alder hey children's hospital newapproachfocused report

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Medical care Good –––

Surgery Requires improvement –––

Alder Hey Children's NHS Foundation Trust

AlderAlder HeHeyy ChildrChildren'en'ss HospitHospitalalQuality Report

East Prescot Road,Liverpool.L14 5ABTel: 0151 228 4811Website: www.alderhey.nhs.uk

Date of inspection visit: 19, 20 April 2017 and 5 May2017Date of publication: 05/10/2017

1 Alder Hey Children's Hospital Quality Report 05/10/2017

Letter from the Chief Inspector of Hospitals

Alder Hey Children’s NHS Foundation Hospital is one of the busiest children’s hospital in Europe and provides care formore than 270,000 children, young people and their families every year. The trust provides a range of services and leadson research into children’s medicine. The trust also provides child and adolescent mental health inpatient andcommunity services.

Before visiting the trust, we reviewed a range of information we held and asked other organisations to share what theyknew about the trust

We carried out this responsive inspection on 19 and 20 April 2017 and 5 May 2017 following increasing concerns we hadabout the services. We inspected surgical and medical care services.

We did not inspect urgent and emergency services, critical care, neonatal services, end of life care, outpatient anddiagnostic imaging or transitional services.

We last inspected the services in September 2015 and we rated the hospital as ‘good’ overall.Surgical and medical careservices were judged to be good overall however, there were areas for improvement.

At this inspection we judged that surgical services requires improvement and medical care services as good. Theseratings did not affect the Alder Hey Children’s NHS Foundation Trust overall rating.

Our key findings were as follows:

Medical care services

• Children, young people, and those close to them were treated with respect, dignity, and compassion.

• Staffing levels at the time of inspection met standards set out by Royal College of Nursing.Staff told us the trustfound it challenging to recruit to junior doctor vacancies but had made an investment to train advanced nursepractitioners to partially address the shortfall.

• Medicines were safely stored in areas that were accessible to staff only, and each area had a dedicated pharmacistbased on the wards.

• Staff were aware of their safeguarding roles and responsibilities and knew how to raise matters of concernappropriately.

• The environment was suitable and welcoming to meet the needs of children and young people and their parentsand carers. The individual needs of patients were met and included children and young people with learning andphysical complex needs.

• The ward areas we visited were visibly clean. We saw that staff followed good practice in relation to the control andprevention of infection.

• Assessment of nutrition and hydration formed part of the nursing record and was completed in all of the records wereviewed at the time of our inspection.We observed fluid balance charts recorded on the electronic record andchildren and young people had their weight recorded to inform dietary requirements.

• A range of menus were available and included age appropriate foods. Children and young people could alsorequest additional options.

• Staff told us they felt supported by their immediate team colleagues and by senior managers and the workingrelationships between nurses and medical staff, and allied health professionals worked well.

Summary of findings


• There were communication systems in place to keep staff informed which included newsletters, emails, and safetyhuddles. Staff confirmed they received updates and information via these systems.

However;

• We were not assured that children and young people were receiving treatment for sepsis that reflected nationalguidance. We found delays in the review process but the trust had commenced training to improve themanagement and identification of sepsis.

• The compliance rate for safeguarding training level three for children was on average 80%, which was below thetrust’s target of 90%. This was highlighted as an area of concern following the last inspection, however there hadbeen an increase in compliance since the last inspection.

• There were low levels of compliance with mandatory training for medical staff within the medicine clinical businessunit. Only 55.2% of medical staff were up to date at the time of the inspection which was significantly worse thanthe trust’s target of 90%.

• Medical records were not securely stored on each ward we visited so confidentiality was at risk. Patient privacy anddignity was not fully maintained on wards we visited due to the display screen which was visible to people enteringthe wards.

Surgical services

• The hospital did not always ensure that a member of staff who was trained in advanced paediatric life support(APLS) was available on each department at all times. This did not meet the Royal College of Nursing (RCN)minimum staffing requirements.The trust had acknowledged this shortfall in a recent review but at the time of theinspection no formal plans had been made to implement the improvements.

• We found that compliance with mandatory training across surgical services was mixed. We had particular concernsthat compliance with safeguarding level three training for surgical staff overall was only 67% at the time of theinspection. This had only slightly improved since the last inspection despite actions being put in place to increasecompliance. At the last overall compliance with safeguarding level three training was 57%

• On surgical wards there was a risk of abduction or that children were able to leave the ward unnoticed. This wasbecause all doors could be opened from the inside and exit buttons were not out of reach from children. This riskwas highlighted when the hospital was built in 2015 but it was unclear if this had been formally risk assessed orwhat actions had been taken to rectify this and it still remained a risk at this inspection.

• We sampled various departmental and clinical business unit risk registers and found that in a number of casesthere was limited or no evidence that the risks had been reviewed fully or details about how the level of risk hadbeen mitigated appropriately.

• Resuscitation equipment was available on every department. However, on the surgical wards the equipment waskept in different boxes and in different locations posing an additional risk.

• Complaince with infection control standards on the wards was consistently low ranging between 54% and 72%.

• There were currently no audits being undertaken measuring if patients were compliant with the fasting guidancebefore undergoing a surgical procedure.

However,

• There were sufficient numbers of staff on the days of our visit to safely care for patients. This was both on the wardsand in theatre. In theatre staffing was in line with national guidance.set by the Association for Perioperative Practice(AfPP).

Summary of findings


• We found a strong, person-centred culture. Holistic care was provided by kind and caring staff who made everyeffort to provide support to patients and their parents.

• Patients and their parents were actively involved with decisions about care and treatment and their views andwishes were respected and valued.

• The surgical clinical business unit (CBU) held monthly morbidity and mortality meetings. We saw evidence ofactions and learning that had been implemented following these meetings.

• We observed both the theatre and ward areas to be visibly clean. In theatre, there was an identified lead forinfection prevention and control (IPC) and they undertook regular audits which showed that overall compliancehad improved to 99%.

• There were procedures in place to provide fasting guidance to patients and relatives at the pre-operativeassessment stage.

• Nutrition and hydration assessments were undertaken as part of the pre-operative assessment and for admissionsto the inpatient wards. There was access to a dietitian during normal working hours between Monday and Friday ifneeded.

• A range of menus were available to all patients. We spoke to several patients and relatives, who told us that thefood was excellent and that there was a lot of choice. Relatives were also able to order food.

We saw several areas of outstanding practice including:

• Each ward had their own dedicated pharmacist and medication was accessed by fingerprint technology thisensured that medication was secured and stock levels were adequately controlled.

• There was a chef allocated to each ward and all food was prepared on the ward.

• A hybrid theatre had recently been opened and a small number of operations had been undertaken using thisfacility. This was the first paediatric hybrid theatre to be opened in Europe.

• The hospital innovation team had worked collaboratively with a local university to develop ‘virtual surgery’ and touse high definition 3D printing so that organs can be viewed in much more detail. This allowed staff to ‘virtuallywalk around’ organs.

• The Trust had pioneered a headspace project which had created the world’s first normal equivalent model of thehuman head. This enables comparison of pre-operative and post-operative 3D images of craniosynostosis patients.

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

Importantly, the trust must:

• The trust must take action to ensure all staff who are involved with assessing, planning, and evaluating care forchildren and young people are trained to safeguarding level three in line with the safeguarding children and youngpeople: roles and competencies for health care staff Intercollegiate Document (2014).

• The trust must take action to ensure all children and young people receive treatment in relation to sepsiswithinappropriate timeframes and have a process tomonitor adherence to policy for patient’s treated for sepsis.

• The trust must ensure that there is a member of staff trained in advanced paediatric life support available in everydepartment at all times as outlined in the Royal College of Nursing guidelines.

• The trust must ensure that compliance with mandatory training is improved, particularly for medical staff.

Summary of findings


• The trust must ensure that formal risk assessments are undertaken in all departments and all identified risks arecaptured on the risk register where needed.

In addition the trust should:

• Review the systems in place to enable staff to be clear about their roles and responsibilities during an emergencyresuscitation scenario.

• The trust should ensure that all resuscitation equipment on inpatient wards is checked fully in line with the hospitalresuscitation policy.

• Review the systems in place to mitigate the risk of children and young people absconding or being abducted fromthe ward areas.

• Expedite plans and actions to enable all staff to improve compliance with mandatory training to the trust’s target ofat least 90%.

• Have safe storage facilities in place for medical records on all wards to protect children and young people’sconfidentiality.

• Have disease specific pathways in place that are based on up to date evidenced based practice and a system forassurance during the period of transition from paper to electronic pathways.

• Improve staff appraisal rates to reach the at least the trust’s target of 90%

• Consider training on the Mental Capacity Act for clinical staff being part of the mandatory training.

• Ensure visual display screens on the wall behind the desk to the entrance of wards do not compromise patientconfidentiality.

• Identify review dates on all risk registers and review monitor that actions identified to mitigate risk are in place inmedical services and surgical services

• Consider implementing a schedule for replacing curtains in the ward areas.

• The management team should consider ways in which to improve monitoring of surgical site infections for patientswho have undergone non-specialist surgery.

• The management team should make sure that discarded controlled drugs across all departments are recordedappropriately.

• The management team should consider ways in which to improve the meditech system so that it accurately reflectsthe time that medicines had been administered, reducing the potential risk of a medication overdose.

• The hospital should find ways in which to make sure that there is always a supernumerary co-ordinator available inall areas, at all times to support staff.

• The management team should ensure that all staff receive a full annual appraisal in line with the trust supervisionpolicy.

• The hospital should consider ways in which to reduce the number of cancelled surgical procedures, and when thisdoes happen to facilitate a further appointment within 28 days of the cancellation.

Professor Ted Baker

Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Medicalcare

Good ––– • There was a positive culture of incidentreporting at ward level and there was evidenceof learning and changes in practice followingincidents. Staff felt supported by theirimmediate team colleagues and by seniormanagers.

• Staffing levels and skill mix was planned,implemented, and reviewed to keep childrenand young people safe.

• Consultants took part in a ‘Consultant of theweek’ rota and were present in the hospitalduring times of peak activity.

• Age dependent pain assessment tools were inuse and analgesia was available to children whorequired it.

• The environment was suitable and welcomingto meet the needs of children and young peopleand their parents and carers. Services wereplanned and delivered to meet the needs oflocal area, the North West of England, NorthWales and the Isle of Man.

• We found consent to treatment was clearlyrecorded in the records we reviewed. Weobserved staff interacting with patients andtheir relatives with kindness, dignity andrespect. Parents and patients told us they wereincluded in decisions about their care and werekept well informed. The patients and parentswe spoke with were extremely positive aboutthe care they received and one parent told us“the staff are like a family, we will miss themwhen the treatment finishes”.

• The trust had achieved 100% compliance withall cancer waiting times for the period April 2016to March 2017 except for one month where theyachieved 88%.

• There was a clear vision which was aligned withthe trust vision to provide ‘a healthier future forchildren and young people’ which wasunderpinned by a set of values. We observedstaff demonstrate the set of values when theywere delivering care.

Summaryoffindings

Summary of findings


• There was a process in place to enable theperformance, safety, and quality of the serviceto be reported and reviewed. Risk registers wereheld at ward and clinical business unit levelwith a process to escalate risks to keep childrenand young people free from harm.

Surgery Requires improvement ––– • The hospital did not always ensure that amember of staff who was trained in advancedpaediatric life support (APLS) was available oneach department at all times. This did not meetthe Royal College of Nursing (RCN) minimumstaffing requirements

• We found that compliance with mandatorytraining across surgical services was mixed. Wehad particular concerns that compliance withsafeguarding level three training for surgicalstaff overall was only 67% at the time of theinspection.

• We found that the governance framework forsurgical services was relatively new and was stillbeing embedded at the time of inspection.

• On surgical wards, there was no evidence offormal risk assessments being completed, such asformally assessing the level of risk posed byresuscitation equipment being in different wardareas. We were therefore unsure if all risks hadbeen identified and mitigated appropriately. Thiswas not line with the hospital’s risk managementstrategy.

Summaryoffindings

Summary of findings


AlderAlder HeHeyy ChildrChildren'en'ss HospitHospitalalDetailed findings

Services we looked atSurgery and Medical care


Contents

PageDetailed findings from this inspectionBackground to Alder Hey Children's Hospital 9

Our inspection team 9

How we carried out this inspection 10

Facts and data about Alder Hey Children's Hospital 10

Our ratings for this hospital 10

Action we have told the provider to take 64

Background to Alder Hey Children's Hospital

Alder Hey Children’s NHS Foundation Trust became afoundation trust in August 2008. The trust provides carefor more than 270,000 children young people and theirfamilies. The trust also leads research into children’smedicines, infection, inflammation and oncology. Thetrust has a broad range of hospital and communityservices, including many for direct referral from primarycare. The trust is a designated national centre for headand face surgery as well as a centre of excellence forheart, cancer, spinal and brain disease. The hospital is arecognised Major Trauma Centre and is one of fournational Children’s Epilepsy Surgery Service centres.

The hospital contains 270 inpatient beds, 48 of which arein intensive care, high dependency and the burns unit. Inaddition, there are 16 operating theatres, including 12 forinpatient use and four for day surgery. The theatre suitehas integrated operating theatres. Seventy-five percent ofthe beds are single occupancy with en-suite facilities,climate control and strip lightening for the child or youngperson to control. Each room contains a sofa bed toenable parents to stay with their child.

Each inpatient room offers natural light and many haveviews of the park. There are separate, dedicated areas,including outdoor space, for children and young peopleon each ward to allow them to socialise, play and relax. Inaddition there is a kitchen situated on every ward with award based chef to ensure that each child is given afreshly prepared, healthy meal of their choice.

There is a new research and education centre builtalongside the hospital. The work of this centre will involvepartnership working with a local university and will allowresearchers to develop safer, better medicines for usewith children, infection, inflammation and oncology.

The inspection team looked at the following core servicesin full at Alder Hey Children’s Hospital:

• Surgery• Medical Care

This was a responsive inspection in response toincreasing concerns we had about the services at thehospital.

Our inspection team

Our inspection team was led by:

Head of Hospital Inspections: Ann Ford, Care QualityCommission (CQC)

The inspection team included two CQC inspectormanagers, four CQC inspectors, a neonatal consultant, alead nurse and a governance specialist.

Detailed findings


How we carried out this inspection

To get to the heart of children and young people’sexperiences of care, we always ask the following fivequestions of every service and provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

Before visiting the trust, we reviewed a range ofinformation we held and asked other organisations toshare what they knew about the trust. These included theclinical commissioning groups, Monitor and NHSEngland.

We spoke with children and young people and staff fromthe ward areas. We observed how children and youngpeople were being cared for, talked with their parents andcarers, and reviewed their records of personal care andtreatment.

We would like to thank all staff, children and youngpeople, their parents and carers and other stakeholdersfor sharing their balanced views and experiences of thequality of care and treatment at Alder Hey Children’s NHSFoundation Trust.

Facts and data about Alder Hey Children's Hospital

Alder Hey Children’s NHS Foundation trust offers 20specialist services, including a designated national centrefor head and face surgery and a centre of excellence forchildren with cancer, heart, spinal and brain disease.Alder Hey Hospital is a teaching hospital and trainsmedical and nursing students each year. The hospital isalso a designated Major Trauma Centre, and is one of fournational Children’s Epilepsy Surgery Service centres.

Alder Hey Children’s Hospital is a paediatric researchcentre, leading investigation into children’s medicines,infections, inflammation and oncology. Between April2016 and March 2017 312 clinical research studies tookplace, ranging from observational studies to complex,interventional clinical trials and 3372 children and youngpeople took place.

