All inspections: Halton General Hospital

Our rating of services improved. We rated it them as good because:

The hospital had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The hospital controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They generally managed medicines well. The hospital managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of services and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
The hospital planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access services when they needed it and did not have to wait too long for treatment.
Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the trust’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The services engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

In surgery, we observed one instance of a controlled drug being left unattended in the operating theatres and found some consumables that were past their use by dates. Some patient trolleys also had not had annual maintenance.
In surgery, some processes around the pre-operative briefing were not thorough, but work was in progress to improve this.
In surgery, we saw an example of mental capacity assessment not in line with current guidance and trust policy.

Halton General Hospital is one of three locations providing care as part of Warrington and Halton Hospitals NHS Foundation Trust. It provides non-complex, elective surgery and a range of outpatient services. There is a minor injuries unit (open 9am to 10pm every day) which provides a range of minor emergency care services, and the hospital provides x-ray facilities until 8pm. There is a step down ward for patients who have had surgery or emergency medical care but who require some further support before going home. There are chemotherapy services on site and the hospital is home to the Delamere Macmillan Unit, which provides cancer support and advice. The site is also home to a specialist orthopaedic facility the Cheshire and Merseyside NHS Treatment Centre (CMTC).

The CMTC is a standalone operating and clinical facility for orthopaedic surgery services across the trust. Warrington and Halton Hospital NHS Foundation Trust provides services across the towns of Warrington, Runcorn (where Halton General Hospital is based), Widnes and the surrounding areas. It provides access to care for over 313,500 patients.

We carried out an announced inspection of Halton General Hospital as part of our comprehensive inspection of Warrington and Halton NHS Foundation Trust.

Overall we rated Halton General Hospital as Requires Improvement.

We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, we found improvements were needed to ensure that services were safe and well-led.

Our key findings were as follows:

Incidents:

There was individual feedback to staff members following an incident and then feedback to all staff by email and through the safety briefing. The nurse manager said that some of the older staff didn’t like to report incidents but the nurse manager had shown how improvements had been made in the department as a result of reporting incidents. One of the issues was that other departments in the hospital were bringing patients to the Urgent Care Centre (UCC), this was inappropriate and as a result of raising incidents the practice was stopped.
The trust reported low numbers of surgical site infections (SSI) following surgery. Between April 2015 to April 2016, there had been four incidents of SSI in knee replacement surgery and three incidents of SSI in hip replacement surgery. SSI’s were monitored by the orthopaedic department in-line with National Institute for Health and Care Excellence (NICE) guidelines for quality standards for orthopaedic surgical site surveillance. The surveillance information collected during April 15 to March 16 showed there had been 672 hip and knee operations and indicated that the orthopaedic joint replacement infections were minimal and mainly superficial infections. This indicated that care and treatment was being delivered with high regard to infection prevention procedures.
The Duty of Candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. There was a trust wide policy and Duty of Candour process in place. Staff we spoke with had an awareness of the need to be honest when things go wrong although they could not fully describe the requirements of the regulation. Senior staff understood the principles of the Duty of Candour.

Cleanliness and infection control

The trust had infection prevention and control policies in place which were accessible to staff.
The areas we visited were visibly clean and tidy. Patients told us areas were clean and that staff washed their hands which reflected what we saw.
There was access to personal protective equipment such as aprons and gloves and we saw staff using this equipment appropriately to prevent the risk of the spread of infection. Decontamination procedures were followed in line with best practice in endoscopy.

Environment and equipment

Daily morning surgical meetings were held to ensure that all staff had the required equipment for the surgeries planned for that day. We observed in theatres staff checking and setting surgical instruments. The check was verbal and visual between two staff in-line with standards and recommendations for safe practice.

Medicines:

There were patient group directives (PGD’s) available for specific nurses to give patients appropriate pain relief. PGD’s allow healthcare professionals to supply and administer specified medicines to pre-defined groups of patients. This helps patients to access medicines in a safe and timely manner and PGD’s were audited by the department. There was a competency framework for those nurses covered by the PGD. Each nurse had their own prescription pad with a dedicated log of the patient’s number, the details of the script and the signature of the nurse prescriber. These logs were checked daily to ensure that the numbers of logs tallied with the number of scripts dispended.
Staff in some outpatient areas used patient group directions (PGD’s) to administer medicine without a doctor, such as eye drops or contrast media. The procedures and staff competencies were inspected and complied with standards.
There were arrangements in place for managing medicines and medical gases. Nursing staff were able to explain the process for safe administration of medicines and were aware of policies on preparation and administration of controlled drugs as per the Nursing and Midwifery Council Standards for Medicine Management. We saw that there was an up to date policy for the safe storage, recording of, administration and disposal of medicines. This was available for staff on the intranet. .

