Clatterbridge Hospital

Clatterbridge Hospital is one of two hospital sites managed by Wirral University Teaching Hospitals NHS Foundation Trust. The hospital provides a range of health care services including elective orthopaedic surgery (planned operations), specialist stroke and neuro-rehabilitation services, elderly care and dermatology treatments. The elective surgery and stroke rehabilitation wards each have a total of 20 beds. In addition, the hospital offers a variety of outpatient services for a full range of specialities including dermatology, podiatry, cardiac, plastics, phlebotomy, x-ray, and the Wirral Breast Centre. Magnetic Resonance Imaging (MRI) scanning appointments were available but delivered by an external provider.

The hospital is located on the Wirral peninsula in the North West of England and serves the people of Wirral and neighbouring areas.

Wirral University Teaching Hospitals NHS Foundation Trust became a Foundation Trust on 1 July 2007. The trust provides services for around 400,000 people across Wirral, Ellesmere Port, Neston, North Wales and the wider North West footprint with 855 beds trust-wide, including 106 at Clatterbridge Hospital.

We carried out an announced inspection of Clatterbridge Hospital on 16 – 17 September 2015 as part of our comprehensive inspection of Wirral University Teaching Hospitals NHS Foundation Trust.

Overall, we rated Clatterbridge Hospital as ‘requires improvement’. We have judged the hospital as ‘good’ for effective and ‘outstanding’ for caring. 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, 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.
• Staff followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures. We observed staff following hand hygiene practice, bare below the elbow guidance and using personal protective equipment where appropriate.
• There had been no cases of methicillin resistant staphylococcus aureus (MRSA) bacteraemia infections or clostridium difficile infections identified in surgical services across the trust between March 2015 and August 2015. However, across the same period, medical care services reported 21 cases of clostridium difficile infections, two cases of MRSA and six cases of MSSA. The data could not be split so as to separate cases that specifically occurred at Clatterbridge Hospital.
• Side rooms were used where possible as isolation rooms for patients at increased risk of cross infection. There was clear signage outside the rooms so that staff were aware of the increased precautions they must take when entering and leaving the room.
• The majority of wards we visited were visibly clean and free from odour. Wards used the ‘I am clean’ stickers to inform colleagues at a glance that equipment or furniture had been cleaned and was ready for use.
• We observed that the disposal of sharps, such as needle sticks followed good practice guidance. Sharps containers were dated and signed upon assembling them and the temporary closure was used when sharps containers were not in use.
• Patient-led assessments of the care environment (PLACE) audits for 2013 and 2014 scored higher than the national average for cleanliness across the trust, specific data for Clatterbridge Hospital was not available.

Nurse staffing

• Matrons met each day to discuss nurse staffing levels across the divisions to ensure that there was good allocation of staff and skills were appropriately deployed and shared across all wards. In July 2015 there were still 70 nursing vacancies in medical and acute services across the trust.
• The trust had a high vacancy rate for nursing staff in medical services trust wide, which was 13% at the time of the inspection. The turnover of nursing staff was 9.7%.
• There were concerns regarding the number of nurses on duty during the night on the Clatterbridge Rehabilitation Centre (CRC) and ward 36, which were both medical wards. The staffing figures provided by the trust, showed that there were only ever two trained nurses planned to be on duty during the night. This was a ratio of one nurse to 13 patients on ward 36 and a ratio of one nurse to 15 patients on the CRC. Patients on the CRC had neurological conditions and some had suffered a stroke, whilst ward 36 was an elderly care ward.
• The staffing and skill mix on surgical ward areas and in theatre areas was sufficient, with some periods of reduced staffing in areas because of last minute sickness and unexpected events. However, there was a lack of surgical staff trained in paediatric life support. This training was not mandatory for staff, despite them working with children.
• The vacancy rate for nurses in surgical services was below 3% for the five month period prior to the inspection. At the time of the inspection the vacancy rate for nurses across surgical services trust-wide was 2.4%.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• There were sufficient numbers of suitably qualified medical staff during the daytime hours. However, there was only one junior or middle grade doctor on duty during the night and at weekends. The doctor was of a medical and not surgical specialty, and may not be able to offer specialist surgical care and advice as a result.
• There were no surgical doctors, anaesthetic or critical care support on the Clatterbridge site after 8pm. If a patient suffered a collapse or became critically unwell, the staff at the hospital would have to call an ambulance.