Alder Hey serves a catchment area of 7.5 million

Alder Hey Children’s Hospital is in West Derby in the northof Liverpool, a city within the metropolitan borough ofMerseyside. Liverpool is the most deprived of 326 localauthorities in England. It has a population of around467,000 (2011). However, 60% of the hospital’s income isfrom specialised services across the North West, NorthWales – a population of around eight million.

The hospital treats 275,000 patients a year and 75% ofchildren have their own room with pull out beds, offeringmore dignity and privacy to visiting families. All patientshave easy access to relaxation areas including a giantindoor tree-house, play desks and fish tanks.

Our ratings for this hospital

Our ratings for this hospital are:

Detailed findings


Safe Effective Caring Responsive Well-led Overall

Medical care Requiresimprovement Good Good Good Good Good

Surgery Requiresimprovement Good Good Requires

improvementRequires

improvement

Overall N/A N/A N/A N/A N/A N/A

Detailed findings


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

Information about the serviceThe hospital is a regional Children’s hospital that admitspatients from a wide geographical area, including theNorth West of England, North Wales and the Isle of Man.

During the inspection, we visited all the wards wherechildren with medical conditions were being cared forand treated. Each ward included a dedicated pharmacist,there were play specialists and a school for olderchildren. There were facilities for parents / carers to staywith their child including overnight stay and food anddrink preparation areas.

As part of our inspection we visited the following wards:

• Ward 4C was a general paediatric ward with 32 beds orcots

• Ward 3C included gastroenterology (conditions of thestomach and intestines), rheumatology (jointconditions), endocrinology (hormonal disorders),nephrology (kidney conditions) and respiratory (lungconditions) with 28 beds.

• Ward 4B included neurology (nervous system care),long-term ventilation and rehabilitation with 24 beds.

• Ward 3B was the oncology area (cancer care) thatincluded 16 inpatient beds, 10 day care beds and adedicated adolescent area.

We previously inspected this hospital in June 2015 wherethe safe domain only was inspected for medical services.This inspection was carried out in response toinformation we had received from routine monitoringand also information received from parents.

We spoke to 38 members of staff of all grades including:children’s nurses, health care assistants, doctors,registrars, consultants, specialist nurses,physiotherapists, pharmacists, senior managers, the bedmanager, domestic staff, and advanced practitioners. Wespoke to three children and young people, two parents,and reviewed parts of 19 care records as well as reviewingfurther information received from the trust.

Medicalcare

Medical care


Summary of findingsWe rated medical care services at Alder Hey Children’sNHS Foundation Trust as ‘Good’ overall because;

• There was a positive culture of incident reporting atward level and there was evidence of learning andchanges in practice following incidents.

• Medicines were safely stored in areas that wereaccessible to staff only, and each area had adedicated pharmacist based on the wards.

• The trust had commenced training to improve themanagement and identification of sepsis. Weobserved sepsis posters on all the wards we visitedto raise awareness.

• Staff were aware of their safeguarding roles andresponsibilities and knew how to raise matters ofconcern appropriately.

• Staffing levels at the time of inspection metstandards set out by Royal College of Nursing (RCN)standards (August 2013).

• The National Paediatric Diabetes Audit 2015/16showed the trust had performed better than theEngland average for the number of individuals whohad controlled diabetes.

• The trust had achieved 100% compliance with allcancer waiting times for the period April 2016 toMarch 2017 except for one month where theyachieved 88%.

• The environment was suitable and welcoming tomeet the needs of children and young people andtheir parents and carers. The individual needs ofpatients were met and included children and youngpeople with learning and physical complex needs.

• Children and young people at trust level had ashorter average length of stay when compared to anaverage of four children’s specialist trusts for bothelective and non-elective medicine.

• Staff told us they felt supported by their immediateteam colleagues and by senior managers and theworking relationships between nurses and medicalstaff, and allied health professionals worked well.

• There were communication systems in place to keepstaff informed which included newsletters, emails,and safety huddles. Staff confirmed they receivedupdates and information via these systems.

• The trust had recognised the difficulty in recruitingjunior medical staff and had made significantinvestment to support and train nurses to becomeadvanced practitioners to bridge the gap.

• Feedback from parents and children and youngpeople was consistently good. Parents, carers, andchildren and young people we spoke with told us”the staff were like a family, we will miss them whenthe treatment finishes”.

• Children, young people, and those close to themwere treated with respect, dignity, and compassion.

• Services were planned and delivered to meet theneeds of local area, the North West of England, NorthWales and the Isle of Man.

However;

• We were not assured that children and young peoplewere receiving treatment for sepsis that reflectednational guidance. We found delays in the reviewprocess of up to 18 hours when a high risk of sepsisalert presented. This was discussed at inspectionand changes to the electronic system and the policywere planned to be reviewed within two weeks of theinspection.

• The compliance rate for safeguarding training levelthree for children was worse than the trust target.

• There were low levels of compliance with mandatorytraining for medical staff within the medicine clinicalbusiness unit.

• Medical records were not securely stored on eachward we visited. We were not assured that childrenand young people’s confidentiality was beingmaintained.

• Patient privacy and dignity was not fully maintainedon wards we visited due to the display screen whichwas visible to people entering the wards.

• We raised concern with the electronic record systemin relation to alerting deterioration in children and

Medicalcare

Medical care


young people that may have a diagnosis of sepsis.The trust responded immediately with actions and atimeframe to ensure the pathway in the system wasrobust.

Are medical care services safe?

Requires improvement –––

We rated medical care services as ‘requires improvement’for safe because;

• The compliance rate for safeguarding training levelthree children was worse than the trust target.

• Records for two children with a history of sepsis werereviewed and both highlighted delays in treatment.We were not assured that children and young peoplewere receiving treatment for sepsis that reflectednational guidance.At the time of our inspection therewere no assurance systems in place to audit andmonitor adherence to policies in relation to managingthe deteriorating patient.

• Resuscitation equipment was not kept together in oneplace and relied on several staff to collect equipmentduring an emergency. There was lack of clarity fromstaff over responsibilities when an emergency call wasraised and both these concerns could present a risk ofa delay in equipment being available.

• Children, young people, and visitors could leave theward unsupervised by using the exit buttons as staffwere not always available to observe the ward exit.This meant there was a risk of children absconding orbeing abducted.

• There were low levels of compliance with mandatorytraining for medical staff within the medicine clinicalbusiness unit.

• Medical records were not securely stored on eachward we visited. Confidential records were kept on theward corridors, in unlocked trolleys, and not alwayssupervised by staff as well as electronic screens thatdisplayed patient details. We were not assured thatchildren and young people’s confidentiality was beingmaintained.

• Due to several electronic systems in place across thetrust for medical records, it was difficult to navigatethe patient’s journey and this could result in allinformation not being reviewed when making clinicaldecisions about care.

Medicalcare

Medical care


However;

• The trust had an incident reporting policy available onthe intranet. Staff knew how to access the policy andhow to report incidents using the on-line reportingsystem. Incidents were investigated with actions forimprovements identified. Staff gave us examples ofhow changes had been made following the learningthat took place from reported incidents.

• The wards and clinical areas were visibly clean. Staffwere aware of and adhered to current infectionprevention and control guidelines such as the ‘barebelow the elbow’ policy. Personal protectiveequipment such as aprons and gloves were readilyavailable throughout the ward areas we visited.

• There was a comprehensive system in place to ensureall equipment was appropriately maintained andreplaced as required. Although resuscitationequipment was not kept together in one place, a planwas in place to introduce standardised resuscitationtrolleys for each ward within two weeks of theinspection.

• Medicines were safely stored in areas that wereaccessible to staff only and each area had a dedicatedpharmacist based on the wards.

• Staffing levels at the time of inspection met standardsset out by the Royal College of Nursing (RCN) standards(August 2013).

Incidents

• The trust had an incident reporting policy available onthe intranet. Staff knew how to access the policy andhow to report incidents using the on-line reportingsystem.

• At the time of our inspection staffdemonstrated howto report incidents. Feedback on the reportedincidents was sent to staff via email. We reviewed thelast nine incidents that were reported across twowards and found that eight of the nine incidents werereported on the same day as the incident occurred.One of the incidents was reported two days after theincident occurred and was in relation to out of dateequipment which was replaced the day the incidentwas reported.

• Between February 2016 and January 2017, the trustreported no incidents which were classified as neverevents for the medicine CBU. a Never events areserious incidents that are entirely preventable asguidance, or safety recommendations providingstrong systemic protective barriers, are available at anational level, and should have been implemented byall healthcare providers. Each never event type has thepotential to cause serious patient harm or death.However, serious harm or death is not required tohave happened as a result of a specific incidentoccurrence for that incident to be categorised as anever event

• The medical specialties and medical clinical businessunit (CBU) reported a total of 1,272 incidents for theperiod April 2016 to March 2017. Of these incidents,1,073 were reported as causing no or minor harm, 191were reported as near misses, two were moderateharm, and one was reported as a serious incident inaccordance with the Serious Incident Framework 2015.

• The serious incident reported in November 2016 wascategorised as sub-optimal care of the deterioratingpatient. The root cause analysis (RCA) investigationidentified that there was no formal procedure in placeto recognise and escalate the deteriorating patientcausing a delay in treatment.

• Actions were identified following the RCA investigationand we saw evidence at the time of our inspectionthat those actions were being implemented. Actionsincluded: training in relation to Sepsis and thePaediatric Early Warning Score (PEWS) which is a toolto monitor whether a child’s condition is deteriorating.

• We were given another example of learning fromincidents following medication errors that werereported. The trust had introduced the use of a redapron to be worn when preparing medication toprevent disturbance, however, this practice was notobserved across all the medical wards: we observed itin place on ward 3C but nurses on other wards wereobserved preparing and administering medication notwearing the red aprons.

• Safety huddles took place on the wards daily whereany key messages were shared and staff we askedconfirmed these took place.

Medicalcare

Medical care


• The medication safety officers had introduced the‘safer times’ monthly poster which we reviewed forMarch 2017 which identified incidents reported inrelation to medicines management. The posteridentified errors and trends, and highlighted lessonslearnt and ‘Good Catch Awards’ which reflected thenear misses. There was also links to policies for staff toreview. We observed the poster for March andFebruary 2017 on the notice board in an office on ward4C at the time of our inspection.

• We saw evidence of the monthly ward reports whichinformed the CBU of incidents.

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson. Some staff we spoke to were unfamiliar withthe term ‘Duty of Candour’ however all could describethe principle and the circumstances in which it wasused. We observed Duty of Candour within the actionsin the RCA investigation for the serious incident wereviewed with a meeting with the family within a weekof the completion of the investigation.

• We saw examples of completed mortality review formsthat were comprehensively completed by consultantshowever: the morbidity forms were not always fullycompleted.

Safety thermometer

• As a children’s trust, Alder Hey were not required tosubmit data as part of the NHS Safety Thermometer (atool designed to be used by frontline healthcare staffto measure a snapshot of specific harms once amonth).

• The trust had introduced a monthly ‘NursingDashboard’ which presented data relating to quality,bed occupancy, and workforce for each of the wards.Within the quality domain data in relation to hospitalacquired pressure ulcers was collated. For the periodJanuary to March 2017 for four medical wards wefound there had been one pressure ulcer reported onward 4B.

Cleanliness, infection control and hygiene

• The ward areas we visited were visibly clean. We sawthat staff followed good practice in relation to thecontrol and prevention of infection. Staff were awareof and adhered to current infection prevention andcontrol guidelines which included the ‘bare below theelbow’ policy. Personal protective equipment such asaprons and gloves were readily available throughoutthe wards we visited.

• We observed ‘I am clean’ stickers in place onequipment and cots on the wards to alert staff at aglance that equipment or furniture had been cleanedhowever; there was no routine schedule in place tochange the ward curtains.

• Hand sanitizing dispensers were available in eachward bay and outside each ward cubicle.We observedstaff and carers using hand gel when entering theward.

• On induction to the trust, nursing staff receivedtraining on the Aseptic Non Touch Technique (ANTT)which is a technique used to prevent microbialcontamination of aseptic parts and sites by ensuringthat they are not touched directly or indirectly. Auditstook place across the medical wards by observing staffperform the process against a range of standards. Thetrust provided data for ANTT audits across six medicalareas which equated to 69 observations for a range ofperiods from 11 August 2016 to 20 April 2017. Wefound three of the six ward areas achieved 100%compliance in this period.

• Each ward area had a Nursing Dashboard whichcaptured a range of data including infection control.We reviewed the data for January to March 2017 forfour of the medical wards which included 3B, 3C, 4C,and 4B. Monthly cleanliness scores ranged from 95%to 99% compliance.

• Monthly hand hygiene audits were completed. Thefour medical wards had achieved between 89% and100% compliance for the three month period. Therewere 13 hospital acquired infections identified in thethree month period of which nine were reported onWard 3C.

• There had been two cases of meticillin-resistantstaphylococcus aureus (MRSA) bacteraemia reported

Medicalcare

Medical care


in the medical division between April 2016 and March2017, both on ward 3C but there were no cases ofClostridium Difficile (C.Diff) reported within the sameperiod.

• The results of a cot audit on ward 3B which identifiedthat beds and chassis were dust free and 100%compliance against standards was achieved for the 18assessed however, the audit was not dated.

• All the wards we visited had single bedded cubicles,this enabled isolation of children and young peoplewho were diagnosed with an infectious disease.Aprocess was in place to ‘deep clean’ cubicles followingthe discharge of all patients.

Environment and equipment

• The trust had an Asset Management System in placewhich held information on medical devices owned bythe trust. We reviewed the database at the time of ourinspection which included the model, purchase date,replacement date, and maintenance schedule foreach device. Engineers ran reports to identify whichequipment required a maintenance review and theservice ran a month end governance report.

• We reviewed the month end report for equipmentreceiving maintenance checks in March 2017 andfound the service had achieved 87.8% against a keyperformance indicator (KPI) of 90% for high riskdevices for example syringe drivers. For low tomedium risk equipment for example blood pressuremonitoring equipment and tympanic thermometers(recorded temperature via the ear), the service hadachieved 79.2% against a KPI of 85%. An identifiableasset number was in situ on equipment we observedon the wards.

• We saw weighing scales had been calibrated andverification checked. The asset manager told us thiswas done on site by an external company every sixmonths and by trading standards every two years.

• We observed cots, beds and equipment stored on theward corridor areas on ward 4C and staff told us thatstorage space was limited. We found this was anidentified risk on the ward risk register with action toidentify an area to store the beds however; this riskhad not been reviewed since 19 July 2016.

• Resuscitation equipment was available on all thewards we visited however there was no identifiedresuscitation trolley or similar which held all theequipment in one place.

• The wards had a trolley with a defibrillator machine, aseparate cylinder for oxygen, a separate orange orsilver case holding equipment and a separate caseholding emergency medication. This equipment wasnot all stored in the same place on the wards andrequired several staff to take equipment to anemergency which could result in a delay to accessequipment.

• The trust informed us at the time of our inspectionthat they had commissioned an external review of theresuscitation equipment, which supported our viewthat there could be a delay in accessing equipmentand there were plans to have trolleys in place withinthe two weeks following the unannounced part of ourinspection to enable resuscitation equipment to bekept together and be easily accessible so it could betransported to an emergency without delay.

• There was an additional orange rucksack withadditional equipment for resuscitation held on eachfloor of the building. Staff on ward 3B told us thatwhen a resuscitation call was raised the porter takesthe rucksack to the area it is required however; not allstaff present were aware of this process and there wassome confusion when talking to staff whoseresponsibility it was to actually take the rucksack.Oneof the morbidity reviews we looked at highlighted thata porter needed to get the emergency drugs duringresuscitation. It was unclear if all staff were aware ofthe process in place when an emergency resuscitationcall was raised.

• Emergency medication that required refrigeration,were stored in locked fridges in locked roomsaccessible by staff with swipe cards. On ward 4C, theportable suction machine was kept in a locked roomthat staff accessed by swipe card. This could present adelay in accessing equipment in an emergency.