Nurse staffing:

The Urgent Care Centre (UCC) used the emergency severity index (EMS) as an acuity tool to determine the staffing of the department and they had received additional funding for staffing from the clinical commissioning group.
Within the Outpatient and Diagnostic department, nursing staff worked between Halton and Warrington sites, covering and responding to change in staffing needs on a day-to-day basis as necessary. Rotas were planned ahead according to clinic demands and staff worked flexibly to cover this.
We saw staffing in theatres met the Association for Perioperative Practice (AfPP) safe staffing guidelines. This ensured that there were adequately trained staff to provide safe surgical care to patients. We saw from the surgical procedures we attended that there was appropriate staffing levels for each theatre.

Medical staffing

A resident medical officer (RMO) was based at Halton Hospital 24 hours a day, seven days a week on a rotational basis.
There was a doctor present in the UCC department from 8am to 10pm. A consultant from Warrington urgent and emergency care department held a weekly clinic in the department.
There were four GP’s who worked in the department. Three of the doctors did one day each and the other doctor worked for four days. The doctors worked from 8am to 10pm. They covered for each other during holiday periods and so there was little use of locum cover
On-call senior medical support was available outside of core working hours. Nursing and medical staff confirmed that they were able to access senior medical support if required.

Leadership and Management

The senior team, in the majority of core services, were visible and accessible and well known to the staff.
The urgent and emergency care department had undergone a change in leadership early in 2016 with the clinical business unit (CBU) model brought in. The trust had used assessment centres and other management tools to identify leaders in the potential applicants for the clinical and nurse leads for the CBU. The CBU had a clinical lead who was a consultant anaesthetist, a lead nurse and a manager. Both of the clinical staff had come from outside of the department. Since the implementation of the CBU, performance in the department had shown marked and ongoing improvements in safety and performance. This was due to the leadership in the department which was robust and the senior staff led by example.

Access and Flow

The urgent care centre, saw between 2,500 and 3,000 patients every month, these numbers had more than doubled since the reconfiguration from a walk in centre to an urgent care centre.
The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the urgent and emergency care centre. In the period from March 2016 to December 2016 the department had consistently achieved over 99%.
Between October 2015 and November 2016, the average length of stay for surgical elective patients was better at the trust at 2.7 days, compared to 3.3 days for the England average.
Halton hospital had a shorter length of stay across both elective and non-elective admissions than both the trust and the England average.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards:

Data showed that of December 2016, 67% of medical staff and 78% of nursing staff had completed their Mental Capacity Act (MCA) training. Staff we spoke with understood the legal requirements of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) in order to protect patients appropriately.
The service accepted children and young people less than 16 years of age and were able to prescribe emergency contraception. Staff were aware of Gillick competencies and Fraser guidelines. They also said that they would raise a safeguarding referral if appropriate.

We saw several areas of outstanding practice including:

The public engagement work at the urgent care centre was innovative using the local rugby league clubs to promote the appropriate use of services on their website with You Tube videos.
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.

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

Importantly, the trust must:

In Medicine:

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

In Surgery

The trust must take action to provide and maintain an assurance system that World Health Organization (WHO) checklists are completed appropriately as to the standard operating procedure.
The trust must take action to provide and maintain an assurance system that all anaesthetic machines are checked in line with trust policy.
The trust should take action to provide and maintain an assurance system that all stocks are within their expiration date.
The trust should take action to improve the number of suitably qualified staff in advanced life support in recovery.

Outpatients & Diagnostic Imaging:

The trust 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 1999.
The trust must take action to ensure equipment is safely maintained at all times, with repairs completed in a timely way.
The trust must ensure all appropriate infection control measures, including environmental cleaning, are observed in all diagnostic and treatment areas, with consistent records

In addition the trust should:

In Emergency Department:

Flagging of patients with a learning disability or those who require special adjustments for their treatment.
Provide a waiting area for children and young people that is separate to the main waiting room.
A registered children’s nurse available on every shift at the centre.
Ensure the closure of the low scoring risks on the risk register.

In Medicine:

The trust should ensure that the required processes and procedures are in place to safely deliver treatment on the planned investigation unit.
The trust should ensure that staff on the planned investigation unit, receive appropriate training and work within their competence level.
The trust should ensure that mandatory training and appraisal levels improve.
The trust should ensure that governance systems are operated effectively at clinical business unit and divisional level.
The trust should ensure that risk registers are complete and are reviewed regularly with evidence of the outcome of review.
The trust should ensure it seeks feedback on medical services at the hospital from patients and the public.

In Surgery:

The trust should take action to improve staffing levels across wards and theatres.
Although mandatory training performance has improved since the last inspection. The trust should take action to improve their mandatory and clinical skills performance across all core areas.