Mortality rates

• Nine patients died on the Clatterbridge Hospital site between April 2014 and March 2015. Mortality and morbidity themes and trends were discussed as part of clinical governance meetings; however, it was unclear if any actions for improvement were agreed at the medical care meeting.
• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. Between October 2013 and September 2014 the trust score was 97.

Nutrition and hydration

• The majority of patients we spoke with said they were happy with the standard and choice of food available.
• Staff in surgical services managed the nutrition and hydration needs of patient’s well, both pre and post operatively. Patients were given information in the form of leaflets about their surgery and told how long they would need to fast pre-operatively.
• In all the records we reviewed, a nutritional risk assessment had been completed and updated regularly. This helped identify patients at risk of malnutrition and adapt to any ongoing nutritional or hydration needs.
• A coloured tray system was in place to highlight which patients needed assistance with eating and drinking. The trust had an internal target to ensure that 75% of patients got assistance with eating when they required it. Information provided by the trust showed that they were not meeting this target in medical specialties.
• Staff consistently completed charts used to record patients’ fluid input and output and where appropriate staff escalated any concerns.

We saw several areas of outstanding practice including:

• We observed staff interacting with patients on a one to one basis and displaying a caring person centred attitude that went beyond what was expected. Staff encouraged patients and their relatives to be partners in their care. Staff went above and beyond to meet patient’s preferences. We observed strong relationships between staff, patients and their relatives.
• Patients’ needs and preferences were central to the planning and provision of services at Clatterbridge Hospital. One example of this was the repurposing of a clinical area into a domestic dwelling. This was designed to help prepare medical and surgical patients for discharge to their own home and bridge the gap between acute patient care and community rehabilitation. Patients could ‘move’ into the dwelling with their relatives for short periods before discharge. This helped staff identify whether any further measures were needed before patients were discharged. It also empowered patients to maintain their independence and improve their confidence prior to discharge. Staff told us that this had been introduced partly due to issues which were raised around patients discharge home when they felt they weren’t ready.
• The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘A’ which was an improvement from the previous audit results when the trust was rated as a grade ‘B’. Since October 2014 the trust had either been ranked first or second regionally in the SSNAP audit.

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

Importantly, the trust must:

Medical care (including older people)

• The trust must ensure that robust information is collected and analysed to support improvements in clinical and operational practice.
• The trust must deploy sufficient staff with the appropriate skills on the Clatterbridge rehabilitation unit at night.
• The trust must ensure there is adequate medical cover out of hours for the hospital.
• The trust must ensure there is a clear operational protocol for the transfer of patients who deteriorate on the Clatterbridge Hospital site.

Surgery

• The trust must ensure that all staff involved with the care and treatment of children receive adequate life support training.
• The trust must ensure there is sufficient medical cover out of hours for the hospital.
• The trust must ensure there is a clear operational protocol for the transfer of patients who deteriorate on the Clatterbridge Hospital site.
• The trust must ensure that the doors which lead to high balconies on the ward areas are suitably secured.

Outpatients and diagnostic imaging

• The trust must take action to reduce the delay in referral to reporting times of urgent diagnostic investigations.
• The trust must resume radiation safety committee meetings and hold them at least annually.
• The trust must take steps to fill vacancies to ensure compliance against their current staffing establishment.

In addition the trust should:

Medical care (including older people)

• The trust should ensure that all patients consent to the use of bedrails and if they lack capacity to consent, the principles of the Mental Capacity Act (2005) are adhered to. Practice should be supported by clear policies, procedures and training.
• The trust should ensure that records are kept secure at all times so that they are only accessed and amended by authorised people.
• The trust should ensure that actions to improve standards of medicines management are identified and addressed in a timely way.
• The trust should consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.

Surgery

• The trust should ensure that senior managers are visible at the Clatterbridge Hospital on a regular basis and that staff at the site are engaged with the overall trust strategy and vision.

Outpatients and diagnostic imaging

• The trust should ensure all resuscitation trolleys are checked within the defined timescales and that documentation is completed to confirm it has been done.

Professor Sir Mike Richards

Chief Inspector of Hospitals