• Entry to all the wards we visited was via an intercomsystem for visitors and a swipe card system for staff.Toexit the ward visitors could exit by pressing a buttonthat was in reaching distance of children.Thispresented a risk that children could leave the ward

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unsupervised and also raised a concern in relation tochild abduction. This was raised at the focussedinspection on 22 September 2015 by CQC to review thenew building and environment before the newhospital opened. However, we observed peopleleaving the ward unsupervised and the reception deskwas not occupied by staff at several times during ourinspection on wards 3C and 4C.

• We found separate fridges were available for thestorage of breast milk on the wards, however; on oneward the fridge was in the unlocked pantry. Weobserved the storage and handling of breast milk onthe medicine risk register where actions to reduce therisk of people other than staff having accesshighlighted. Staff told us that this area was for parentsand two nurses checked the milk prior to handing toparents or carers. This presented a risk of crosscontamination or tampering with the breast milk.

• Staff completed daily work sheets, for their allocatedpatients, for the checking of equipment, via the trustselectronic system.

Medicines

• Medicines, including controlled drugs, were storedsecurely, stock levels checked twice daily and accesswas limited to staff.

• Fingerprint technology was in place for staff to gainaccess to stock medication including medications fordischarge.

• There was a ward based pharmacist on wards 4C and3B. Stock controls and expiry dates were monitoredand take home medication was available from thewards when children and young people weredischarged.

• A pharmacist told us that the fridges were linked to acentral system that monitored the temperatures werein the appropriate range of two to eight degrees. Thefridges alarmed if the temperature was out of range,alerting the pharmacist to investigate the reason forthe alarm and take appropriate action. In addition tothis fridge temperatures were monitored and recordedon paper daily by the ward housekeepers, although;

there were no ranges recorded. We found that therewere omissions in recording temperatures when thehousekeepers were not working, with no system toensure they were checked by another member of staff.

• There was a specialist nurse, on ward 4B (neurology),who was a non-medical prescriber and advancednurse practitioners on ward 3B (oncology) who couldprescribe medication.

• There had been 30 medication incidents reported forthe period January to March 2017 for the four wardswe reviewed. We reviewed the ‘safer times’ poster forMarch 2017 to identify trends for medication incidents.We found these related to staff reporting that whenthey had signed for medication on the trust electronicsystem. The system did not show the medication hadbeen signed for, dates when medicines were openedwere not documented, and diagnostic tests notperformed prior to administration of medication.

Records

• Nursing records were held electronically and medicalrecords were paper based with some elementsavailable electronically.

• Since the last inspection in 2015 the trust hasimplemented an electronic patient recordsystem.However there were different electronicsystems used for medical records across the trustwhich presented difficulties when trying to navigatethe full patient’s journey. There was a differentelectronic system in place in critical care areas thatwas different from the system used on the medicalwards.

• We reviewed ten sets of medical records and found allto be legible, signed and printed, with clearmanagement plans in place. We saw evidence ofdisease specific pathways within the medical records.

• We reviewed electronic prescription charts whichdetailed the allergy status, medicines prescribed,doses, and frequency for administration.

• The records we reviewed included evidence of inputfrom members of the multi-disciplinary team (MDT)and discussions with the children and young people’sparents and carers.

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• Patient medical records were not securely stored inany of the wards we visited at the time of ourinspection. Medical records were available on theward near the nursing station in unlocked trolley’s thatwere not always supervised by staff.

• Electronic screens were present that displayed patientdetails that were clearly visible to staff and visitors tothe ward which included the patient name, this didnot provide us with assurance that confidentiality wasbeing maintained for children and young people onthe wards.

Safeguarding

• Safeguarding policies and procedures were in placeacross the trust and these were availableelectronically for staff to refer to.

• In discussion with us, it was clear that staff were awareof their roles and responsibilities, and knew how toraise matters of concern appropriately. Staff we spokewith were aware of the safeguarding team and how toaccess support and advice.

• A database of all referrals and notifications ofattendance for children and young people known to aSocial Worker was kept by the safeguardingdepartment. During the period April 2016 to March2017, 1,491 referrals/notifications were completedtrust wide.

• We were provided with information from referralsmade and evidence of multi-professional meetingrecords which clearly identified ongoing actions andthe partnership working with local authorities andother agencies.

• Safeguarding training was part of the mandatorytraining matrix and required all patient facing staff tobe trained to level three. The safeguarding childrenand young people: roles and competencies for healthcare staff Intercollegiate Document (2014), states thatclinical staff who contribute to assessing, planning,and evaluating the needs of a child or young personand parenting capacity where there are safeguarding/child protection concerns should all be at Level three.

• We reviewed training compliance for safeguardinglevel three for wards 3B, 3C, 4B, and 4C and foundcompliance ranged between 78% to 85.2% with amean average of 80% across the four wards. This waslower than the trust target of 90%.

• Child sexual exploitation and female genitalmutilation were included in the safeguarding levelthree mandatory training.

Mandatory training

• Mandatory training was provided by the trust andattendance at modules were determined by staff roles.The mandatory training programme for all staffincluded modules for fire, major incidents, handlingcomplaints, information governance, fraud awarenessand bullying and harassment. The additional modulesfor clinical staff included:inflection control,safeguarding level three children, medicinesmanagement and paediatric life support. Eachmodule had a timeframe for completion.

• Staff told us they were alerted via email when theywere approaching renewal and were required toattend mandatory training

• Staff told us there was a mandatory training dayavailable on a Friday once a month to complete arange of modules.

• At the time of our inspection we reviewed mandatorytraining compliance for nursing staff for wards 4B, 4C,3B, and 3C for March 2017 and all were achievingbetween 80.7% to 88.1% with a mean average acrossthe wards of 85.4%. However, the medical staff in themedical CBU were achieving 55.2% which wassignificantly lower than the trust target of 90%compliance. This compliance rate for medical staffwas worse than the findings in our previous inspectionin May 2014 when the compliance for mandatorytraining was 67%.

Assessing and responding to patient risk

• The trust used a Paediatric Early Warning Score(PEWS) system, which is a tool designed to identifychildren who are at risk of their clinical conditiondeteriorating. PEWS were used to monitor thecondition of a child or young person and wasautomatically populated on the electronic recordwhen physiological observations were recorded.

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• In November 2016 there had been a serious incidentwhich resulted in an unexpected death. Followinginvestigation it was identified that all observationswere not recorded to generate an accurate PEWS andescalation of PEWS was not done in a timely manner.

• A sepsis steering group was set up to monitor sepsis inthe trust. A training programme in relation to sepsiswas set up and delivered by a designated team thatincluded: awareness of the PEWS policy, the SepsisPolicy and pathway, the completion of scenarioson-line and the completion of a competencydocument for all clinical staff.

• Ward 3C were the first ward to do the sepsis training inFebruary 2017 and at the time of our inspection 44 outof 50 clinical staff had completed all the trainingcomponents.

• Ward 4C had gone live with the sepsis pathway theweek prior to our inspection. We reviewed trainingrecords which identified 31 out of 66 clinical staff hadcompleted all components of the training. Thepermanent night staff on the ward had not completedthe training however, the Band 6 staff members thatrotated onto night shifts had completed all thetraining.

• We asked a Band 5 staff nurse what action they wouldtake if a patient had a PEWS score of three. We weretold that a repeat set of observations would be takenimmediately and if there were no significant changethey would continue to monitor. The nurse informedus if a patient had a new PEWS of four or more theywould contact the registrar to review. This actionreflected the trusts PEWS Policy.

• Medical staff told us that during out of hours, if apatient presented with a new PEWS of four, the trustpolicy advocates a discussion with the consultanthowever, if the registrar is satisfied with the patient’scondition they did not contact the consultant athome. At each recording of physiological observationson the electronic system there was a prompt withoptions to consider if a patient had any identified risksof developing sepsis. When the physiologicalobservations were input, a PEWS score was calculated

and there was an additional prompt which identified ifthere is a medium or high risk of sepsis. This isdisplayed for the clinician to consider again if a patientmay have sepsis.

• We reviewed an electronic record where a child had anincreased respiratory rate which had triggered amoderate to high risk of sepsis and a PEWS score ofnil. This prompted the clinician to consider and recordif the child could have sepsis. Nursing staff used theirclinical judgement and could document that therewas no risk however: Although the trust agreed policywas that all health care assistans worked under thedirect supervision of a qualified nurse we were madeaware of a risk that when health care assistantsinputted the physiological observations they couldalso complete this area of the assessment withoutdiscussion with a qualified clinician.

• During the inspection, records for two children with ahistory of sepsis were reviewed and both highlighteddelays in treatment. Both these children had alerts onthe electronic system saying ‘high risk of sepsis,immediate review’ for up to 18 hours, yet there was noreview in that time period, and it was only after 12hours in one case and 18 hours in the other, that theywere escalated, for medical review and antibioticsadministered in a timely manner. There was a risk ofdelay in on-going treatment.There were two earlywarning systems running concurrently where one (thePEWS) can give a score of zero yet the other (sepsisrisk) can say ‘high risk of sepsis, immediate review’ or‘moderate risk of sepsis, urgent review’ calculatedfrom the very same parameters entered into theelectronic system. This is supported by nationalguidance which advocates separate sepsis scores.

• This was raised with the Executive Team at the time ofthe inspection and as a result of the feedback of ourfindings, the sepsis steering group agreed that theescalation advice in the electronic system could leadto confusion about appropriate action to take. Thetrust proposed changes to the way this presented tostaff on the system to be completed within two weeksalong with updating the sepsis policy to reflect thechanges.

• The trust required registered nurses to complete apaediatric life support course that included‘intraosseous infusion’ (injecting into the marrow of a

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bone) as well as ‘cardiac arrest rhythms anddefibrillation familiarisation’. We reviewed data fromthe 5 May 2017 for wards 3B, 3C, 4B, and 4C and foundpaediatric life support mandatory training complianceranged from 72.9% to 97.3% across the four wardswith a mean average of 85.9% compliance. The trusttarget was 90%.

• The Royal College of Nursing documentdefining-staffing levels for children and young people’sservices, identifies at least one nurse per shift in eachclinical area (ward/department) to be trained inAdvanced Paediatric Life Support (APLS) dependingon the service need as a core standard to be applied inservices providing health care for children and youngpeople.

• The trust told us that staff rotas were completed toensure appropriately trained staff were available atany time of day or night and this was monitored by theward managers. We were told that all senior medicalstaff and the out of hour’s senior nursing team weretrained in advanced paediatric life support (APLS) toensure that wards could access a health professionalwith the necessary emergency skills wheneverneeded. There were also some nurses trained to APLSlevel on the medical wards.

Nursing staffing

• Staff informed us that the staffing levels were basedon the Royal College of Nursing (RCN) standards(August 2013) which recommends a staff ratio of 1:3(nurse:children) for children under two years of ageand 1:4 for children above two years of age.

• At the time of our inspection, ward 4C worked to ninenurses on a day and night shift and two health careassistants.On the 19 April 2017 the ward had eightnurses and four healthcare assistants on duty duringthe day. The ward was split into four pods and eachpod reviewed the acuity twice daily. There were 31inpatients on the ward of which 14 were under the ageof two years of age. This meant that the number ofstaff met the RCN recommendations. For the samedate we reviewed the staffing on ward 4B where therewere 17 inpatients with five nurses and six healthcareassistants on duty which also met the requirement.

• Staff worked ‘long days’, ‘nights’ or internal rotationthat was a combination of day and night duties. Thenumbers of staff required were the same over the 24hour period.

• The sickness rates for registered nurses in the medicalCBU for wards 3B, 3C, 4B and 4C were an average of6.9% between April 2016 and March 2017 and forhealth care assistants the sickness rates were anaverage of 5.5% for the same wards and the same timeperiod.

• Rotas were planned so that the nurse- in charge couldact as supernumerary (surplus to as to oversee and co– ordinate care through the wards), however; in theevent of unplanned absences such as sickness, thenurse in charge assisted in patient care also.

• Between April 2016 and March 2017, the turnover ratefor registered nurses was an average of 0.6% permonth and the turnover rate for health care assistantswas an average of 1.1% per month for the same timeperiod.

• We received the staffing numbers at the time ofinspection. These showed the numbers of staff wereless than planned for each of the medical wards ofabout one registered nurse, although ward 3C had theplanned number. This resulted in the wardco-ordinators who are usually supernummary havingto participate in providing care to patients. The wardnursing dashboards, we received, included theavailable staffing between January and March 2017.That showed an average of 85% of the staff wereavailable to work across the four wards.

• We observed a ward handover from the night staff tothe day staff on ward 4C. All the day staff attended asafety briefing where they were alerted to particularconcerns for the ward. Staff were provided withprinted handover sheets which included patientdetails. The nurse in charge on nights did a handoverfor the whole ward to the nurse in charge on days. Theother staff members attended a detailed handover fortheir allocated patients. This meant that if a nurseneeded to be moved to one of the other three podareas on the ward they would not have received ahandover for those patients.

• Any shortfalls in staffing levels were supplemented bybank or agency staff. Between April 2016 and March

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2017 the medical CBU areas:ward 3B filled an averageof 29 shifts per month with bank staff, for 3C it was 80shifts, for 4B it was 24 shifts and for 4C it was 55shifts.Agency staffing was less with 3B filling two shiftson average per month; for 3C it was 11 shifts, for 4B itwas one shift and for 4C it was nine shifts filled byagency staff on average per month for the same timeperiod.

• On ward 4C there was a tendency to use their ownstaff to cover bank shifts. Staff told us this had beendifficult of late as staff had experienced being movedto another ward so had declined to work additionalhours.

Medical staffing

• We observed a medical handover which took placeverbally walking round the ward and seeing patients.We saw that observations recorded on the electronicsystem were reviewed and observed discussions withparents however: there was no registrar in attendanceon this ward round which meant there was lack ofsupport for junior doctors when complex issues arose.

• Following the inspection we were told thatthere werethree handovers every day. The morning handoverwas with the team following the post take wardrounds;. there was a consultant led evening handoverfrom 4pm-5pm followed by ward rounds and aSpecialist Registar led night handover.

• The ‘consultant of the week’ was available daily foreach ward.

• Junior doctors could access specialist registrars via ableep system if they required assistance.

• We reviewed the medical rotas for March 2017 andfound there was 24 hour cover by consultants andsenior doctors.

• From April 2016 to March 2017 the estimated wholetime equivalent (WTE) locum usage for medicine wason average 11 WTE per month.

• The medical staffing turnover trust wide was 1.2%from April 2016 to March 2017.

• Staff told us the trust found it challenging to recruit tojunior doctor vacancies but had made an investmentto train advanced nurse practitioners to partiallyaddress the shortfall and we observed advanced nursepractitioners on wards.

Major incident awareness and training

• Major incident awareness training formed part of themandatory training. There was a policy in placeshould a major incident occur.

• The hospital had an emergency power supply whichwas tested on a regular basis by the on sitemaintenance team.

Are medical care services effective?

Good –––

We rated effective as ‘good’ because:

• The service used national and best-practice guidelinessuch as those from the National Institute for Healthand Care Excellence (NICE) to determine care andtreatment provided. Records we reviewed confirmedthere were a number of evidence-based pathways inplace.

• Age related pain assessment tools were available toassess and respond to children and young people whowere experiencing pain. There was access to a painspecialist team if additional review was required.

• Nutrition and hydration needs were assessed onadmission, all food was prepared on the ward in thekitchen, and there was access to a dietician if required.Children and young people and visitors all gavepositive feedback in relation to the food and thechoice available. We found menus on the ward to beage appropriate.

• The risk of readmission for non-elective medicine washigher when compared to an average of children’sspecialist trusts but remained within the expectedratio for haematology, oncology and respiratorymedicine.