In Outpatients and Diagnostic Imaging:

The trust 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 trust 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.
The trust should ensure departmental risk registers are clearly identified and recorded, with implementation and monitoring of associated action plans
The trust should ensure directorate communications are in place to provide staff with appropriate support and inform staff regarding departmental arrangements
The trust should consider actions to improve child-friendly aspects of waiting room environments in outpatient departments.

Professor Ted Baker

Chief Inspector of Hospitals

Halton General Hospital is one of three locations providing care as part of Warrington and Halton Hospitals NHS Foundation Trust. It provides non-complex, elective surgery and a range of outpatient services. There is a minor injuries unit (open 9am to 10pm every day) which provides a range of minor emergency care services, and the hospital provides x-ray facilities until 8pm. There is a step down ward for patients who have had surgery or emergency medical care but who require some further support before going home. There are chemotherapy services on site and the hospital is home to the Delamere Macmillan Unit, which provides cancer support and advice.

The site is also home to a specialist orthopaedic facility – the Cheshire and Merseyside NHS Treatment Centre (CMTC). The CMTC is a standalone operating and clinical facility for orthopaedic surgery services across the trust.

Warrington and Halton Hospital NHS Foundation Trust provides services across the towns of Warrington, Runcorn (where Halton General Hospital is based), Widnes and the surrounding areas. It provides access to care for over 313,500 patients.

We carried out this inspection as part of our comprehensive inspection programme.

We carried out an announced inspection of Halton General Hospital on 28 January 2015. In addition an unannounced inspection was carried out between 3pm and 5.30pm on 11 February 2015. As part of the unannounced visit we looked at the management of medical emergencies out of hours.

Overall we rated Halton General Hospital as good.

Our key findings were as follows:

Access and flow

The hospital was an elective surgical centre with a full range of outpatient and step down care facilities. The hospital specialised in routine, non-complex surgery.
There were low operation cancellation rates, as routine surgery was not as affected by emergency cases.

Incident reporting

There were systems in place for reporting incidents and ‘near misses’ across the hospital. Staff had received training and were confident in the use of the incident report system, but in medical care services and the outpatient department they did not always report incidents appropriately or in a timely way. This meant that opportunities for learning or improvement were sometimes missed.

Cleanliness and infection control

There was a high standard of cleanliness throughout the hospital. Staff were aware of current infection prevention and control guidelines and observed good practices such as:

Staff following hand hygiene and ‘bare below the elbow’ guidance.
Staff wearing personal protective equipment, such as gloves and aprons, while delivering care.
Suitable arrangements for the handling, storage and disposal of clinical waste, including sharps.
Cleaning schedules in place and displayed throughout the ward areas.
Clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

Hand washing facilities and hand gel were available throughout the department.
Data showed that healthcare-associated infections with MRSA and Clostridium difficile (C. difficile) rates for the hospital were low.

Nurse staffing

Nursing staffing levels had been reviewed throughout 2014 and were due to be reviewed again. Staffing levels had been assessed using a validated acuity tool. There were minimum staffing levels set for wards throughout the hospital, and required and actual staffing numbers were displayed outside each ward and department.
Use of agency nursing staff was rare at the hospital. Short-term absences were covered by permanent staff working additional hours.

Medical staffing

Surgical treatment was delivered by skilled and committed surgeons.
Out-of-hours medical cover was provided to patients in the surgical wards by the two Resident Medical Officers (RMO) as well as on-call registrar.
Medical cover in the medical care services was also provided by the RMO both in and out of hours. RMOs were provided by an agency and were on duty, day and night, for periods of up to two weeks. There were several RMOs who provided medical cover, sometimes for one week at a time, returning several weeks later, again on a short-term basis.
The RMO was on duty without time off, day and night, for periods of up to two weeks. Any calls by nursing staff to the RMO were routed via the senior nurse in charge of the hospital out of normal working hours, to ensure the RMO was not disturbed unnecessarily. The RMO we spoke with told us that it was not unusual to be disturbed two or three times during the night. There was no cover provided the next day if they had been awake for most of the night. This represented a risk that the RMO’s judgement could be impaired due to tiredness

Care of the deteriorating patient

Staff used the National Early Warning Score (NEWS) that is designed to identify patients whose condition is deteriorating. Staff were prompted when to call for appropriate support. The chart incorporated a clear escalation policy and gave guidance about ensuring timely intervention by appropriately trained personnel. We found that that staff understood the tool and escalated changes in the patient’s condition appropriately.
There was a transfer policy in place for patients whose condition was deteriorating, and safe and timely transfer was supported by the RMO and suitably trained critical care nurses who were on site out of hours. Staff also had access to the on-call registrar and the on-call consultants based at Warrington Hospital.
The trust had arrangements in place with the local ambulance service to ensure patients transferred between the hospitals were accompanied by a trained paramedic. However, the RMO in post at the time of our inspection was not aware of the standard operating procedures regarding the transfer of deteriorating patients to Warrington Hospital and was unclear about how to access a senior medical opinion.
A review of medical cover at Halton hospital undertaken by the trust in May 2014 recommended that “training to specifically include accessing a medical opinion and the transfer policy from Halton” should be undertaken. The RMO on duty at the time of our inspection had not received training in either of the above and stated that the nurses would direct him.

