Whiston Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Our rating for safe stayed the same. During the assessment we identified 4 regulatory breaches relating to the key question for safe, where we told the service it needs to make improvements. We found that the service did not have enough nursing staff and mandatory training compliance in specific subjects was below Trust targets. Audits of compliance with some key processes were below Trust target. The service frequently had delays in ambulance handovers and triage and was at full capacity or over, meaning patients had long waits and were cared for in non-clinical areas. However, leaders had put processes in place to help mitigate the risks of care in non-clinical areas and efforts had been made to ensure that these areas were safe. We found that safety was a priority for everyone, safety incidents and concerns were managed well, and lessons learned. The department was clean and well maintained.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed investigation reports for incidents which demonstrated a good level of family and patient involvement in the investigation of incidents. Families and patients were given the opportunity to ask questions as part of the investigation and these were investigated and reported on. Patients and their families received copies of the final report.

Leaders could articulate the themes and trends of incidents in the department, the action they had taken to address these, and the methods used for feeding back to staff. Staff told us the organisation had a good culture of safety and learning.

Staff told us they were encouraged to report concerns and incidents and had regular feedback when they do report incidents. Staff knew of freedom to speak up, how to access them and where the policy was. Staff felt well supported by senior staff and that the Trust would take action to ensure that incidents and near misses reported would not happen again.

The service had the relevant policies and procedures in place to learn from incidents and near misses and this learning was shared with staff. Risks were not overlooked or ignored. Safety incidents were investigated as an opportunity to put things right, learn and improve. Managers kept staff aware of safety incidents and complaints, with learning shared through daily safety huddles. Lessons were learned, resulting in changes that improved care for others. Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

Healthwatch reviews for January to March 2024 showed negative comments relating to length of waiting time for treatment and medication.

However, patients told us that they were informed of why they were being moved between areas in the department and felt involved in discussions around referral and treatment options.

Leaders told us that safety and continuity of care was a priority throughout people’s care journey and that this happens through a collaborative, joined-up approach to safety that involves patients, along with staff and other partners in their care.

Leaders and staff had a strong awareness of the risks to people across their care journeys. Leaders told us they were cautious about which patients were cared for on the “back corridor” and had a standard operating procedure for care in non-clinical areas for staff to follow. This included a risk assessment to ensure that patients allocated to this area were not likely to deteriorate.

The service had multiple levels of triage processes to direct patients to the most appropriate care. The service also utilised virtual wards for paediatrics, frailty, respiratory and oncology.

Staff told us that the triage and flow pathways worked well and were safe, the main issues were due to lack of beds and long waits for specialty reviews.

Feedback from partners for systems, pathways and transitions was mixed. Some partners reported that there were improvements to be made around collaboration between teams, whilst others reported that there was a joined-up approach and a positive safety culture.

Some partners raised concerns about access and flow through the department resulting in delays in ambulance handovers and the negative impact and outcomes for the people in the community.

The percentage of ambulance handovers taking over 60 minutes at Whiston has been higher than the average for all hospitals served by the Ambulance Service since February 2023 and were much worse than the national mean handover time and the national standard with delays of over 12 hours. We saw improvement work between the organisations to reduce ambulance handover delays.

Adult and paediatric trained triage nurses or consultants triaged patients. The average time for triage was worse than the national standards between October 2023 to March 2024 for both adults and paediatrics for physical and mental health attendances.

The Trust had implemented schemes to enable patients to be diverted away from emergency department (ED). Patients were streamed and referred internally to the urgent treatment centre and the same day emergency care (SDEC) service. Patients were also referred to various virtual wards and the frailty and surgical SDECs. The ambulance service had direct access to stroke and frailty services.

The Trust had an MDT Hub phone line for all community-based providers to speak to an ED clinician and access direct pathways and advice. This resulted in less patients attending ED and the hospital.

The Trust had a standard operating procedure for caring for patients in non-clinical areas such as corridors in ED. This policy detailed the process for responding to limited capacity and the inclusion/exclusion criteria for patients to reside on the corridors. It contained the Trust’s risk assessment for corridor care and the mitigating actions included in this were all observed on the day of our inspection.

Patients we spoke with told us they felt safe and that if they had any concerns or issues, they would feel comfortable to tell someone.

There was a strong understanding of safeguarding and how to take appropriate action.

There was a clear understanding of the Deprivation of Liberty Safeguards (DoLS), and staff knew when and how to use these in the best interest of the person.

There was a commitment to taking immediate action to keep people safe from abuse and neglect.

There were effective systems, processes and practices to make sure people were protected from abuse and neglect.

Healthwatch reports showed multiple patients and relatives had waited longer than the time communicated on the waiting time screens in the waiting room and had not been communicated with about times or what they were waiting for.

However, on the day of inspection patients told us that they were informed of why they were being moved between areas in the department and waiting times for things had been communicated.

Leaders and staff could articulate what risk assessments they used to keep patients safe. Staff said that risk assessments were done early in the patient’s journey and care plans would be reviewed and updated to reflect patient choice. However, staff told us that it was difficult to complete all risk assessments required due to staffing and time constraints.

Staff used risk assessment tools to keep patients safe and were trained in least restrictive restraint, which was appropriately only used as a last resort and was monitored by leaders.

Feedback from partners for involving people to manage risk was mixed.

Partners raised concerns about access and flow through the department resulting in delays in ambulance handovers. Partners shared examples of poor care and harms caused by delays.

However, feedback from other partners showed senior leaders had good oversight of risks and engaged in quality improvement projects.