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• There were processes in place to obtain informedconsent either from a young person or from theirparent or carer on their behalf. Staff cited thesafeguard team as a point of contact if they had anyconcerns in relation to consent.

However;

• It was not clear when certain disease specificpathways had been reviewed or if based on up to datepractice; this may place a child or young person atrisk.

• We requested outcomes for National Clinical Auditshowever: the data was not available from the trust.

• Mandatory training did not include mental capacityact training.

• Staff appraisals were below the trust standard at March2017.

Evidence-based care and treatment

• Policies and procedures were in place and could beaccessed via the trust’s intranet and staff we spokewith were aware of how to access them.

• The service used national and best-practice guidelinessuch as those from the National Institute for Healthand Care Excellence (NICE) to determine care andtreatment provided.

• We observed the pathway for children and youngpeople with newly diagnosed diabetes which wasdated version 3, 2013. The medical pathwaycoordinator informed us that the newly diagnoseddiabetes pathway was in the process of being updatedand was waiting for sign off however, this had been inprogress for at least two years.

• We observed the pathway for diabetic ketoacidosishad been implemented in the accident andemergency department where a child presented andthe pathway was ongoing when the child wasadmitted to the ward. We observed medicationprescribed and administered in line with the pathwayalong with the recording of hourly physiologicalobservations.

• We reviewed the pathway for the management ofdifficult to control asthma which was dated version 7,2015 and referred to the British Thoracic Society (BTS)

Guidelines for management of asthma (2007)however; new guidance on the management ofasthma was published by the BTS in September 2016.We spoke with a member of the respiratory team whoinformed us that this pathway was used on homevisits and that there was a different acute asthmapathway that was used for inpatients. We reviewed theacute asthma pathway which was version nine, datedJanuary 2013 and therefore could not have takenaccount of the 2016 guidance from the BTS.

• We spoke with the Medical Pathway Coordinatorabout the process for updating and reviewingpathways. We were told that due to the introduction ofthe electronic records system, pathways were beingreviewed and updated when they were merged ontothe system. We asked how the trust were assured thatchildren and young people were given the most up todate care and there were no systems in place toprovide this assurance. The delay in reviewing andupdating disease specific pathways had not beencaptured as a risk on the risk register.

• The trust Sepsis Steering Group, which included seniorclinicians from across the trust, had developed asepsis pathway to implement the NICE sepsisguidance from July 2016. This was prioritised for rapiddevelopment in February 2017 within the hospital’selectronic record, and was being introduced acrossthe trust at the time of our inspection using a phasedimplementation process.

• The process was introduced on one ward from the 13March 2017 and was being rolled out to other wardsacross the clinical business unit (CBU) with completeimplementation planned to be in place across theCBU by 30 June 2017. A monitoring and evaluationprocess was due to be in place by 31 May 2017 and wewere told it would include data from the introductionof the process and include an audit of the PaediatricEarly Warning Score (PEWS).

• We reviewed the trust Guidelines for Care andMaintenance of Intravenous Access Devices inPaediatric Patients which was dated February 2017and was evidenced based. We observed staff at thetime of our inspection providing care in line with thepolicy.

Pain relief

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• The medical wards used age dependant painassessment tools. For younger children, observationsand crying were used to assess pain. There was a facespain rating scale in place where children could pointto a picture that most represented how they felt andfor young people, pain was assessed using a numberscoring system.

• We observed a pain audit to measure complianceagainst three standards which included: Initial painassessment was completed, daily pain assessmentwas completed, and pain score frequency wasdocumented. The audit was performed on wards 3Band 3C in April 2017 which included six patients. Theaudit identified 100% compliance against all threestandards for both wards however: the audit onlyincluded six patients and a larger audit may providemore assurance.

• The wards had access to the pain specialist team andplay specialists. Pain was discussed at handovers andmulti-disciplinary meetings where patients care wasreviewed.

Nutrition and hydration

• Assessment of nutrition and hydration formed part ofthe nursing record and was completed in all of therecords we reviewed at the time of our inspection.Weobserved fluid balance charts recorded on theelectronic record and children and young people hadtheir weight recorded to inform dietary requirementsfor example: children with failure to thrive, diabetes,and those receiving intravenous feeding as totalparenteral nutrition (TPN) to enable correct provisionof fluids and nutrients.

• TPN regimes were reviewed and prescribed by themedical team and were prepared and stored inpharmacy and were delivered to the ward daily.

• The wards had access to a dietitian and were aware ofhow to refer to the service.

• All food was prepared on the wards in the wardkitchen by a ward based chef. Special milkpreparations were prepared off the ward in a centralplace or were delivered ready prepared.

• There was a separate kitchen area on the wards forcarers and parents and they could also request a mealfrom the menu for a small charge.

• We observed breast milk clearly labelled and stored indesignated fridges.

Patient outcomes

• Between 1 December 2015 and 30 November 2016,elective patients for rheumatology, gastroenterologyand oncology had a mixed performance whencompared to the average risk of readmission of thefour children’s specialist trusts in this core service witha higher proportion of patients readmitted foroncology.

• For non-elective medicine, the risk of readmission forAlder Hey was higher when compared to an average ofchildren’s specialist trusts but remained within theexpected ratio for haematology, oncology andrespiratory medicine.

• A project to develop a model of care for children withcomplex needs called potential, organised, involved,needs-based and together (POINT) was introduced.The project, which focused on children who had beenin hospital for more than 30 days, found that, byfocusing on aspects of the child’s care journey, therewas a reduction in the length of stay for these childrenand young people.

• The trust measured HbA1c as an indicator of how wellan individual’s diabetes was controlled over time. Thetrust performed better than the England average forthe period 2015 to 2016.

• There had been 402 medical outliers (patients on adifferent ward to the one they would require) onsurgical wards for the period April 2016 to March 2017with the higher numbers from November 2016 toFebruary 2017, which would represent the time ofwinter pressures.

• During the reporting period 1 April 2016 to 31 March2017, the trust submitted data to 10 of 11 NationalClinical Audits and five National Confidential Enquiriesthat it was eligible to participate in. The trust hadsubmitted data to the ulcerative colitis and crohnsdisease national audit, the paediatric diabetes audit,and Asthma care in Emergency Departments RoyalCollege of Emergency Medicine audit.

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• We requested data for outcomes of National Auditshowever: the trust did not provide any data only thenumbers of cases submitted to the audits. We weretherefore unable to make any comparisons tobenchmark against other trusts.

• We reviewed six patient records and found that all sixpatients were seen by a doctor within 43 minutes ofarrival with the shortest wait time being 35 minutes.

Competent staff

• Staff identified their learning needs through the trustsappraisal process. We reviewed the appraisal rates forthree wards at the end of March 2017. Ward 3B hadachieved 85%, ward 3C had achieved 84%, and ward4C had achieved 72%. Although this was lower thanthe trust standard of 90%, it was better than theoverall trust compliance of 67%.

• Induction processes were in place for new staff andstudents. Preceptorship was in place for newlyqualified staff and included demonstration ofcompetencies with equipment. A newly qualifiednurse showed us their in-house workbook where weobserved clinical competencies had been completedfor a range of clinical procedures for example, intravenous training for a newly qualified nurse.

• We spoke with a newly qualified staff nurse whoinformed us they had received a six week inductionprogramme and remained supernumerary (out of thestaffing numbers for learning purposes) for their firstfour weeks.

• The respiratory physiotherapy team described howthey had weekly training sessions on various subjectsand also shared findings from literature reviews. Therewas an annual competency based review whichincluded a peer review of three cases to reviewassessment and treatment plans.

• The cystic fibrosis team identified attendance at theannual cystic fibrosis conference and staff weresupported to attend the cystic fibrosis Europeanconference as a way to share learning.

• Doctors had an induction meeting and training whenthey commenced at the trust. Doctors we spoke withconfirmed they had attended the induction trainingwhich included the management of sepsis.

• Ward 4B had a training room on the ward where staffcould be trained and assessed on a range ofprocedures.

• The medicine CBU was meeting standards set out inFacing the Future: Standards for acute generalpaediatric medicine services (2015). We saw evidencein medical records which included; being seen by amiddle grade or consultant within four hours ofattendance, there is at least one medical handover ineach 24 hour period led by a consultant, consultantswere available in the hospital during peak times, andthere was a ‘consultant of the week’.

• Learning from incidents had prompted the trust totrain staff on the screening, management, and thepolicy, in relation to sepsis and the deterioratingpatient. This training had commenced prior to ourinspection and was being rolled out to wards with acomprehensive training plan delivered on the ward bya separate team.

• We were told that all senior medical staff and the outof hours senior nursing team were trained in advancedpaediatric life support (APLS) to ensure that wardscould access a health professional with the necessaryemergency skills whenever needed. There were alsonurses trained to APLS level on the medical wardshowever: not all nurses had received this level and hadcompleted the PLS training.

Multidisciplinary working

• Good multidisciplinary team (MDT) working was notedin areas we visited. Clinical staff told us there weregood working relationships between medical andnursing staff.

• Our observation of practice, review of records, anddiscussion with staff confirmed effective MDT workingpractices were in place. This included working withinternal services including radiology, pathology, andpharmacy and external services including specialistdoctors across the country and countries outside ofGreat Britain.

• In the CQC Children’s survey 2014 the trust scored 8.62out of ten for the question ‘Did the members of staffcaring for your child work well together?’ This wasabout the same as other trusts.

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• A child and adolescent mental health service (CAMHS)was available at the trust and referrals to the servicecould be made.

• We reviewed meeting records for children and youngpeople where a safeguarding concern had been raisedand these evidenced close working with socialservices, local authorities, health visitors and thepolice.

• Play specialists were available on the wards and therewas also a school available on ward 3C.

• A consultant from the trust informed us at the time ofour inspection that the trust was actively engagedwith experts in other centres to understand how bothadult and paediatric providers were implementingsepsis pathways so they can share learning.

• The cystic fibrosis team were a fully integrated teamwhich included: advanced nurse practitioners,specialist nurses, consultants, physiotherapists,dieticians and a pharmacist. The team worked with anetwork of trusts in the North West and Wales toprovide MDT annual reviews for children in their care.

• Ward 3C had a training room where they were able toprovide training to staff in the community that wouldbe providing care to children and young people ondischarge. Staff told us that community staff wereinvited to the ward to be trained and to provide care tothe patient under the supervision of ward staff. Thisprovided the opportunity to build workingrelationships and communication networks tosupport safe discharge for children and young people.

Seven-day services

• The medical wards had seven day access to servicesincluding radiology, pharmacy, and some allied healthprofessionals which included physiotherapists.

• Medical cover was provided and there was consultantcover provided on-call.

• Two medical staff we asked both told us they couldaccess registrars and consultants out of hours and hadnot experienced any difficulties.

• Ward rounds took place daily and all new patientswere seen by the medical team at weekends.

• The physiotherapy service was available 24 hours aday with an on-call system in place after 9pm to 8ameach day.

• Take home medications were stored on the ward andcould be dispensed out of hours to prevent delays inthe discharge process.

Access to information

• Policies and procedures were kept on the trustsintranet and staff we spoke with confirmed they werefamiliar with how to access them.

• Staff could access diagnostic results for exampleblood tests and x-ray results via the electronic system.

• The trust had a discharge planning policy which wasdue for review in September 2018. We saw evidence inthe patient’s records that the policy was beingfollowed: there were discharge summaries to the GP,referrals to community and others services whererequired with follow up arrangements.

• Young people or their carers were given a copy of theGP discharge letter at the time of discharge.

• Staff received information in a variety of methodswhich included: emails, newsletters and ward‘huddles’ we observed this on inspection and staff weasked confirmed this.

• There was immediate telephone advice available fromspecialist paediatricians for acute problems.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff told us that formal consent to treatment wasassessed and gained from the medical team. Whereappropriate some young people were able to providetheir own consent to treatment.

• Staff described how they worked on the principle ofverbal consent for some procedures such as takingobservations of temperature and pulse.

• Staff could describe the principles of Gillickcompetency used to assess whether a child had thematurity to make their own decisions and howdecisions were made with the involvement of parents.

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Gillick is a term used to describe if a child under 16years of age is able to consent to their own medicaltreatment without the need for parental permission orknowledge.

• Nurses we asked were not clear about Fraserguidelines which are specifically related to consent forcontraception and sexual health.

• We found consent had been gained and was clearlyrecorded in the records we reviewed.

• Staff told us they would gain advice from thesafeguarding team when dealing with parents whomay lack capacity however: staff explained that anyparents that may lack capacity would already beknown to social services and their nominatedkeyworker would attend the hospital to aid support inthis instance.

• Training in relation to Mental Capacity Act (2005) did notform part of the mandatory training requirements.

Are medical care services caring?

Good –––

We rated medical care services as ‘Good’ because;

• Children and young people, carers, and parents wespoke with at the time of our inspection werecomplimentary about the staff that cared for them. Weobserved staff treating patients and their families withcompassion and respect.

• At the time of our inspection we observed staffresponding to parent’s emotional needs andsupporting and including the sibling of a childreceiving treatment.

• Parents and patients told us they were included indecisions about their care and were kept wellinformed. There was evidence that they were valuedas individuals and partners in the care provided.

• Parents told us “the staff are like a family, we will missthem when the treatment finishes”.

• The NHS Friends and Family Test (FFT) asks patientsand their carers how likely they are to recommend ahospital after treatment. We reviewed the results forfour medical wards for December 2016 and January2017, which were positive.

• There were a range of clinical nurse specialistsavailable to support children and young people andreferrals could be made to mental health services ifrequired.

However;

• Patient privacy and dignity was not fully maintained onwards we visited due to the display screen which wasvisible to people entering the wards.

Compassionate care

• Medical services were delivered by caring staff. Staffwere committed and compassionate about their role.We observed staff interacting with patients and theirrelatives with kindness, dignity and respect.

• The children and parents we spoke with wereextremely positive about the care they received andone parent told us “the staff are like a family, we willmiss them when the treatment finishes”.

• The trust performed about the same as the Englandaverage for all 14 of the questions relating tocompassionate care in the CQC Children’s survey 2014.

• The NHS Friends and Family Test (FFT) asks patientsand their carers how likely they are to recommend ahospital after treatment. The FFT Test response rate atthe trust in January 2017 was 22% which was aboutthe same as the England average of 23%. We reviewedthe scores for wards 3B, 3C, 4B, 4C, for December 2016and found three of the wards scored 100% with theother scoring 96%. In January 2017 the scores rangedbetween 87% to 100% with two of the four wardsachieving 100%.

• We observed the digital display screen containinginpatient details was visible to the public at thenursing stations on entering the ward. This meant thatthere was a risk that their privacy and dignity may notbe fully maintained.

Understanding and involvement of patients andthose close to them

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• In the CQC Children’s Survey 2014, the trust performedabout the same as other trusts for 16 out of 19questions relating to understanding and involvementof patients and those close to them.The trustperformed better than other trusts for keepingpatients and relatives informed, and communicatingwith children in a way they understood.

• In the CQC Children’s survey 2014 the trust scored 9.01out of ten for the question ‘Did a member of staffagree a plan for your child’s care with you?’ This wasabout the same as other trusts.

• The friends and family test results in March 2017 forward 3B identified that all 16 respondents hadreceived information to enable them to make choicesabout their care.

• A parent showed us the patient information folderthey were given, the parent and the child both saidthey had been involved in all aspects of care withdoctors and nurses discussing options with themboth.

• Peer support groups and trips, were organised, forchildren, young people and those close to them,particularly in the oncology service, such as weeklymovie and pizza events.

Emotional support

• Children requiring child and adolescent mental healthservices (CAMHS) admitted to the medical wards weresupported by staff however; there was no registeredmental health nurse on the ward.

• We observed a parent becoming emotionally upset onthe ward and observed staff responding to them andoffering support.