Mandatory training

Mandatory training attendance varied across the hospital. In the majority of cases, compliance fell below the trust’s 85% target.

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 coloured jug system in place that identified patients who needed assistance with eating and drinking.
Support was given in a sensitive and discreet way.

Medicines management

Medicines were provided, stored and administered safely and securely. However in the outpatients department the medicine stock levels were not recorded and stock checks did not take place. This meant that medicines could be removed or misappropriated without staff being aware.

Areas of outstanding practice included:

The hospital ran a "Hello, my name is...would you like a drink?" campaign to raise awareness within the service of issues surrounding hydrating patients, the importance of accurately filling in fluid balance charts and the prevention and treatment of patients with Acute Kidney Injury.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Health and Social Care Act 2008 (Regulated Activities) Regulations 2014] and the trust needs to make improvements in these areas.

Importantly, the trust must:

Ensure adequate medical staffing levels outside of normal working hours.
Ensure all the resident medical officers have the appropriate skills and competencies so there is consistency.
Improve incident reporting in the outpatient department.
Take action to improve mandatory training completion levels.
Ensure patient records are complete and ready for patient appointments.
Ensure medicine stocks in the outpatient department are recorded and checked.

In addition the trust should:

In medical care services:

Increase seven day working for all disciplines across the medical directorate.
Improve the way risks are communicated to nursing staff within the medical directorate.

In outpatient and diagnostic services:

Reduce patient waiting times and did not attend rates.
Develop a strategy for the expansion of outpatient services to meet patient demand and preferences.
Increase the visibility of executive staff and the board in the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We began our inspection on 30th September 2013 by visiting the Minor Injuries Unit outside of normal working hours. We returned the following day 1st October 2013 and visited the Orthopaedic, Intermediate Care, Elective Surgical Services and Step down wards. We spoke with patients and staff of different grades on all the wards we visited.

Patients spoke positively about their experience at Halton General Hospital. One said, 'I much prefer this hospital to another, I have been in both for long periods of time and this hospital gives great attention to patient care, I cannot praise staff highly enough, the nurses especially night staff are just fantastic and very dedicated'.

Patients we spoke to felt that they had a full and clear understanding of their individual programmes of care and treatment. They commented that they felt they were given sufficient details and answers to any questions they may have, which they felt allowed them to make informed decisions.

They understood the care and treatment choices available to them and were given appropriate information and support regarding their care or treatment.

We saw that staff were well supported and had regular personal development reviews. Training was monitored and we saw evidence that staff had the opportunity to attend more specialist training courses when appropriate. There were enough staff on duty at the time of our inspection and we saw that additional staff could be accessed at short notice if required.

On both wards that we visited, we observed that staff were respectful, they explained to the patient what they were going to do and permission was asked before any procedures were carried out. We saw that staff were sensitive to patients needs, had good relationships with them and made eye contact with patients. Call bells were within reach and staff answered them promptly.

Relatives spoken with said staff informed them of any up dates to the care and discharge plans that were being discussed for their relative. All patients spoken with said they were given information about their care and felt confident that if they didn't understand they could ask for further explanation. All said they were called by their preferred name.

Comments made by relatives of one patient said, 'nurses here are very good and give information.' Patients said, 'Staff are wonderful, the hospital is wonderful,' 'Staff are excellent.' All patients spoken with said that staff treated them with respect and that their dignity was maintained at all times.

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People we spoke with were positive about the food provided and said that there was choice made available on a daily basis. People said that dietary choices and requirements were discussed either prior to or during the admission process. Overall the comments we received were very positive and evidenced that most people were satisfied with the food in the hospital.

Comments made by patients we spoke with were :-

'Food is very good and always a choice'.

'I have a choice of portion size.'

'Absolutely first class.'

Halton General Hospital

All Inspections

29 March to 2 May 2019

During a routine inspection

7 to 10 March and 23 March 2017

During a routine inspection

Professor Ted Baker

28 January and 11 February 2015

During a routine inspection

Areas of outstanding practice included:

Professor Sir Mike Richards

28 January 2015

During an inspection of this service

30 September and 1 October 2013

During a routine inspection

24 March and 13 April 2011

During a themed inspection looking at Dignity and Nutrition