Whiston Hospital is part of St Helens and Knowsley Teaching Hospital NHS Trust and provides a full range of hospital services, including an urgent and emergency care facility, general and specialist medicine, general and specialist surgery full consultant led obstetric and paediatric hospital service for women, children and babies.

Whiston Hospital is situated in Prescot and serves a population of approximately 350,000 people residing in the surrounding area of Knowsley, Halton and St Helens. In total, the trust has 887 beds.

We carried out this inspection as part of our scheduled program of announced inspections

We visited the hospital on the 19, 20, 21 August 2015. We also carried out an out-of-hours unannounced visit on 05 September 2015. During this inspection, the team inspected the following core services:

• Urgent and emergency services
• Medical care services (including older people’s care)
• Surgery
• Critical care
• Maternity and gynaecology
• Children and young people
• End of life
• Outpatients and diagnostic services

Overall, we rated Whiston Hospital as ‘good’. We have judged the service as ‘good’ for safe, effective, and well led and 'outstanding' for caring. We noted that there were elements of outstanding practice in caring overall and in caring and well led in outpatients and diagnostic services. However maternity and gynaecology were judged as requiring improvement in three of the five areas safe, responsive and well-led.

Our key findings were as follows:

Leadership and management

• The hospital was led and managed by a cohesive and visible executive team. The team were very well known to staff and were regular and frequent visitors to the wards and departments. Staff were well engaged and were aware and committed to the organisational vision of five star patient care. There were good opportunities for staff to be included and active in service design and delivery. There was a range of reward and recognition schemes that were highly valued by staff. Staff were supported and encouraged to be proud of their service and achievements. Successes were actively acknowledged and celebrated.
• There was a positive culture throughout the hospital. Staff were open and honest and were very proud of the work they did and proud of the services they provided although there was additional work to be done to support a positive culture in maternity services. Overall staff morale was good with the exception of some staff in maternity services who were concerned regarding recent changes to shift patterns and internal rotation. Some also expressed a desire for their senior manager to be more visible and accessible to them. The senior team are aware of this concern and expressed a commitment to addressing the issues identified.

Access and Flow

• Access and flow in the emergency department remained a continuous challenge. The trust had a mixed performance against the four hourly national target over the year.
• The proportion of all patients that attended the emergency department and were treated within four hours was 93.2% (2,099 attendances) between October and December 2014, 91.7% (2,548 attendances) between January and March 2015 and 93.2% (2118 attendances) between April and June 2015.
• An action plan was in place to improve performance in the four-hour waiting time targets. This included actions to review medical staffing arrangements to improve treatment and discharge times and to improve medical cover during nights and weekends.
• Patient flow through the hospital and discharge had improved. Between July 2014 and July 2015 data showed that there had been 87 medical outliers at the hospital. At the time of our inspection there were ten medical outliers. These were managed effectively from the point of admission which resulted in reduced bed moves during the hospital stay. Patients who were outliers were reviewed on a daily basis by a member of the medical team.
• There had been issues with delayed and out of hours discharges from critical care. More recently the figures for delayed and out of hours discharges had improved and are now comparable with similar units in other hospitals. This improvement has been attributed to team work, improved communication between departments and bed managers, a tightening up of the discharge process and more accurate data collection.
• Bed occupancy rates were higher than the England average from July 2014 to December 2015 in maternity, with the rates ranging from 73-88 % compared to 56 to 60% nationally. This meant the maternity services were running at a higher than usual capacity and we were not made aware of plans for managing this. Only 9.3% of midwives were trained to complete the new-born infant physical examinations and there was a lack of paediatric doctors to complete these. This led to delays in discharge within the maternity service.
• Patients were seen and assessed by the special palliative care team within 24 hours of referral. A rapid discharge processes were in place in getting people to their preferred place of care prior to their death.
• The outpatient department undertook 234,725 outpatient appointments during 2014/15. The trust met internal and national referral to treatment targets and was easily meeting the national six week target for patients waiting for a diagnostic appointment. The also trust performed better than the England average during 2013/14 and 2014/15 for patients waiting less than 32 and 62 days for treatment. We found the trust was consistent with the England average for patients seen by a specialist within two weeks from 2013/14 to 2014/15.

Cleanliness and Infection control

• Patients were cared for in a visibly clean and hygienic environment.
• Staff followed the trust policy on infection control and adhered to the ‘bare below the elbows’ policy.
• Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
• There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There was a suitable supply of hand wash sinks and hand gels available.
• Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.
• Patients identified with an infection were isolated in side rooms. We saw that appropriate signage was used to protect staff and visitors. The trust had employed a number of infection control link nurses and a surgical site infection specialist nurse worked across both sites. Their role was to provide training and to liaise with staff so patients that acquired infections following surgery could be identified and treated promptly.