• We observed a play specialist playing with a patient’ssibling whilst the child and parent went off the wardfor treatment. The parent told us the sibling wasalways kept involved and enjoyed the trips to thehospital.

• There was an ablution room for patients and carers toperform ritual ablutions available within a “treehouse” in the main area of the hospital. The“treehouse” included a quiet room with kitchenfacilities and a chaplaincy and was accessible to allchildren and young people, parents, and carers.

• Clinical psychologists provided therapies in variousforms for adults and children and staff could makereferrals for the families to the service. There was anon-call psychologist available Monday to Friday. Wesaw evidence that counselling services were offered inthe morbidity and mortality reviews.

• There were a range of clinical nurse specialistsavailable to support children and young people andtheir families and those close to them.

Are medical care services responsive?

Good –––

We rated medical care services as ‘Good’ for responsivebecause:

• Services were planned and delivered to meet theneeds of local area, the North West of England, NorthWales and the Isle of Man.

• Parents and young people we spoke with told us theyfelt their individual needs had been considered whentheir care and treatment was planned.

• The trust had achieved 100% compliance with allcancer waiting times for the period April 2016 to March2017 except for one month where they achieved 88%.

• The environment was suitable and welcoming to meetthe needs of children and young people and theirparents and carers.

• Children and young people had a shorter averagelength of stay when compared to an average of fourchildren’s specialist trusts for both elective andnon-elective medicine.

• There was a multi faith spiritual care service team anda ‘treehouse’ which included a quiet room withkitchen facilities and a chaplaincy and was accessibleto all young people, parents, and carers.

• There were various ways that people could make acomplaint and this included: via the website, writing orspeaking to the Patient and Liaison Service or speakingto staff on the wards.

Service planning and delivery to meet the needs oflocal people

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• The trust accepted admissions from the local area,and the North West of England North Wales and theIsle of Man for some specialities.

• The hospital had a helipad on site to enable speedyaccess for emergency cases.

• Wards worked with other referring trusts and localagencies to coordinate care for children and youngpeople. We saw evidence of this documented in thepatient records we reviewed.

• The trust performed about the same as other trusts forall four questions relating to responsiveness in theCQC Children’s survey 2014.

• Parents were able to stay overnight with their childrenand there were pull down beds in the ward cubicles,that were en-suite.

• There was open visiting for parents and carers.

• There was access to facilities in the ‘Ronald McDonaldHouse’ near to the hospital for parents to stay thatneeded to be close by or had a lengthy journey to thehospital.

• There were outside areas to play however: these areaswere only accessed by staff via a swipe card systemand only used under supervision. The outside areason ward 3B could not be used and windows were keptclosed due to the demolition of the old hospital andthe risk of dust.

Access and flow

• Children and young people were admitted to thewards from a variety of routes including theemergency department, GP referral, transfers fromother departments within the hospital, transfers fromother hospitals, and direct self-referral to the ward.

• The total number of admissions from January 2017 toMarch 2017 was 1,748 for the four wards we reviewed.Bed occupancy for the same period ranged from67.9%to 94.9%.

• Ward 3C had the highest occupancy rates; however, atthe time of our inspection there were available beds.

• Patients who received Oncology or Haematologyservices that become unwell at home between thehours of 08:30 and 17:00 Monday to Friday couldphone the day care number and could be assessed on

ward 3B. Outside of these hours patients couldcontact ward 3B and receive an assessment using thetelephone triage pathway which we observed on theward at the time of our inspection. If the triage processidentified the need to attend the hospital, the patientthen attended the Emergency Department. Patientswere given an Alert Card which they presented at thereception so they could be directed to a cubicle andbe assessed by the triage nurse.

• Between 01 December 2015 and 30 November 2016,patients had a shorter average length of stay whencompared to an average of four children’s specialisttrusts for both elective and non-elective medicine.

• The trust had a discharge planning policy which wasdue for review in September 2018. We saw evidence inthe patient’s records that the policy was beingfollowed: there were discharge summaries to the GP,referrals to community and others services whererequired and follow up arrangements documented.

• We saw evidence in medical records which included;being seen by a middle grade or consultant within fourhours of attendance, there is at least one medicalhandover in each 24 hour period led by a consultant,consultants were available in the hospital during peaktimes, and there was a ‘consultant of the week’.

• For the period April 2016 to March 2017 the paediatriccancer waiting time standards for two week waits, 31day referral to treatment, and all cancers 31 day waitsuntil subsequent treatment, were achieved in 100%ofcases, with the exception of the cancer two week waitsin November 2016, which was 88%.

Meeting people’s individual needs

• The parents and young people we spoke with saidthat their individual needs had been taken intoaccount when planning their care. Parents and carerswere able to stay overnight with their children andthere were beds available in the cubicles that wereen-suite.

• We saw information displayed encouraging parents todiscuss with staff if their child had a learning disabilityor special requirement. Staff adopted amulti-disciplinary approach when planning care toenable all needs to be met.

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• Staff on the wards could access interpreters either inperson or by a telephone service for those childrenand young people whose first language was notEnglish.

• British sign language interpreters were available tobook in advance.

• We observed a range of books in the format of a storyto assist children to understand their condition,treatment, and what to expect.

• The wards had designated play areas with child sizedfurniture with a range of toys available. On ward 3B weobserved a dedicated area for teenagers which had apool table and games consoles.

• Ward 3B had an Oncology/Haematology informationbooklet for new families which covered a range ofinformation including: contact details, support groups,medication, and support on discharge.

• There was a lift available to the upper wards and theenvironment was accessible by people with mobilityaids including wheelchairs.

• There was a multi faith spiritual care service team whowere available on site at the hospital during corehours and available 365 days a year, 24 hours a day,seven days a week through an on call service. Therewas an ablution room for patients and carers toperform ritual ablutions available within a “treehouse” in the main area of the hospital. The“treehouse” included a quiet room with kitchenfacilities and a chaplaincy and was accessible to allyoung people, parents, and carers.

• A range of menus were available and included ageappropriate foods. Children and young people couldalso request additional options. One child told us “thechef will cook anything”. Parents and children weasked all told us the food was good.

• The Beads of Courage Programme had beenintroduced at Alder Hey and other hospitals in the UKwhich is designed to support children going throughtheir treatment for Oncology/Haematology. It allowsthem to tell their story using colourful beads. Thebeads are used as symbols of courage that

commemorate different milestones in treatment. Thebeads build up over time to create a unique record ofwhat treatment and care the young person or childhad been through.

Learning from complaints and concerns

• The hospital operated an online patient feedbackforum which was open and visible to website visitors.There was an option to raise concerns or poorexperiences and to provide positive feedback. Theposts were reviewed and responded to by Alder Hey‘post authors’ and individual posts were referred tothe relevant service managers.

• Share your experience online feedback could bedirected to specific departments as each departmenthad a feedback option on their website page.

• We reviewed the website and found comprehensiveinformation and advice regarding the various methodsof communicating and feeding back complaints andconcerns to the hospital. Patients and parents weregiven a range of options such as the patient adviceliaison service (PALS), written or electronic complaints,informal feedback, and telephone contacts, directedto NHS choices or the friends and family test.

• At the hospital we asked two volunteers how we couldraise a complaint and they directed us immediately toan area where the PALS team could be contacted.

• There were 24 complaints between April 2016 andMarch 2017 with the Division of medicine; seven ofthese were raised against the gastroenterologyspecialist services.’

• One complaint related to an alleged failure in nursingcare, one was an alleged communication failure, andthe remaining seven complaints were alleged failuresin medical care. Of the nine complaints seven hadbeen closed. The length of time taken to close thecomplaints ranged from 22 days to 73 days however:one complaint took 128 days to close. Following theinspection, we were told that this was due to thecomplex nature of the complaint.

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Are medical care services well-led?

Good –––

We rated medical services as ‘Good’ for well led because;

• The Medicine Clinical Business Unit (CBU) had a clearvision which was aligned with the trust vision toprovide ‘a healthier future for children and youngpeople’ which was underpinned by a set of values. Weobserved staff demonstrate the set of values whenthey were delivering care to children and youngpeople and their parents and carers.

• The CBU had a process in place to enable theperformance, safety, and quality of the service to bereported and reviewed.

• We raised concern with the electronic record system inrelation to alerting deterioration in children and youngpeople that may have a diagnosis of sepsis. The trustresponded immediately with actions and a timeframeto ensure the pathway in the system was robust toenable children and young people with a potentialdiagnosis of sepsis to be escalated for review andtreatment without delay.

• Staff told us they felt supported by their immediateteam colleagues and by senior managers and theworking relationships between nurses and medicalstaff, and allied health professionals worked well.

• There were communication systems in place to keepstaff informed which included newsletters, emails, andsafety huddles. Staff confirmed they received updatesand information via these systems.

• There was an open transparent culture around raisingconcerns and reporting incidents and staff we spokewith felt supported to do this.

• The trust had recognised the difficulty in recruitingjunior medical staff and had made significantinvestment to support and train nurses to becomeadvanced practitioners to bridge the gap. Theadvanced practitioners we spoke with felt empoweredand had welcomed this development.

However;

• Risk registers were held at ward and CBU level with aprocess to escalate risks to keep children and youngpeople free from harm however,it was not clear that allrisks identified on risk registers were being regularlyreviewed, and that actions to mitigate risks were beingmonitored.

Leadership of service

• CBU managers and leads told us they were planningto have a weekly presence on the wards to encouragestaff engagement.

• Staff told us that since the restructure of the new CBU,they had seen more of the senior managers on thewards and it “had a good feel about it” and they ‘feltsupported’.

• Ward managers told us they were never counted in theward staffing numbers and were alwayssupernumerary (surplus so as to support the runningof the ward) but they would provide nursing care tochildren and young people if required due tounexpected leave.

• Doctors told us that they were able to escalateconcerns to consultants and registrars and feltsupported to do so.

• Information was cascaded to staff in a variety of wayswhich included: via emails, monthly newsletters,multi-disciplinary team management minutes, and if asafety issue has been raised this is disseminated via‘huddles’ on the wards and at each handover.

• Staff knew how to raise any concerns and cited theirline manager as the initial contact. Policies in relationto whistleblowing and bullying and harassment wereavailable to staff via the intranet.

Vision and strategy for this service

• The hospital had undergone a change in theorganisational structure and since October 2016 therewas a Medicine Clinical Business Unit (CBU) whichcomprised of seven care groups which included 36departments. The CBU vision was aligned with that ofthe Trust to provide “A healthier future for children andyoung people”. This was underpinned by a set ofvalues; respect, excellence, innovation, openness, andtogether.

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• A clinical director headed each of the seven caregroups and the two that we spoke with shared thevision for the medical services CBU. The CBU caregroups were led by a clinical lead, a manager, and amatron; however, recruitment was ongoing for thematron posts.

• We found the vision and values formed part of theappraisal process; however, as we got to ward level,staff were less clear on the vision and values of thetrust. We asked two nurses and one health careassistant, and all three were not able to recall thevision or values but we saw that staff displayed thevalues through our observations of staff treatingpeople with respect, working together, and beingopen and honest.

• The vision and values were not displayed on any of theward areas we visited at the time of our inspection butthey were displayed in the atrium in the entrance areato the hospital. The ward managers we spoke withwere clear about their roles in delivering quality andsafe care to children and young people whichreflected the trust and CBU strategy.

Governance, risk management and qualitymeasurement

• Reporting lines for the CBU were centred on quality,finance, and performance. The CBU had a Structure,Governance, and Strategic Plan dated 6 April 2017which detailed the CBU governance and reportingarrangements.

• A monthly quality and governance CBU meeting wasidentified to provide assurance to the CBU Board andClinical Quality Steering Group relating to qualityperformance. Agenda items at this meeting included:progress and actions against current risks,identification of risks requiring escalation to thecorporate risk register, recognition of themes andtrends from complaints and incidents, sharing lessonslearnt from root cause analysis investigations, and toreceive the monthly care group quality reports.

• The CBU structure and governance was in its infancyand had been in place since October 2016 there wereplans for strategic meetings to be attended by stafffrom all care groups within the CBU which will enablelearning from incidents and sharing of good practice

• At ward level a monthly quality report which included:risk management, monitoring, clinical care, safeenvironment, competent and capable workforce, andpolicies procedures and guidelines as key headings,was completed which then fed up to the monthly CBUQuality and Governance Meeting.We saw evidence ofthe ward quality reports and reviewed these for threewards which included ward 4B, 3C, and 3B for March2017. We saw that new risks were identified andcurrent risks were escalated as required to beconsidered for the CBU risk register. This gaveassurance that risks were escalated to the CBU usingthis governance process.

• We reviewed the minutes of the EmergencyDepartment Governance Meeting which formed part ofthe acute care group for 23 March 2017 which had theclinical director and manager for the care group inattendance. Quality indicators and audits werediscussed and there was reference to the sepsispathway being rolled out in the emergencydepartment in three weeks’ time from the meeting.Lessons of the week, safety, incidents, and the riskregister were all discussed within the meeting.

• We reviewed the minutes of the General PaediatricForum for the 21 November 2016 which had medicalstaff and leads in attendance. We saw that escalationof the PEWS had been discussed in the meeting.Wefound that training for sepsis and the recognition forthe identification and escalation of the deterioratingpatient was identified on the CBU risk register. Thecontrol measure was that a sepsis pathway was beingpiloted on a medical ward. We were told that thesepsis risk had been identified on the risk register inMarch 2017.’

• We found at the time of our inspection that thepathway for sepsis was being rolled out to other wardsbut there had been no audit or review of the pilotphase. This meant that there was a potential lack ofoversight due to lack of evidence of review andmonitoring of risks.

• The CBU were improving the process of embeddingsepsis in their incident reporting processes and theCBU quality and governance structures.

• At the time of our inspection the Sepsis SteeringGroup held an extra-ordinary meeting on the 26 April

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2017 In response to the issues we identified at time ofour inspection. There was consensus that the displayof the sepsis pathway and associated escalationadvice within the electronic patient record could leadto confusion as to when action was recommended.This lead to the impression that importantmanagement escalation was not occurring when thesepsis tool appeared to be advising urgent action butthat action was not taken where the clinical contextdid not fit with sepsis. The trust aimed to have this inplace safely within two weeks of our inspection.

• The trust informed us at the time of our inspectionthat they had commissioned an external review of theresuscitation equipment and there were plans to havetrolleys in place within the two weeks of ourunannounced inspection to enable resuscitationequipment to be kept together and be easilyassessable and transported to an emergency withoutdelay.

• Ward managers we spoke with were aware of the risksfor their own wards and they had an electronic riskregister. We reviewed the ward level risk registers forwards Ward 4B, 3C, and 3B and found risks had acause, consequence, set of controls and most hadreview dates identified.

• We were given examples of how ward managers hadperformed risk assessments. One manager hadcontacted the mental health team to support the wardto complete an environmental risk assessment forpatients with mental health concerns. This hadresulted in training for staff on caring for children andyoung people with mental health concerns. We weremade aware that risk assessments were in place forchildren and young people that were at risk ofabsconding which had resulted in one to one care.

• We found that cross contamination of expressedbreast milk had been identified on the medicine riskregister. We were told this was placed on the register inFebruary 2017 and review was required by May 2017.’We found evidence that actions to reduce risks werenot in place on all wards. We found breast milk storedin a pantry on one ward which was accessible tovisitors to the ward.

Culture within the service

• Staff we spoke with were passionate about their workand were committed to providing high quality care.

• Doctors and nursing staff said they were supportedand encouraged to raise concerns and reportincidents which reflected an open and transparentculture.

• Doctors told us consultants were approachable andthere was a good working relationship between thenursing and medical staff and we were told ‘the teamworks well across the nursing and medical staff’.

