capacity to make certain decisions for themselves were protected. Staff members were also aware of the action they would take if they suspected that someone was being abused.

We looked at how the hospital managed medicines for patients and we found that they were managed safely and effectively. We also spoke with 10 staff members who told us that staffing levels were adequate as long as people arrived for their shifts.

We looked at 18 sets of patient records during our visit and we found that they were not always accurate. Senior managers showed us the plans in place to deal with the shortfalls that the hospital had identified. We will check records again at our next visit.

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.

Areas visited by Care Quality Commission as part of this review were Accident and Emergency Unit, Clinical Decisions Unit, Urgent Care Centre and ward A1.

People we spoke with on all units were satisfied with the care and treatment they received. They said that staff kept them fully informed of all procedures and treatment and gave them reassurance. Comments made included “the staff are very good”, “staff have been marvellous”, “I know what is happening to me”, “ all very good”, “ staff very informative”, “staff have explained to me what is happening and where I will be sent to next”.

Patients said the food was “good”.

We carried out an announced inspection of Warrington Hospital  between the 7 and 10 of March 2017. In addition, we carried out an unannounced inspection between 3pm and 9pm on the 23 March 2017. This inspection was to follow up on the findings of our previous inspections in January and February 2015, when we rated the trust as requires improvement overall. We also looked at the governance and risk management support for all of the core services we inspected.

At this inspection we inspected the following services at Warrington Hospital:

• Urgent and Emergency Care

• Critical Care Services

• Services for Children and Young People

• Maternity and Gynaecology Services

• Medical Services [Including the care of older people]

• Surgery

• End of Life Services

• Outpatient and Diagnostic Services

As part of this inspection, CQC piloted an enhanced methodology relating to the assessment of mental health care delivered in acute hospitals; the evidence gathered using the additional questions, tested as part of this pilot, has not contributed to our aggregation of judgements for any rating within this inspection process. Whilst the evidence is not contributing to the ratings, we have reported on our findings in the report.

We rated Warrington Hospital as requires improvement overall with Medicine [including older people’s care] Critical Care, Outpatient and Diagnostic services and Maternity and Gynaecology Services as requires improvement. We rated Urgent and Emergency , Surgery, End of Life Services and Services for Children and Young People as good.

There had been progress since our previous inspection with, improvements noted in urgent and emergency care, maternity, surgery, outpatient and diagnostic services  and Critical care. However, Warrington Hospital continues to require improvement in key areas.

Our key findings were as follows:

• Systems had been put in place to improve access and flow through the Accident and Emergency department and although targets were not been met there had been a continuous improvement in waiting times.

• The trust monitored the number of cancelled operations on the day of surgery. Performance data showed that the number of cancelled operations on the day of surgery had improved from 11.9% in February 2016 to 8.8% in January 2017.

• The National Paediatric Diabetes Audit 2014/15 showed that Warrington hospital performed better than the England average for the number of individuals who had controlled diabetes.

• There had been some improvements since our last inspection in January 2015: working relationships between medical staff and midwifery staff, overall culture was improving, WHO checklist and consent forms, laparoscopic hysterectomies were undertaken and mandatory training for nurse and midwifery compliance rates had improved.

We saw some areas of outstanding practice including:

• The trust had developed the Paediatric Acute Response team to deliver care in a Health and Wellbeing Centre in central Warrington. This allowed children and young people to access procedures such as wound checks and administration of intravenous antibiotics in a more convenient location. It also allowed nurse-led review of a range of conditions such as neonatal jaundice and respiratory conditions in a community setting that would have previously necessitated attendance at hospital.

• Within the urgent and emergency care division, the use of the Edmonton frailty tool in the treatment of older people in the department and the wider health economy.

• The training of all the consultants within the accident and emergency department in the use of ultrasound for timely diagnosis of urgent conditions.

• The trust 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 medicine.

• The environment on the Forget Me Not ward had been designed using the recommendations set out by The Kings Fund to be dementia friendly. The ward was designed to appear less like a hospital ward and featured colour coded bay areas and a lounge and dining area designed to look like a home environment. There was access to an enclosed garden and a quiet room. 

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

Importantly, the hospital must:

• The hospital must ensure that staff receive training on the Mental Capacity Act (2005) and that staff work in accordance with The Act.

• The hospital must ensure that paper and electronic records are stored securely and are a complete and accurate record of patient care and treatment.

• The hospital must ensure that staff receive the appropriate level of safeguarding training.

• Critical care services must improve compliance with advanced life support training updates and ensure that there is an appropriately trained member of staff available on every shift.

• The hospital must ensure that the formal escalation plan to support staff in managing occupancy levels in critical care is fully implemented.

• The hospital must ensure that there are appropriate numbers of staff available to match the dependency of patients on all occasions.

• The hospital must ensure that all risks are formally identified and mitigated in a timely way as part of the risk management process.

• The hospital must take action to ensure that all safety and quality assurance checks are completed and documented for all radiology equipment, in accordance with Ionising Radiations Regulations.

• The hospital must ensure midwifery, nursing and medical support staffing levels and skill mix are sufficient in order for staff to carry out all the tasks required for them to work within their code of practice and meet the needs of the patient.

• The hospital must ensure all necessary staff completes mandatory training, including Level 3 safeguarding training.

• The hospital must ensure that the assessment and mitigation of risk and the delivery of safe patient care is in the most appropriate place.

• The hospital must review the impact of the triage system on access and flow and the appropriate assessment of patient safety.

• The hospital must review the safety of the induction bay environment to ensure patient safety is maintained at all times and that the premises are safe to use for the purpose intended.

• The hospital must ensure that all staff receives medical devices training and this is recorded appropriately.

• The hospital must ensure that that the risk register and action plans are comprehensive, robust and adequate to improve patient safety, risk management and quality of care.

• The hospital must ensure staffing levels are maintained in accordance with national professional standards.

• The hospital must ensure that there is one nurse on duty on the children’s unit trained in Advanced Paediatric Life Support on each shift.

In addition the trust should:

• The hospital should ensure that the mandatory and safeguarding training rates are monitored for medical staff.

• The hospital should consider that the urgent and emergency care department make improvements to the room used to see patients with mental health problems, particularly to the doors so that they open outwards.

• The hospital should make reasonable adjustments for appropriate patients including those with a learning disability.

• The hospital should improve appraisal rates for nurses and medical staff.

• The hospital should consider that the Early Pregnancy Assessment Unit (EPAU) is opened seven days a week.

• The hospital should identify ways to improve multidisciplinary attendance at local and divisional meetings.

• The hospital should consider the safe storage of patient’s notes on the wards.

• The hospital should consider the dignity and privacy of patients within the clinical areas and maternity theatre.

• The hospital should review accommodation on wards where patients are at the end of their lives. To allow them to supported in rooms that afford privacy for the patient and families.

• The hospital should review access to specialist palliative care medical support out of hours.

• The hospital should continue to review compliance with DNACPR policy and clear application and documentation of mental capacity assessments.

• The hospital should ensure all patient case note records are maintained in a complete and chronological order, with accurate details of follow up for patients who did not attend appointments.

• The hospital should ensure patients receive sufficient, clear and appropriate information regarding their hospital appointment. This should include adequate directions to clinic locations and relevant written information about treatment plans where this is indicated.

Professor Ted Baker

Chief Inspector of Hospitals