The Royal Liverpool and Broadgreen University Hospitals NHS Trust is one of the largest hospital trusts in the north of England serving more than 465,000 people in Liverpool. The trust currently delivers acute services from two sites: Royal Liverpool University Hospital and Broadgreen Hospital. It also includes the Liverpool University Dental Hospital at a third site. There is a new hospital project underway which is due for completion in 2017. As well as providing general services to local communities, the trust provides regional and national specialist services and is considered to be one of the UK's leading cancer centres. The trust is closely linked with the University of Liverpool and John Moores University for teaching and research.
The Royal Liverpool University Hospital is the largest hospital in Merseyside. It has over 40 wards, more than 750 beds (excluding day case and dialysis beds). It has the main accident and emergency department for the city of Liverpool capable of dealing with major trauma and life threatening illness. Broadgreen Hospital is the main location for the trust's elective general, urological and orthopaedic surgery, diagnosis and treatment, along with specialist rehabilitation. It has 3 medical wards, 2 surgical wards, a theatre suite and a Postoperative Extended Care unit (PAECU).
We inspected this trust as part of our new in-depth hospital inspection programme. It was being tested at 18 NHS trusts across England, chosen to represent the variation in hospital care across England. Before the inspection, our ‘Intelligent Monitoring’ system indicated that the Royal Liverpool and Broadgreen University Hospitals NHS Trust was considered to be a low-risk provider. CQC had inspected across both of the acute sites four times in total since it was registered in April 2010. It had always been assessed as meeting the standards set out in legislation.
Before the visit our analysis of data from our ‘Intelligent Monitoring’ system indicated that the hospital was operating safely and effectively across all key services. The trust’s mortality rates in cardiology, other injuries and conditions due to external causes and miscellaneous were worse or much worse than expected although in infectious diseases they were much better than expected. The trust had been identified as a mortality outlier for patients admitted as an emergency case with an acute myocardial infarction. Investigation by the trust concluded that this was due to miscoding and action plans were put in place which will be monitored by the CQC local compliance team. We also reviewed information that we had asked the trust to provide and received valuable information from local bodies such as the clinical commissioning groups, Healthwatch, Health Education England and the Medical and Nursing Royal Colleges.
We also met with a group of local people representing people who can be more difficult to reach for their views before the inspection. We listened to people’s experiences of the trust and during the inspection we held a public listening event in Liverpool and heard directly from 30 people about their experiences of care. We spoke with more than 100 patients throughout the inspection.
We issued six compliance actions to the trust in February 2014 in respect of following national and local guidance and policy. We re-inspected to monitor compliance with these compliance actions on 30 June and 1 July 2014. We found that the trust was compliant in respect of the issues contained within five of the compliance actions. Where this follow up inspection reviewed issues at the trust this report has been updated to reflect this.
At the inspections in November and December 2013 and January 2014 our team included CQC inspectors and analysts, doctors, nurses, experts by experience and senior NHS managers. The team spent two days visiting the two acute hospitals, conducted a further unannounced visit a week later, and returned to Broadgreen for a follow up visit in January. Between the hospitals we held focus groups with different staff members from all areas of both hospitals and spoke to 100 members of staff. We looked at patient records of personal care or treatment, observed how staff were providing care, and talked to patients, carers, family members and staff.
Overall we found the trust provided excellent care in some areas including the end of life care service which was of a high standard and provided care seven days a week. In critical care, there was a formal critical network in place with other local trusts which ensured the needs of patients were met effectively. There was also an effective Critical Care Outreach Team (CCOT) and an Acute Response Team who support patients who had received care within the Intensive Care Unit. Medical and surgical care at the Royal Liverpool was being delivered well under difficult staffing circumstances and the staff should be praised for their commitment and hard work to maintain safe practice. The emergency department should also be commended for the hard work they put in to caring for the large numbers of people who attend the department.
The team were impressed with the surgical services provided at Broadgreen, seeing many examples of very good responsive care and received consistently complementary feedback regarding medical and surgical care. Wards and departments were well staffed and there was evidence of innovative practice within the surgical department and the postoperative extended recovery unit provided good care.