Nurse staffing

• Nurse staffing levels were determined using an evidence based tool.
• The expected and actual staffing levels were displayed on a notice board on each unit/ward and these were updated on a daily basis.
• Staffing levels were planned to ensure an appropriate skill mix to provide care and treatment for patients.
• However, nurse staffing levels, although improved, remained a challenge in some areas. This was particularly the case in medical care services and maternity and gynaecology. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff. Where possible, regular agency and bank staff were used which meant they were familiar with policies and procedures. Any new agency staff received an induction prior to working on the wards.
• The trust had implemented a number of initiatives to address shortages in nurse staffing including: actively recruiting nursing staff from overseas and linking with local universities.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• Consultant cover was provided 24 hours a day seven days a week on the critical care unit.
• In the emergency department the proportion of registrars and junior doctors was greater than the England average. The proportion of consultants was below the England average (19% compared with the England average of 23%). The proportion of middle grade doctors was also below the England average (4% compared with the England average of 13%).
• Consultant staff in children’s and young people’s services reported a shortfall in middle grade doctor staffing. Ten middle grade doctors were required but the service only currently employed eight. The two remaining vacancies were filled by locum doctors and through extra staffing in A&E.
• The trust's own specialist consultant in palliative medicine was on secondment at the time of inspection. Cover was provided by the community consultant in palliative medicine for St Helen’s, Knowsley and Halton who provided five sessions per week at the hospital. In addition the hospice’s specialist registrar provided two sessions per week. Managers were aware of this shortfall and plans were in place for the recruitment of a specialist consultant.
• Staff rotas were maintained by the existing staff and through the use of agency or locum consultants. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The majority of locum and agency doctors had worked at the hospital on extended contracts so they were familiar with the hospital’s policies and procedures.

Mortality rates

• Multidisciplinary mortality and morbidity reviews were held for a 20% random sample of every death in medical services. If the review indicated any issues these were then rated as amber and further in-depth investigation took place. There had been six amber reviews in the last nine months prior to inspection.
• Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies and procedures. Deaths were reviewed thoroughly and appropriate changes made to help to promote the safety of patients.
• Mortality meetings were held in the form of critical reviews for any deaths involving children. The service linked with maternity services to ensure a multi-disciplinary approach to review and learning.

Nutrition and hydration

• Where possible there was a period over meal times where all activities on the ward stopped, if it was safe for them to do so. These protected meal breaks enabled staff to assist patients who needed assistance to eat and drink.
• A coloured tray and jug system was in place to highlight which patients needed assistance with eating and drinking. The mealtime co-ordinators wore red aprons and other staff wore blue aprons at mealtimes. The mealtime co-ordinators communicated with the catering staff and ensured all patients had a hot meal.
• Patients we spoke with said they were happy with the standard and choice of food available. The menus were comprehensive and there was a wide variety for patients to choose from. Patients said they were also encouraged to go to the hospital restaurant to eat their meals and that they ordered their meals the same day to ensure they chose what they felt like eating that day
• Meals were managed and served by the housekeeping staff in children’s services and nurses did not have an oversight of the meals provided or consumed.

We saw several areas of outstanding practice including:

• The trust had developed a pressure ulcer (PU) risk assessment tool used by the tissue viability nurses across the wards. This took into account the grade of the PU risk and a care plan was determined which included the equipment to be used for the patient.
• The additional needs pathway and coordinated approach to a patient with additional needs reduced the need for repeat procedures and enhanced the patient’s experience.
• In order to improve the response time and access to timely treatment for a patient, if a critical or abnormal finding on an X-ray was seen detected radiology staff could book another follow up appointment with the appropriate specialist at the time of reporting.

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

Importantly, the trust must:

• Continue its efforts to meet four-hour emergency department national targets.
• Meet the DH target for handovers between ambulance and emergency department.
• Ensure there is the appropriate skill mix of staff and patient’s privacy and dignity is maintained at all times on the coronary care unit.
• Ensure there is a system in place to assess and improve the quality and safety of the services provided following a serious incident. This must include actions to mitigate the risks relating to the health and safety of service users. (Maternity services).
• Ensure systems in place for the storage of medicines are safe.

In addition the trust should:

In urgent and emergency care services:

• Improve mandatory training and staff appraisal compliance in some areas.

In medical care services:

• Conduct a review of training of the medicines policy in relation to the administration of regular medication via oral or intravenous routes.
• Ensure that the implementation of the care certificate is implemented across all services within the national timeframe.
• Ensure that all staff are applying the mental capacity act principals to the use of bedrails.
• Ensure that hazardous chemicals are stored appropriately in a locked cupboard when not in use.

In surgery:

• Ensure all prosthetists receive an appraisal in a timely manner

In critical care:

• The trust should ensure that the use of CCTV cameras does not impact adversely upon patients’ dignity and respect.
• Ensure that all dialysate fluids are kept locked and only accessible to appropriate staff.
• Ensure that all equipment for use in the resuscitation of patients is in date and regularly checked.
• Consider the intensive care society standards for supernumerary staffing when calculating the nurse establishment.