Partners reported that staff were skilled and very rarely required more restrictive measures to manage patients, but described that it was always lawful, proportionate and reasonable when used.

Audit compliance rates showed that not all adult patients were having their observations taken in a timely manner with monthly rates ranging from 10% to 70%. Patients did not always have sepsis screening performed at triage with monthly audit rates ranging from 60% to 100%.

Senior leaders were aware of these shortfalls and actions were in place to address these. An update was requested in May 2024 and audit results showed that compliance had improved and was now within target.

Audit compliance rates showed that for paediatric patients the paediatric early warning score observations had been taken at triage, with all patients escalated in line with protocol. However, observations repeated in line with the protocol was below the target (70%), and the sepsis screening and action tool being present in records too was below target (75%).

The Trust had policies, processes and risk assessments in place to manage risks and emergencies.

Staff knew how to escalate and monitor patients identified as deteriorating. Audits of patients records who had deteriorated showed staff escalated and acted in 100% of cases, showing staff were responsive to patients deteriorating and escalated appropriately.

People were not cared for in environments that were designed to meet their needs. People’s feedback showed that there was not enough seating in the waiting room, people were cared for in non-clinical areas such as corridors that were busy and bright and lacked toilet and shower facilities.

However, there was feedback that the design of the department was accessible.

Staff and leaders acknowledged that corridors were not “ideal” for patient care, and they would do what they could to avoid this. However, when the department was over capacity, they worked hard to make this as safe and as dignified as possible for patients. They gave examples of changes they had made to the environment to improve patient experience and safety when being cared for in these non-clinical areas.

Staff told us that they had enough equipment.

Due to demand on the ED service, capacity was regularly exceeded. Due to this, the department regularly cared for patients in non-clinical areas/corridors. These areas had no call bells or piped oxygen, though leaders told us that oxygen requirement was included in patient risk assessments and patients who required high volume oxygen were not nursed on the corridor. Oxygen concentrators were available and used where required for patients requiring low volume oxygen. The Trust had installed plug sockets in the corridors for the use of clinical equipment and electric operated beds and 1 corridor also had privacy curtains between each allocated “bed space” along the corridor to improve dignity. For patients waiting for ward beds, they were placed on pressure relieving mattresses to prevent pressure ulcers caused by long stays.

Equipment was mostly in date and serviced, however we did find some equipment that was not.

The Trust had appropriate risk assessments in place for the environment, however people were not cared for in environments that were designed to meet their needs.

The ED had a Patient-Led Assessments of the Care Environment (PLACE) assessment in November 2023 with an outcome of “confident that a good level of patient care and experience will be delivered within the environment”.

The friends and family test responses for April 24 showed a theme of patients saying that they had long waits and only more staff would improve this.

While the people we spoke to expressed that they were generally happy with staffing, our assessment found that staffing levels did not meet the expected standards. NICE (National Institute for Health and Care Excellence) state that majors areas should have 1 nurse to 4 cubicles, however in some cases there was only 1 nurse to 8 patients.

Patients told us there seemed enough staff at reception and triage and had managed to speak to staff when required. Patients told us that staff were knowledgeable and competent.

Staff feedback demonstrated that there were not always appropriate staffing levels to make sure people received consistently safe, good quality care that met their needs.

The 2023 staff survey results for ED showed only 49% of respondents felt they were “able to meet all the conflicting demands on my time at work.” And 27% of respondents felt “there are enough staff at this organisation for me to do my job”. Reflecting our findings around staffing.

However, leaders told us that staff turnover rate in the ED had improved and staff told us that agency and bank staff had a full induction, training and felt supported by the team.

The trust and department had a staffing escalation process in place.

We observed that there were not appropriate staffing levels to make sure people received consistently safe, good quality care that met their needs.

On the day of inspection, we observed that majors areas were below the recommended nurse staffing ratios with 1 nurse to 8 patients in one area of majors. The resuscitation area had 1 nurse to 2.33 patients in resus without an additional coordinator and leaders told us that staffing ratios would be increased in line with guidance for cardiac arrest and major trauma. However, these nurses would be moved from another area of the department, which then reduced the nurse to patient ratio in those areas.

We observed an area of majors where a healthcare assistant was the only member of staff present. This healthcare assistant was on 1-1 observations for a patient in this area, but due to no other staff being present was observed attending to other patients out of sight of the patient they were to be constantly observing.

Processes did not ensure appropriate staffing levels to make sure people received consistently safe, good quality care that met their needs.

Nurse staffing ratios were below the national minimum requirement.

For mandatory training, medical staff were below the target compliance for resuscitation training (59% for adults, 62% for paediatrics) and below target for sepsis training (75% for adults and 68% for paediatrics). Leaders told us that medical staff mandatory training compliance had been affected by the industrial action.

However, nurse staffing training was above target compliance for resuscitation and sepsis.

People told us that the department was clean and hygienic, and they had seen domestic staff and staff using PPE appropriately and hand washing. Patients told us there were plenty of stations for hand cleaning and sanitising gel.

Leaders told us the Trust had a proactive infection prevention and control team that did regular walk arounds in the department with the matrons, to identify any areas of concern or of improvement in in the department.

Leaders had a strong understanding of managing the risk of infection.

We observed the department was clean and tidy. We saw staff cleaning regularly and were all bare below the elbow in line with national guidance.

The department consisted mostly of cubicles which provided more areas for isolation.

Infection prevention and control was audited regularly, and action plans were created in response to any concerns or issues.

Each area of the department had a dedicated cleaner 24 hours a day to ensure all areas were cleaned thoroughly.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.