On both sites we met staff who were hardworking, caring and compassionate and who were proud to work for the trust. We found an open culture where staff could raise their concerns and felt supported in their roles. The trust was clean and there was hand hygiene gel available in all areas.
However, we also found there were some areas of concern which the trust must address.
Staffing was found to be adequate at the time of the inspection, but this was being supported by overtime, bank and agency work, particularly at the Royal Liverpool. The recruitment of substantive staff was being significantly delayed and this was impacting on staff morale. The excessive workload of junior doctors in vascular and colorectal surgery needs to be addressed to maintain safe and effective care delivery. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
In critical care the roles of the Acute Response Team and the Coronary Care Outreach Team must be clearly defined to ensure the appropriate specialist skills are employed to deliver care to the vulnerable patients these teams care for. The response to patients whose condition is deteriorating should be improved by the support of training for ward staff in how to respond to the needs of these patients in order to ensure specialist intervention in a timely manner to promote the best outcomes. Training for ward based staff regarding the care of patients with tracheostomy will relieve the pressure on critical care beds once they can be cared for on the wards. The Postoperative critical care unit (POCCU) at the Royal Liverpool must ensure that the staff working there are appropriately trained and registered post-anaesthesia care unit practitioners. In addition, the trust must address the inappropriate use of the theatre recovery area at the Royal Liverpool as overnight accommodation for which it is not designed. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
In the emergency department, the use of an observation room as overnight accommodation for which it is not designed must also be addressed. There were also concerns raised regarding the adherence to infection control policies in the emergency department, especially at times of high demand. Some equipment used at these times was not clean and should not have been used. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
The limited allocated space between beds in the Heart and Emergency Centre is unsafe and must be addressed as it currently poses a risk to effective care if patients need emergency equipment by the bed. At our inspection on 30 June and 1 July 2014 there was no actual change to this environment but the trust had robust plans in place to relocate the service to a more appropriate area. Patient safety had been risk assessed for the interim time.
Medicines were administered and stored safely throughout the hospitals. However, at the Royal Liverpool hospital some patients informed us that they had been without at least one item of medication for more than a day during their stay and staff told us the system for obtaining medication for patients to take home once they had been discharged did not work efficiently, particularly at weekends. We noted that there was not a pharmacy service after 12 mid-day on a Saturday until 9am on Monday. This is currently having a detrimental effect on patients who are not receiving all their medication from admission and delaying discharges which is compounding the pressure for beds when the hospital is constantly functioning at high levels of bed occupancy. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
There was also no electronic drug dispensing system in use in the emergency department at the Royal Liverpool. The staff told us that the pharmacy was not always open and accessible. Staff told us they did not stock all necessary drugs in A&E so they often ended up running to other wards. The emergency department was not set up for ward type drug rounds when people were accommodated for longer periods than usual meaning that the dispensing of drugs was often not safe, there was an additional drain on staff resources and records were not always kept for auditing purposes. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
At Broadgreen it appeared that up until recently, transfers to the Royal Liverpool site were not being audited. This meant that staff were not able to tell us exactly how many patients had needed to be transferred between the sites and how often this occurred. Although the postoperative extended care unit and recovery area appeared to have very good consultant support, it was not clear to our inspection team whether this was the same on the general medical and surgical wards. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
From a trust wide perspective, the excessive delays in the recruitment of substantive staff needs to be resolved to reduce the use of temporary staff therefore providing a consistent staff base on which to deliver best quality care. Improvement is required in the care received by patients not cared for on wards of the relevant speciality (known as outliers), it is essential these patients are monitored and managed robustly to ensure they receive the same level of care as patients cared for on relevant wards. These issues were found to have been addressed at our inspection on 30 June and 1 July 2014.
The trust is also required to improve the failings of the risk management processes for the analysis and reporting of potential risks. The evidence has shown that not all significant areas of risk are being escalated appropriately to ensure the senior management and the board are fully informed. If the risks are not fully known they cannot be fully addressed and mitigated. The risk management processes also need to interact with the information from complaints to ensure holistic learning is made and the quality of care assured. We noted that the trust reported a significantly lower number of incidents in comparison to trusts of similar size. This can mean that not all incidents are reported and therefore appropriate lessons are not being learned.