• Staff we asked described colleagues as ‘approachableand friendly’; they enjoyed their role and feltsupported by managers and their immediate team.

• Some staff we spoke with had worked in the hospitalfor many years.

Public engagement

• On Ward 3B monthly coffee mornings were in place forparents and carers and feedback forms were beingdeveloped at the time of our inspection.

• Friends and family test (FFT) for February 2017 onward 3B included 16 respondents and 15 of thosewere extremely likely to recommend the hospital tofriends or family.

• Feedback received on ward 3C in March 2017 fromcarers and parents included good feedback withimprovement suggestions of: microwave for parentuse and improved parent sofa beds. There were plansin place for these suggestions to be discussed with thepatient experience team.

• Feedback was constructed to enable younger childrenteenagers and adults to respond.

Staff engagement

• The trust had a ‘Listening in Action’ lead that had beenin post since April 2016. Listening in action enablesorganisations to engage with employees to contributeto the improvement of the organisation in a way tomake them feel proud.

• In the 12 months prior to our inspection there hadbeen six ‘Big Conversation’ events resulting inattendance of 50-80 staff across the trust.

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• The trust received staff feedback via a monthlyemployee temperature check. We reviewed the resultsfor October to December 2016 for the two elements ofthe check. In December 2016, 95% of staff askedrecommended the trust as a place to receivetreatment which had improved by 3% since October2016. In December 2016, 73% of staff asked wouldrecommend the trust as a place to work which hadimproved by 13% since October 2016. This data wastrust wide.

• We saw evidence where senior staff acknowledged thededication of staff to support their colleagues; thenight matron had praised ward staff for assistinganother department at a time of high demand.

Innovation, improvement and sustainability

• The medical services had made investment in thetraining of Advanced Nurse Practitioners andnon-medical prescribing to partially address the juniordoctor shortage.

• The trust were proposing to be one of the trusts to trialthe new Extranet which will enable records to beaccessed remotely to increase agile working and allowmore effective management for staff on-call.

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Safe Requires improvement –––

Effective Good –––

Caring Outstanding –

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceAlder Hey provides surgical care to children from the localarea and from a wider geographical area, including theNorth West of England, North Wales and the Isle of Man.

The hospital provides services across a number ofspecialities including cardiac surgery, burns and plastics,neurosurgery, orthopaedics, ophthalmology and urology.The hospital is one of two centres nationally that provideextracorporeal membrane oxygenation (ECMO) for children.

Records indicated that between April 2016 and March 2017,the hospital had undertaken 13,497 procedures. Thisincluded, 9,018 day case procedures, 3,480 electiveprocedures and 999 unplanned procedures.

During the inspection,we visited all surgical wards as wellas theatre areas, but this did not include critical care orneonatal services.. This included theatres (12 inpatient andfour day case), as well as ward 1C (cardiac), 3A (generalpaediatrics) and 4A (orthopaedic and neurosurgery).

We spoke to members of staff of all grades including:children’s nurses, health care assistants, doctors, registrars,consultants, specialist nurses, physiotherapists,pharmacist’s, senior managers, domestic staff, andadvanced practitioners. We spoke to children, youngpeople and their families. We observed a variety of carethat was delivered in both theatre and in the ward areas aswell as reviewing care records and further informationreceived from the trust.

Summary of findingsWe rated surgical services as ‘requires improvement’overall because;

• The hospital did not always ensure that a member ofstaff who was trained in advanced paediatric lifesupport (APLS) was available on each department atall times. This did not meet the Royal College ofNursing (RCN) staffing recommendations.

• We found that compliance with mandatory trainingacross surgical services was mixed. We had particularconcerns that compliance with safeguarding levelthree training for surgical staff overall was only 67%at the time of the inspection.

• On surgical wards there was a risk of abduction orthat children were able to leave the ward unnoticed.This was because all doors could be opened from theinside and exit buttons were not out of reach fromchildren. This risk was highlighted when the hospitalwas built in 2015 but it was unclear what actions hadbeen taken to rectify this and it was still a risk at thisinspection. Additionally, there was no evidence onany of the wards that this had been formally riskassessed.

• We found that the governance framework for surgicalservices was relatively new and was still beingembedded at the time of inspection.

• On surgical wards, there was no evidence of formalrisk assessments being completed, such as formally

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assessing the level of risk posed by resuscitationequipment being in different ward areas. We weretherefore unsure if all risks had been identified andmitigated appropriately. This was not line with thehospital’s risk management strategy.

• We sampled various departmental and clinicalbusiness unit risk registers and found that in anumber of cases there was limited or no evidencethat the risks had been reviewed fully or detailsabout how the level of risk had been mitigatedappropriately.

• Resuscitation equipment was available on everydepartment. However, on the surgical wards theequipment was kept in different boxes and indifferent locations. This meant that there was a riskof delays in an emergency situation. Also, theequipment was not checked fully on a daily basiswhich was not in line with the trust’s resuscitationpolicy.

However,

• Surgical care was provided following evidence-basedpractice, standards and legislation in line with expertand professional bodies such as the NationalInstitute for Health and Care Excellence (NICE).

• There were sufficient numbers of staff on the days ofour visit to safely care for patients. We reviewed saferstaffing reports for January 2017 and February 2017,which showed a high average fill rate for registerednurses across all surgical wards (94%).

• In theatre, staffing met the guidelines set by theAssociation for Perioperative Practice (AfPP). Therewas also a recovery nurse allocated to each theatreso that patients were recovered on a 1:1 basis, whichwas in line with national guidance.

• We found a strong, person-centred culture. Holisticcare was provided by kind and caring staff who madeevery effort to provide support to patients and theirparents.

• Patients and their parents were actively involved withdecisions about care and treatment and their viewsand wishes were respected and valued.

Are surgery services safe?


We rated surgical services as ‘requires improvement’ forsafe because;

• The hospital did not always ensure that a member ofstaff who was trained in advanced paediatric lifesupport (APLS) was available on each department at alltimes. This did not meet the Royal College of Nursing(RCN) staffing recommendations.

• We found that compliance with mandatory trainingacross surgical services was mixed. We had particularconcerns that compliance with safeguarding level threetraining for surgical staff overall was only 67% at thetime of the inspection.

• We found that the process for reviewing seriousincidents was not robust. This was because initialinvestigations were not always being undertaken within72 hours in line with recommendations by NHS England.This meant that there was a risk for initial learning andimmediate actions to be missed. In addition, there wasno formal system for recording initial actions taken inresponse to immediate concerns.

• On surgical wards there was a risk of abduction or thatchildren were able to leave the ward unnoticed. Thiswas because all doors could be opened from the insideand exit buttons were not out of reach from children.This risk was highlighted when the hospital was built in2015 but it was unclear what actions had been taken torectify this and it was still a risk at this inspection.Additionally, there was no evidence on any of the wardsthat this had been formally risk assessed.

• Resuscitation equipment was available on everydepartment. However, on the surgical wards theequipment was kept in different boxes and in differentlocations. This meant that there was a risk of delays inan emergency situation. Also, the equipment was notchecked fully on a daily basis which was not in line withthe trust’s resuscitation policy.

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• On surgical wards, a supernumerary co-ordinator wasnot always available at night time. In addition, thehospital did not always have access to an on site seniorpaediatric nurse in line with RCN guidance.

• Records indicated that between April 2016 andDecember 2016 compliance with infection controlaudits had been consistently low across all surgicalwards.

However,

• We found that actions had been implemented andimprovements had been made following three ‘neverevents’ that had taken place since January 2016.

• We observed a number of surgical procedures, findingthat staff followed all stages of the ‘5 steps to safersurgery’ and audits undertaken highlighted continuallyhigh levels of compliance with this.

• There were sufficient numbers of staff on the days of ourvisit to safely care for patients. We reviewed saferstaffing reports for January 2017 and February 2017,which showed a high average fill rate for registerednurses across all surgical wards (94%).

• In theatre, staffing met guidelines set by the Associationfor Perioperative Practice (AfPP). There was also arecovery nurse allocated to each theatre so thatpatients were recovered on a 1:1 basis, which was in linewith national guidance.

Incidents

• The hospital had an up to date incident reporting policythat was available on the intranet. Staff that we spoke towere able to identify types of things that should bereported as incidents.

• The hospital used an electronic reporting system andstaff were able to demonstrate how this was used. Allstaff, including agency staff and locum doctors hadaccess to the system.

• Staff confirmed that they had received feedback aftersubmitting an incident report. We were given examplesof how learning from these had been disseminated.Examples of this included via the daily handover. Thehospital held a weekly meeting of harm, which gaverepresentatives from each area in the hospital anopportunity to share incidents and lessons learned fromtheir own area. However, we were made aware of a

small number of examples when incidents had not beenreported in line with hospital policies. For example, wedid not see any examples of surgical site infectionsbeing reported on the electronic reporting system.Additionally, members of staff informed us that they hadnot always reported these or staffing issues.

• Between April 2016 and March 2017, there had been atotal of 2,172 clinical and 278 non-clinical incidentsreported. Out of these, 302 had been reported as nearmisses, 1,724 had resulted in no harm, 411 had resultedin a low level of harm and 12 had resulted in a moderatelevel of harm.

• Between January 2016 and March 2017, there had beenthree ‘never events’ reported in surgery. These had beena wrong site anaesthetic block, wrong side surgery anda retained foreign object. Never events are seriousincidents that are entirely preventable as guidance, orsafety recommendations providing strong systemicprotective barriers, are available at a national level, andshould have been implemented by all healthcareproviders. Each never event type has the potential tocause serious patient harm or death. However, seriousharm or death is not required to have happened as aresult of a specific incident occurrence for that incidentto be categorised as a never event.

• For the same period, an additional three seriousincidents had also been reported to the strategicexecutive information system (STEIS) by surgicalservices.

• When serious incidents had been reported, we sawevidence they had been investigated using a root causeanalysis (RCA) approach. We also saw evidence of actionplans being implemented as a result and we found thatchanges had been made following these. However, wefound that two of the three serious incidents had notbeen reported in a timely manner. On these occasions ithad taken over seven days for the initial incident reportsto be submitted. Trust policy stated that all incidentswere to be reported within 24 hours of it occurring. Inaddition, the NHS England serious incident framework(2015) states that all incidents should be reported within48 hours and an initial review of every serious incidentshould be undertaken within 72 hours of the eventoccurring. This meant that there were potentiallydelayed opportunities for initial learning to be identifiedand changes to be implemented.

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• The management team had recently introduced a 72hour review template for all staff to follow, but we foundthat it was not yet fully embedded as not alldepartments were currently using it.

• We also found one example of an incident that met theserious incident criteria but was not reported as one.This involved a patient being transferred from anotherhospital for a surgical procedure. The incident reportstated that the full records were not handed overproperly as part of the transfer. A surgical procedure wassubsequently started, before it became apparent thatthe initial incision had been made on the incorrect side.We were informed that this incident was beinginvestigated using a RCA methodology, but there was noevidence of a 72 hour review taking place.

• The surgical clinical business unit (CBU) held monthlymorbidity and mortality meetings. We saw evidence ofactions and learning that had been implementedfollowing these meetings. The hospital had set their ownstandard for all cases to be reviewed by the CBU withintwo months. After a review by the CBU, deaths weresubject to a second review by the hospital mortalityreview group (HMRG) to ensure that there were nofurther lessons to be learned.

• Members of the management team were aware of theduty of candour process and understood the legalrequirements of the duty. The duty of candour is aregulatory duty that relates to openness andtransparency and requires providers of health and socialcare services to notify patients (or other relevantpersons) of certain ‘notifiable safety incidents’ andprovide reasonable support to that person. We sawexamples of the duty of candour being fully dischargedfor incidents when it was required.

Safety thermometer

• As a specialist children’s trust, it was not mandated forsurgical services to provide data to the NHS safetythermometer. NHS safety thermometer is a tool that isused to measure a snapshot of patient harm everymonth but the trust has developed its own dashboardfor a variety of metricsIn theatre, monthly submissionswere provided to ‘safety scan’ which was a tool used tomeasure various aspects of performance in surgicalservices. This was displayed in the theatre departmentfor all staff to see. However, we found that the

measurements that were included as part of this weremainly focussed on operational performance, such asmonthly budgets and theatre utilisation. Themanagement team informed us that there were plans toinclude further indicators from March 2017 onwards,which were more clinically focussed.

• A similar dashboard was included for surgical wards andincluded a limited amount of additional informationsuch as the number of hospital acquired pressure ulcersor infections. Records indicated that between March2016 and March 2017, there had been 10 hospitalacquired pressure ulcers and 12 hospital acquiredinfections on surgical wards.

• However, there was no information displayed in any ofthe ward areas that informed staff or the public ofcurrent performance or numbers of patient harms.

Cleanliness, infection control and hygiene

• The hospital had an infection and prevention control(IPC) policy that was available on the intranet. Staffknew of this and were able to access it if needed. Thehospital also had an infection and prevention controllead.

• IPC was included as part of the mandatory trainingprogramme. Records indicated that compliance forsurgical staff was 84%.

• The hospital had reported 12 incidences of hospitalacquired infections between April 2016 and March 2017.Records indicated that there had been two incidencesof methicillin-resistant staphylococcus aureus (MRSA),nine incidences of methicillin-sensitive staphylococcusaureus (MSSA), one incidence of carbapenemaseproducing enterobacteriaceae (CPE) and no incidencesof colostrum difficile (CDIFF).

• We observed both the theatre and ward areas to bevisibly clean. Housekeepers were available duringnormal working hours, seven days a week and wereresponsible for cleaning the theatre and ward areas.

• In theatre, there was an identified lead for IPC. Their roleincluded completing audits, disseminating informationto staff and making improvements within the theatreenvironment when needed. We saw evidence ofimprovements being made to compliance with IPCstandards in this area. For example, an audit that wasundertaken in May 2016 showed that only 86% overall

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compliance was achieved. The theatre managementteam had implemented clear actions as a result to makeimprovements. Subsequently, an audit undertaken inMarch 2017 showed that overall compliance hadimproved to 99%.

• In contrast, compliance with IPC standards on surgicalwards between April 2016 and December 2016 wasconsistently low. For example, compliance on ward 1Branged from 59% to 72%, on ward 3A ranged from 54%to 72% and on ward 4A ranged from 61% to 63%.

• Six inpatient theatres used a laminar flow system.Laminar flow is a system that is used to circulate filteredair in order to reduce the risk of airborne contaminationand exposure to chemical pollutants. If staff were toenter or leave theatre during an operation, they had touse the anaesthetic room so that the air flow in theatrewas not affected.

• The hospital had a decontamination suite that waslocated next to the theatre area. Decontamination staffwere available during normal working hours, five days aweek and were responsible for co-ordinating themovement of surgical instruments to an off-sitedecontamination unit for sterilisation.

• Endoscopes and bronchoscopes (instruments used toexamine the internal cavities of the body) weredecontaminated and sterilised after use. There wereclear processes in place to ensure that this compliedwith national guidance.

• Records indicated that all theatres had been deepcleaned approximately every six months. This wascompleted by an external provider.

• Patients were not always screened for infection (such asMRSA, MSSA or CDIFF) as part of the pre-operative clinicwhich meant that the risk of infectious patients notbeing managed correctly was increased. Only certaingroups of patients were screened, including thoseundergoing cardiac surgery. However, a care bundleaudit that was completed in January 2017 for patientswho had undergone cardiac surgery indicated that onlythree out of 19 patients had been screened for MSSA.

• Informal procedures were in place for patients to bescreened for CPE if they had been transferred from a

different hospital, although this was not reflected in theIPC policy. However, records indicated that compliancewith this had improved from 40% in April 2016 to 90% inFebruary 2017.

