Victoria Infirmary

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