In maternity and gynaecology

• Ensure all midwives are competent in the assessment of CTG monitoring.
• Ensure the procedures for CTG monitoring, including assessment, are in line with best practice guidance.
• Ensure the systems for checking emergency equipment include details of which parts of the equipment are checked and how this is completed.
• Ensure the matrix used to grade incidents is reviewed to ensure near misses are included.
• Ensure specific maternity safety thermometer is used to monitor the delivery of harm free care.
• Ensure the bereavement rooms are a less clinical and provide a more comfortable environment for bereaved patients and their supporters.
• Ensure records are filed in such a way as to afford easy access for medical staff to the record required.
• Ensure medical records are stored confidentially in all areas.
• Ensure all anaesthetists are up to date with the obstetric skills and drills training.
• Ensure band 7 shift co-ordinators on the delivery suite work in a supernumerary capacity to meet best practice guidance.
• Ensure the system for documenting patients being admitted to the delivery suite, including those coming into the unit for ante-natal assessment at evenings and weekends are reviewed to ensure it is clear where patients are at all times .
• Ensure there is a seven day service for ante-natal patients to access support, including in early pregnancy.

Children and young people’s services

• Ensure staff consistently follow trust policy and best practice in relation to completing vital sign observations for children and young people.
• Ensure nurses on wards 3F and 4F take an active part in managing meals and mealtimes.
• Ensure food and nutrition is always stored and accessed safely.
• Ensure staff receive training about when to consider the Mental Capacity Act for young people over 16 years old.
• Ensure a variety of opportunities are provided for children, young people and their parents to comments about the service.
• Consider promoting use of the translation service in all instances when a child or young person when English is not their first language.
• Consider additional steps to ensure all children and young people departments provide relevant and required governance reports when expected.
• Consider analysing staff survey according to directorate so specific experiences and ideas are used to influence the development of the service neonatal, children and young people service.
• Consider setting target dates by which plans should be achieved so improvements can be measured.
• Make the development of robust succession plans for the neonatal unit and children’s wards a priority involving staff in the planning and delivery process.
• Consider reviewing the environment of the neonatal unit alongside best practice for example the Health Building Note 09-03: Neonatal units department of health publication.

End of life

• Develop an EOL strategy.
• Appoint a palliative care consultant.
• Discharge summaries should be sent to patients GPs when patients the have been seen by the trust SPC team.
• Consider the provision of a fully functional electronic palliative care co-ordinating System (EPACCS) across all relevant sites would enable service providers across boundaries to share information.
• Consider how the amber care bundle is to be rolled out as the facilitators post had ceased and there were currently no plans to replace this position.

In outpatients and diagnostic imaging services:

• Ensure that the therapy review is concluded to facilitate the integration of therapies into the trust following their transfer from another provider.
• Continue to seek ways to work with other partners to lessen the impact of the national shortfall of prosthetic services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We carried out this inspection to follow up on non-compliance found at a previous inspection in September 2013. Previously the complaints system was ineffective as complaints people made were not handled and responded to in the timescales expected by the Trust. At this inspection, we found this concern had been addressed.

We did not speak to people as part of this inspection.

During our visit we visited two wards: Ward 1B and Ward 3 Alpha. Ward 1B is the medical assessment unit and Ward 3 Alpha is a dedicated ward for the treatment of hip fractures.

We spoke with eight patients and two relatives during the visit and listened to their experiences of care and treatment at the hospital. Patients on both wards told us they were very happy with the care and treatment they had received. One patient said “Staff are fantastic.” Another patient said “They really have looked after me. Nothing is too much trouble.”

Patients said that staff treated them with dignity and respect. One person on Ward 1B said “[staff are] so respectful” and that “I am treated like a person not a patient.” One relative on 3 Alpha said they were “really pleased with mum’s care.” Patients and relatives told us that staff kept them informed about their care including explaining any tests or procedures.

We were told that the hospital was very clean and that staff were often seen washing their hands. One person said “They always use hand gel between every patient.” Another patient said “They never stop cleaning the place.”

We heard that staff were responsive to requests and that nurse call bells were usually responded to in a timely way. Patients told us that there seemed to be plenty of staff. One patient said “they [staff] never tell you they will be back in five minutes. If you ask for something they will come and help straight away.”

People using the service told us that the majority of the time their personal dignity was respected. We observed staff interact with people using the service in a manner that maintained their dignity.

The management of peoples nutrition needs had significantly improved. Protected mealtimes had given staff time to make sure that they were able to meet and monitor people's nutritional needs. People in the service told us that they generally enjoyed the food and were offered a wide range of choices.

We had received concerns from Social services regarding the management of safeguarding and complaints. The management team acknowledged that mistakes had been made but felt confident that they had put systems and training in place that would improve both these areas. People we spoke with told us that they felt supported to raise concerns as needed.

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

• We rated safe, effective, responsive and well led as good at the hospital with caring being rated outstanding.
• Safe and effective were the same good ratings as at the previous inspection in August 2015.
• Caring remained outstanding as at the previous inspection.
• The rating in responsive had improved one rating to good from the previous inspection.
• The rating for well led went down one rating to good.