• In theatre we found that surgical staff showedconsideration to IPC procedures and best practiceguidance (NICE CG74) in using sterile gloves as well asthe use of incise drapes and antiseptic skin preparation.When preparing to go to theatre, patients were asked toshower and were given the appropriate gowns to wear.However, care bundle audits that had been undertakenshowed poor compliance with this. For example, anaudit completed in January 2017 for patientsundergoing cardiac surgery showed only 37%compliance with this. A further audit in February 2017showed 54% compliance which was a slightimprovement.

• In all ward areas, each individual room had two sinks,which met the recommendations of the health buildingnote 00-09; infection control in the built environment(Department of Health).

• There were hand gel dispensers at the entrance to everyarea where patient treatment was carried out. We sawthat all staff followed ‘bare below the elbow’ guidanceand we observed all staff either using hand gel orwashing their hands after each patient contact.

• In theatre, the IPC lead was responsible for monitoringsurgical site infections (SSI). The hospital had alsorecently recruited a nurse who was responsible formonitoring SSI’s in the ward areas. SSI’s that occurred inspecialist surgery were being monitored and reported toPublic Health England at the time of the inspection.Records indicated that between April and December2016, there had been no incidences of SSI for patientswho had undergone spinal surgery, neurosurgery orelective implant surgery.

• However, we were unsure how many incidences therehad been of SSI in groups of patients who hadundergone other general surgery as this was not alwaysbeing monitored effectively. The hospital were unable toprovide the number of overall incidences of SSI for thelast 12 months when requested.

• In addition, we found that the hospital were notcurrently undertaking audits to monitor catheteracquired urinary tract infections (infections that had

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been acquired as a result of catheter insertion). Thismeant that there were was limited oversight of this andthere was a potential for areas where improvementsneeded making to be missed. However, there was anaction plan to improve the number of staff trained in theinsertion of urinary catheters as well as undertakingaudits of compliance.

Environment and equipment

• Surgical wards were based over four main areas; ward1B (burns and plastics), 1C (cardiac), 3A (generalsurgery) and 4A (specialist surgery which includedorthopaedics and neurosurgery). There were 12inpatient operating theatres, four day case theatres, anendoscopy room and a room which was used to providelaser treatment. Additionally, there were two separaterecovery areas for inpatient and day case theatres.

• Each hospital ward had been laid out in the samedesign with room numbers being consistent throughoutthe hospital. This was designed to assist the orientationof junior doctors and new staff members and to allowfor consistency across the hospital. However, there weresome variations to the layout to meet the needs of theward speciality.

• Ward areas were secured by swipe card access whichhad been designed to prevent unauthorised peopleentering. Access to ward areas was via an intercom andtheatre was via a staffed reception area. However, wefound that there was a risk of abduction or that childrenwere able to leave the ward unnoticed. This wasbecause all doors could be opened from the inside andexit buttons were not out of reach from children. Thisrisk was highlighted when the hospital was built in 2015but no actions had been taken to rectify this.Additionally, there was no evidence on any of the wardsthat this had been risk assessed.

• Each ward had access to an outdoor play area. Thehospital had a policy for the use of these areas, whichindicated that they were only to be used if there was amember of staff available to provide supervision. Onward 1C, there was a small fence that preventedchildren from accessing the helipad. The managementteam informed us that this was closed in the event of ahelicopter landing.

• The ward manager was responsible for completing adaily environmental check, and each nurse was

responsible for completing a further check for the bedspaces that they had been allocated to. We sampledrecords of these and found that they had beencompleted on a regular basis.

• Ward staff were not always assured that the correctresuscitation equipment was readily available for use inthe event of an emergency. This was because althougheach ward area had access to resuscitation equipment,it was stored in different boxes and some equipmentwas spread over the ward. For example, there was aseparate box for emergency drugs and another forairway management devices. Theatre staff wereresponsible for replacing equipment when it had beenused, but there were no records to indicate that wardstaff checked the contents on a daily basis. This was notin line with the resuscitation policy which stated thatthere should be an equipment checklist available, andall equipment should be checked twice per day.

• Additionally, we reviewed a sample of incident reports,finding that on two occasions the correct equipmenthad not been immediately available when anemergency had occurred. As a result, some ward staffhad put their own extra pieces of equipment together inaddition to the resuscitation equipment that wasavailable.

• The senior management team had responded to thisand had commissioned an external review ofresuscitation equipment at the beginning of 2016.Despite this, no action had yet been taken to implementthe recommendations from this report. There was alsono evidence of this being risk assessed and it had notbeen added to any of the departmental risk registers.This meant that we were unsure of what controls, if any,had been put in place to reduce the level of risk that thisposed.

• There were 12 inpatient theatres which were located onthe first floor and four day case theatres which werelocated on the ground floor. Each theatre had its ownanaesthetic room. We sampled a number of anaestheticrooms and theatres, finding that all areas wereuncluttered and visibly clean.

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• Each anaesthetic room had a daily checklist that wascompleted by the operating department practitioner(ODP). We sampled a number of these and recordsindicated that items such as anaesthetic equipment hadbeen checked on a daily basis.

• There was access to a resuscitation and a difficultairway trolley in both theatre areas. We found that allrequired equipment was available in these and recordsindicated that they had been checked regularly.

• There were appropriate waste management systemsavailable for staff to use in all areas. This included clearsegregation of clinical waste and dirty linen, as well asthe storage of used sharps.

• The hospital had an electronic biomedical engineering(EBME) department who were responsible for theservicing and maintenance of all equipment withinsurgical services. The EBME department held a databaselisting all equipment and its location and wereresponsible for monitoring service dates andcompliance with portable appliance testing (PAT).

• We reviewed the month end report for March 2017 andfound the service had achieved 87.8% against a keyperformance indicator (KPI) of 90% for servicing andtesting high risk devices, such as syringe drivers. For thetesting of low to medium risk equipment for exampleblood pressure monitoring equipment and tympanicthermometers, the service had achieved 79.2% against aKPI of 85%.

Medicines

• The hospital had a medicines management policywhich was available on the intranet. Staff we spoke toknow about it and knew how to access this if required.

• All wards had a clinical room and medication storagesystem that was accessed by fingerprint scanning. Thisensured that only staff that had been authorised toaccess medications were able to. Staff informed us thatthere were always appropriate levels of medicationavailable and a pharmacist attended on a regular basisto make sure that the medication system wasadequately stocked.

• We sampled controlled drugs cabinets on each ward,finding that the amount of controlled drugs talliedagainst what was recorded in the register. However, wefound that over a two week period in April 2017, the

amount of controlled drugs disposed of had not beenrecorded in line with the medicines management policyon a number of occasions. Additionally, we were showna medicines management audit that had beencompleted in October 2016, which had identified thesame issue. The management team were aware thatimprovements were needed, and an audit completed inApril 2017 had shown some improvements.

• We also sampled medication that required refrigeration,finding that all were in date and stored correctly.Records indicated that fridge temperatures had beenchecked on a daily basis. There was also a centralmonitoring system in use which alerted pharmacy staffif fridge temperatures went out of range.

• There was a system in place for patients who broughttheir own medication. General medicines were added totheir own locked cupboard which was kept by the staffareas and controlled drugs were stored appropriately.All patients own medication was added to themedication chart on the electronic records system sothat they were administered at the correct time.

• However, we found that the electronic records systemwas not always up to date with the administration ofmedication, which meant that there was a risk that anoverdose of medication could be given. This wasbecause when a member of staff had signed foradministering medication, the prescription chart did notalways reflect that it had been given. We sampled sevenprescription charts, finding this to be an issue on fiveoccasions. For example, on one occasion, medicationhad been administered at 1pm but the prescriptionchart stated that it was last administered over 12 hourspreviously. This risk was highlighted on the medicinesrisk register, with one of the key controls indicating thatany occurrences should be reported as a clinicalincident. Staff informed us that this had not been done.

• We did note that allergies were clearly highlighted andthat each patient’s weight and height was documentedon all of the prescription charts.

• In theatre, we saw that medicines and controlled drugswere stored appropriately in each anaesthetic room. Wesampled records for April 2017, finding that the amountof controlled drugs tallied against what was recorded inthe register and that documentation had beencompleted correctly on a daily basis. However, on one

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occasion we found that the amount of ketaminerecorded did not match the amount that was present.We brought this to the attention of the managementteam. They informed us that this had not been reportedand that it had been missed in the weekly audit, butprovided assurance that it would be investigated.

Records

• The hospital used a combination of electronic andpaper based records. All staff had access to theelectronic system and had undergone training in its use.

• Pre-operative assessments and consultations werecompleted on paper and were available on the day ofsurgery. In theatre, safety checklists were paper based,as were patient observations while undergoing surgery.On the ward, all medical notes were paper based.

• Additionally, if a patient followed a care pathway, thesewere printed and placed in the medical notes with allother patient information.

• The electronic system was used to record all otherobservations, risk assessments and records.

• If a patient had a concern recorded such assafeguarding or a do not resuscitate order, this wasclearly identifiable by an icon appearing on the patientrecord. All staff that we spoke to were aware of this andknew how to access relevant information if needed.

• We sampled seven patient records, finding that theywere up to date with all relevant information. We alsofound that medical records had been updated when apatient had been reviewed, were legible and had beensigned and dated.

• All paper based records were stored securely and wereclearly identifiable at every nursing station.

Safeguarding

• All non-clinical staff were required to complete level onesafeguarding training for adults and children.Additionally, all clinical staff were required to completelevel three safeguarding training for children, which metthe recommendations of the ‘Intercollegiate Document;Safeguarding Children and Young People (2014)’. Topicssuch as female genital mutilation and child sexexploitation were included as part of this training.

• Records indicated that at the time of our inspection,overall compliance in surgery with safeguarding levelthree training was only 67%. This meant that there was arisk that not all staff were up to date with the latesttraining and that there was the potential forsafeguarding concerns to be missed. We did notehowever, that overall compliance with safeguardinglevel one training for non-clinical staff was 87%.

• The hospital had safeguarding children, safeguardingadult and child abduction policies. These were lastupdated in January 2016 and were available to staff onthe intranet. Staff had knowledge of this and were ableto access it if needed. However, we found that althoughthe safeguarding children policy referenced ‘WorkingTogether to Safeguard Children’ guidance from2015,topics such as female genital mutilation (FGM) or childsexual exploitation were detailed in a different policythat was created in June 2016. Staff that we spoke to didnot have an awareness of topics such as FGM and wereunclear where this policy was located. This wasimportant as reporting any recognised incidents of FGMis a legal requirement for all healthcare staff.

• Staff that we spoke to were able to articulate otherexamples of what would be considered a safeguardingconcern. We were informed by staff that any concernswere escalated to the co-ordinator or the ward manager.Out of hours, concerns were escalated to the nightmatron.

• The hospital had a designated safeguarding team whowere available during normal working hours betweenMonday and Friday. The safeguarding team wereresponsible for reviewing all safeguarding concerns thathad been raised. Staff informed us that when referralshad been made, the safeguarding team had been quickto respond in providing advice.

• There were processes in place for safeguarding concernsto be raised as part of the pre-surgical assessment. If aconcern was identified, the relevant information wasadded to the electronic records system. Thisinformation was highlighted to staff by the use of asymbol on the electronic system. Staff were able todescribe this process and demonstrate how to find anyinformation if required. However, there was no clearprocess for staff to follow when raising concerns overchildren who repeatedly failed to attend anappointment.

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Mandatory training

• The hospital provided mandatory training modules forall nursing and medical staff. As part of the inductionprogramme, all new employees were required tocomplete all elements of it. The hospital had amandatory training policy which stated that thecompliance target for all modules was 90%.

• At the end of the inspection period, the managementteam submitted the most up to date figures withtraining compliance in all other areas. Records indicatedthat overall compliance for staff in surgical services wasmixed. The more positive examples included infectioncontrol (84%), health and safety (74%) and equality anddiversity (83%). However, these were still below thetrust’s target and there were areas of lower compliancewhich included information governance (57%), and firesafety (68%).

• We noted that the compliance rates for medical staffwere particularly low, for example health and safety(48%) and information governance (41%).

• Mandatory training was monitored using a centralrecording system which had been designed to reflectthe most up to date information across all departments.However, the management teams across all areas wereconcerned that the data was inaccurate. This meantthat it was unclear how valid the information that theTrust was using to assure themselves that importanttraining had been completed was.

Assessing and responding to patient risk

• The hospital were unable to ensure that there wasalways a member of staff trained in advanced paediatriclife support (APLS) in every department or ward area.This did not meet the minimum requirements outlinedin the Royal College of Nursing; Defining Staffing Levelsfor Children and Young People’s Services (2013). Thiswas the case on wards 1C and 3A as members of themanagement team informed us that no nurses hadbeen trained in APLS. Importantly, a number of patientson ward 1C had undergone cardiac surgery so were athigher risk of requiring emergency treatment. Thisshortfall had also been acknowledged in a recentnursing staffing review which stated the need for allband 6 co-ordinators to be trained in APLS.However, noformal plans had yet been made to implement theimprovements.

• In contrast, we did note that on ward 4A, all band 6co-ordinators had received training in APLS andadditionally, there was always a member of staff whowas APLS trained in theatre recovery as there was asupernumerary anaesthetist available in both recoveryareas, meaning that the required standard was met.

• In case of an emergency, there was a team of bleepholders allocated to respond to calls throughout thehospital, some of who had received training in APLS.This was available 24 hours a day, seven days a week.Staff across all areas informed us that they had receivedquick responses if an emergency had occurred.

• Advanced paediatric life support training was providedby an external provider. The theatre management teaminformed us that it was sometimes difficult to facilitateresuscitation training. However, during our inspectionwe saw examples of where the management team haddiscussed making improvements. An example of thiswas the possible implementation of a ‘train the trainercourse’ in theatre. If staff complete this, it means thatthey are able to provide training to other staff.

• The hospital used a paediatric early warning score(PEWS) system, which was a system to identify whenphysiological observations indicate that a child may bedeteriorating. Staff were aware of this system and wereable to show us how it was used. PEWS was calculatedautomatically on the electronic records system whenbaseline observations such as blood pressure and pulsewere inputted.

• The PEWS policy had recently been updated to includea flowchart outlining the escalation pathway. Staff thatwe spoke to knew of the policy that was available on theintranet but were unaware that any amendments hadbeen made.

• Staff were aware of how and when to escalate adeteriorating patient. The policy stated that if a patienthad a PEWS of 4, they were to be escalated forconsultant review. However, we found that all reviewswere being done by a junior doctor in the first instanceand consultants were contacted for further review ifneeded.

• We sampled seven patient records, finding that PEWShad been completed correctly on all occasions. Themanagement team had undertaken audits on eachward on a monthly basis to monitor compliance.

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Records showed that compliance across surgical wardsin March 2017 ranged from 80% to 100%. However, wedid note that the sample size for these audits was 10records per ward.

• The hospital had recently implemented a sepsis policywhich was aimed at supporting staff in the timelyidentification and management of patients withpotential sepsis. There was an ongoing working groupwho were in the process of developing a paediatricsepsis 6 tool that was to be rolled out across thehospital, along with a full training programme for allstaff.

• We saw evidence of screensavers on computersreminding staff to think about potential sepsis. Staffwere able to tell us about the signs and symptoms ofsepsis.

• In addition, sepsis had been identified on the corporaterisk register. However, there was no evidence that themanagement team had monitored compliance withNICE NG51 (sepsis; early recognition and management)while this system was being introduced.

• Pre-operatively, patients attended an appointment witha consultant which was held in the outpatientdepartment. As part of this appointment, patients andrelatives were given a medical questionnaire tocomplete. This was used to identify if a patient had anyspecial requirements or any pre-existing medicalconditions that needed to be considered.

• Some patients were offered a further pre-operativeappointment and some received a telephone call. Thiswas managed by a team of nurses who hadcompetencies in pre-operative assessments. Thenursing team was supported by an anaesthetist whowas available to review patients if there were anyconcerns.

• Patients were assessed by an anaesthetist and surgeonon the day of surgery to identify patients with anymedical conditions or those deemed at risk ofdeveloping complications after surgery and a decisionwas made whether the operation was to go ahead.

• All theatre staff attended a safety huddle in themornings. We attended one of these and found thatthey were well organised. Also, individual theatre teambriefs were held before each theatre list was started.

• Pre-operative marking is required to promote correctsite surgery, including operating on the correct side ofthe patient and / or the correct anatomical location orlevel. The national patient safety agency (NPSA) and theRoyal College of Surgeons (RCS) strongly recommendthat the mark should subsequently be checked againstreliable documentation to confirm that it is correctlylocated and still legible. This checking should occur ateach transfer of the patient’s care and end with a finalverification prior to commencement of surgery. All teammembers should be involved in checking the mark.

• There had been a ‘never event’ reported as a result of asurgical procedure being undertaken on the incorrectside. The investigation that was completed showed thatthe main cause of the incident was that the site markingwas incorrect and all the necessary procedures were notfollowed. Although in the cases we observed this wasdone correctly, records indicated that monthlycompliance rates with this had varied. For example, only82% had been achieved in March 2017. However wenoted that compliance rates in April 2017 had increasedto 100%.

• Guidance from the National Patient Safety Agency(NPSA) states that ‘stop before you block procedures’should be used when patients are undergoing ananaesthetic. ‘Stop before you block’ is used to preventany avoidable patient harm caused by a wrong siteanaesthetic block. There had been a further ‘neverevent’ reported due to a wrong site anaesthetic blockbeing administered. We found that actions identifiedfrom the completed investigation into this incident hadbeen completed. This included the delivery of humanfactors training to all theatre staff, visual aids beingdisplayed in all anaesthetic rooms and audits beingundertaken to monitor compliance. An audit that hadbeen completed in December 2016 showed 100%overall compliance with this.

• The World Health Organization (WHO) surgical safetychecklist identifies three phases of an operation; beforethe induction of anaesthesia (sign-in), before theincision of the skin (time-out) and before the patientleaves the operating room (sign-out). In each phase, achecklist co-ordinator must confirm that the surgeryteam has completed the listed tasks before theyproceed with the operation. We found that ‘sign-in’,‘time-out’ and ‘sign-out’ were completed on all

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occasions that we observed as part of the inspection.Audits to monitor compliance with this were completedon a monthly basis. Results between April 2016 andDecember 2016 ranged between 98% and 100%compliance.

• Patients were recovered on a 1:1 basis by competentstaff which was in line with national guidance.

• In inpatient theatres, there was a clear discharge criteriathat had to be met before a patient was handed over toan inpatient ward. In the day case unit, there was astandard operating procedure for staff to follow as alldischarges were nurse led. If a day case patient did notrecover as expected following surgery, staff were able toaccess a bed on an inpatient ward. There was also aclear process in place for patients to be admitted to thehigh dependency unit or intensive care unit if needed.

Nursing staffing

• Staffing levels on the surgical wards had beencalculated to meet guidance from the Royal College ofNursing (RCN) which states that registered staff to childratios must not exceed 1:4 and any patients requiringhigh dependency care must be no more than 1:2.However, the guidance also states that children undertwo years old or requiring specialist care such aspatients who had undergone neurosurgery must notexceed 1:3. We found that staffing levels for children inthese brackets did not meet the RCN guidance as theywere nursed on a ratio of 1:4.

• As part of the move from the old hospital, the seniormanagement team had undertaken a ‘shift and lift’ forall nursing staffing.This had included a review of thenursing establishment against the new environment.However, there had been no formal review of this since..This was important because not all children were easilyvisible due to them being cared for in individual rooms.However, a baseline establishment had been set foreach ward which was based on the number of beds thatwere available. For example, ward 4A had a setestablishment of 11 registered nurses both in the dayand in the night.

• Staffing levels were reviewed by ward managers on adaily basis. If there were staff shortages, this wasdiscussed at one of the three daily bed meetings.Members of the management team informed us that

vacant shifts were filled with NHS Professionals (NHSP)nurses (bank staff) or agency staff. Additionally, apatient dependency score tool (SCAMP) was used toidentify the need for increased nursing intervention.

• There were sufficient numbers of staff to care forpatients on the days that we visited. We also reviewedsafer staffing reports for January 2017 and February2017, which showed that the average fill rate forregistered nurses across all surgical wards was high(94%). Additionally, for the same period the average fillrate for healthcare assistants was 122%. This wasbecause an additional number of healthcare assistantshad been used in addition to the numbers that hadbeen planned.

• RCN guidance also states that the shift supervisor ineach clinical area should be supernumerary (surplus tothe staffing numbers so as to oversee the running of theward) to ensure effective management, training andsupervision of staff. This had been achieved on ward 4Aon a regular basis as there was a full establishment ofband 6 nurses who undertook this role. However, onward 3A and 1C there were shortages in band 6 staff,which meant that at night time there was nosupernumerary band 6 nurse.

• At night time, the hospital did not have access to an onsite senior children’s nurse. This was not in line with RCNguidance which states that the minimum expectationfor someone undertaking this role is for them to be aband 8a matron or above. However, there weremembers of the management team who operated a 24hour on call rota and were contactable if required.

• On wards 3A and 4A, staff attended a safety huddle atthe beginning of every shift. This was used todisseminate any important information such as learningfrom incidents or safety alerts. Staff then completed afurther handover of patients that they were lookingafter. Staff followed a set structure for this, whichincluded a patient overview, medicine administration,observations and any other concerns. However, we didnot see evidence of a safety huddle on ward 1C,although a full handover of individual patients wascompleted.

• Records indicated that there were currently 10.53 wholetime equivalent (WTE) band 5 and 0.69 WTE band 6nursing vacancies as well as 3 WTE play specialist

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vacancies. These vacancies were mainly as a result ofmaternity and sick leave which meant that there wereno current plans to recruit to these positions. This wasbecause the Trust had a pool of their own nurses whichwas used as much as possible to fill vacant shifts. Arecent review of nurse staffing confirmed that this wasthe case.

• Agency and bank staff usage across surgical wards washigh between January 2017 and March 2017. Recordsindicated that during this period, 107 members ofagency staff and 783 members of bank staff had beenused.

• A full review of nurse staffing across the hospital hadbeen recently undertaken by the senior managementteam. This identified both areas of compliance andnon-compliance with RCN standards. A number ofrecommendations had been made to meet the areasthat indicated non-compliance and these were to bepresented at the next board meeting. For example, wardmanagers had been asked to complete a full trainingneeds analysis so that advanced paediatric lifesupport(APLS) training could be provided to staff inareas that were either partially or non-compliant withthis standard.

• In theatre, staffing met guidelines set by the Associationfor Perioperative Practice (AfPP). These guidelines statethat if there is more than one procedure on the theatrelist, the staffing requirements are a circulating nurse, anoperating department practitioner (ODP) and two scrubpractitioners. The AfPP guidelines also state that if anoperation requires a surgical first assistant(SFA), thenthey must be in addition to the numbers previouslymentioned.

• There was also a recovery nurse allocated to eachtheatre so that patients were recovered on a 1:1 basis,which was in line with national guidance.

• On the days of our inspection, we found that thenumbers of staff available in each theatre met nationalguidance. Additionally, we reviewed rotas for theprevious two weeks, which also showed that the correctnumber of staff had been achieved.

• In the surgery day case unit, there was an open wardand staffing was calculated on a registered nurse topatient ratio of 1:5.

• Records indicated that there were currently vacanciesfor 2.55 WTE band 2 staff, 2.37 WTE band 5 staff, 0.16WTE band 6 staff and 1 WTE band 7 staff in theatre.

• The senior management team informed us that sinceApril 2016, there had been a consistent reduction in thenumber of agency staff used to fill vacant shifts. This hadbeen as a result of a workforce plan which had reducedthe amount of money spent on agency staff. Recordsindicated that there had been no occasions of agencystaff being used between October 2016 and March 2017.However, in March 2017, 35 members of NHSP (bank)staff had been used to fill vacant shifts.

Surgical staffing

• All surgical specialities were consultant led and a leadfor each speciality had been identified. Additionally,some specialities had a number of registrars and juniordoctors assigned to them.

• Surgical wards had access to a general surgical‘consultant of the week’. When on-call, consultants werefree from other clinical duties to ensure they wereavailable when needed. Out of hours, there was aresident registrar and a junior doctor allocated to coverall hospital wards. We reviewed medical rotas betweenJanuary 2017 and March 2017, finding that all shifts hadbeen filled.

• Medical staff informed us that it was sometimes difficultto reach referrals in a timely manner due to the lownumbers of medical staff available. The seniormanagement team had highlighted the low number ofjunior doctors as a concern. They informed us that it hadbeen difficult to recruit and that they were currentlyreliant on existing staff completing overtime shifts to fillvacancies. However, the junior doctors and middlegrade doctors we spoke with told us they received goodsupport and could easily access the on-call consultant ifneeded.

• Each speciality had their own arrangements forreviewing patients who were under their care. Forexample, in neurosurgery, ward rounds were led daily bythe registrar, which also included junior doctors and theadvanced nurse practitioner when available. Inmaxillofacial services, all post-surgical patients werereviewed by a consultant, along with the registrar.

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• As part of the on-call rota, different specialities haddifferent arrangements for cover. For example, inophthalmology there was an on site consultantpresence during normal working hours. Outside of thesehours, an on-call service was provided by a service levelagreement with another Trust as there were currentlytwo WTE vacancies in this speciality. In neurosurgery,there was a 24 hour, seven days a week consultant oncall rota and there was always a resident junior doctoravailable to review patients if needed.

• Locum doctors were used to cover for existing vacanciesand for staff during leave. Where locum doctors wereused, they underwent recruitment checks and inductiontraining to ensure they understood the hospital’spolicies and procedures.

Major incident awareness and training

• The hospital had an up to date major incident andbusiness continuity policy which was available to staffon the intranet.

• In theatre, action cards were available which highlightedthe roles and responsibilities of individual members ofstaff which were to be used in the event of a majorincident. Staff were aware of these and knew how tolocate them if needed. Members of the theatremanagement team attended major incident committeemeetings that were held bi-monthly. However, on theinpatient wards, staff were unsure of what their rolewould be in the event of a major incident. Additionally,there was no supporting documentation readilyavailable such as action cards for staff to use in theevent of an incident.

• The hospital had an emergency power supply whichwas tested on a regular basis by the on sitemaintenance team.

• Fire safety training was part of the mandatory trainingprogramme for all staff. However, records indicated thatonly 68% of surgical staff were up to date with this at thetime of inspection. Additionally, a fire policy wascurrently in draft form and staff had not yet undertakenany practical scenarios which simulated evacuatingpatients in the event of an emergency.

Are surgery services effective?

Good –––

We rated surgical services as ‘good’ for effective because;

• Surgical care was provided in line with evidence-basedpractice and standards from expert and professionalbodies such as the National Institute for Health and CareExcellence (NICE).

• Records between April 2016 and March 2017 showedthat measurable outcomes for patients who hadundergone cardiac surgery were slightly better thansimilar services nationally.

• We saw positive examples of multidisciplinary teamworking.

• Pain relief and pain management was discussed at thepre-operative assessment stage so that patients andrelatives were fully informed prior to attending forsurgery. We also found that pain was managedappropriately on reviewing records and talking topatients.

• Nutrition and hydration was assessed appropriately andthere was access to dietitian if needed. Fluid balancecharts that we checked had been completed correctly.

• Most wards had practice education facilitators availablewho were responsible for monitoring mandatorytraining and facilitating further training for all nursingstaff.

However,

• In theatre, we found a range of standard operatingprocedures that were out of date which meant thatthere was a risk of staff following out of date guidance.

• The central audit team were responsible for completingaudits against topics such as compliance with NICEguidelines across the hospital. However, we found thatdifferent groups of staff in surgical services did not havean awareness of results from these or more importantly,if improvements had been required.

• We found that there were processes in place for staff toundertake yearly appraisals. However, between April2016 and March 2017, records indicated that overallcompliance with this for nursing and some medical staffwas low.

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Evidence-based care and treatment

• Surgical care was provided in line with evidence-basedpractice and standards from expert and professionalbodies such as the National Institute for Health and CareExcellence (NICE), the Royal College of Surgeons (RCS)and the Royal College of Anaesthetists (RCoA).

• Ward staff were able to access policies, procedures andtreatment pathways on the intranet. Patient pathwayswere printed and placed in the medical notes if needed.

• In theatre, there were a range of local policies, standardoperating procedures and clinical guidelines that wereavailable for staff to follow. We checked a sample ofthese, finding that the majority which were paper basedwere out of date, with the date of expiry varyingbetween 2012 and 2015. This meant that there was apotential risk that these did not always reflect up to dateguidance. A member of the theatre management teamwas currently in the process of going through all of thestandard operating procedures, updating them andadding them to the electronic system for staff to access.

• We found that there were some medical pathways thatwere out of date. We spoke to the medical pathwaysco-ordinator who informed us that all pathways werecurrently being reviewed and placed on the electronicmanagement system. This was important as medicalpathways were used to support staff from the surgicalwards when providing care and treatment to patientswith conditions such as diabetic ketoacidosis (DKA).

• Care bundle audits had been undertaken for differentsurgical specialities. Examples for these were forpatients who had undergone neurosurgery and cardiacsurgery. We were provided with results from auditsundertaken in November 2016 and February 2017,which indicated 100% compliance against correctantibiotic administration. However, these audits werelimited and did not measure all elements of carepathways within each speciality.

• The hospital had a central audit team who wereresponsible for completing audits against topics such ascompliance with NICE guidelines across the hospital.However, we found that different groups of staff insurgical services did not have an awareness of resultsfrom these or more importantly, if improvements hadbeen required.

• There were also examples of when planned audits hadnot been completed. An example of this was againstNICE NG51 (recognition, diagnosis and earlymanagement of sepsis). This meant that there wascurrently limited assurance that NICE NG51 guidelineswhere being adhered to. The management teaminformed us that plans were in place to audit this duringMay 2017 and results from this would be available inJune 2017.

• A peer review had been undertaken for the burns servicein 2016. The review had identified a number of areas forimprovement, including providing better dischargeinformation and having a nominated lead therapist forthe burns service. The management team hadimplemented an action plan to make improvementswhere needed.

Pain relief

• Pain relief and pain management was discussed at thepre-operative assessment stage so that patients andrelatives were fully informed prior to attending forsurgery. Patients were given prophylactic pain reliefprior to undergoing surgery when appropriate.

• In recovery, the anaesthetist was responsible formanaging post-operative pain. There was a standardoperating procedure which stated that pain must becontrolled before patients were discharged to the ward.We observed a patient being transferred to the ward andsaw that this was completed appropriately.

• In day case surgery, there were procedures in place forstaff to follow when providing pain management topatients before they were discharged home. Nursingstaff had access to patient group directive (PGD)medication as patient discharge was nurse led. PGD’sare lists of medication that nursing staff are allowed togive to patients without them being prescribedindividually by a member of medical staff.

• Age appropriate pain assessment systems were usedboth in theatre and on surgical wards. For youngerchildren, observations and levels of agitation were usedto assess pain. For older children, there was a scoringtool that used facial expressions as a visual mechanismfor patients to indicate if they felt happy or sad inrelation to their levels of pain. A pain scoring tool usingnumbers was also in place for those children and youngpeople that understood it.

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• Staff were able to make referrals to a specialist painmanagement team if needed. This service was run bythe anaesthetic department.

• In seven records that we reviewed, we saw that pain hadbeen reviewed on a regular basis, and appropriate painrelief had been given. There was also evidence of painmanagement being discussed as part ofmulti-disciplinary team meetings and staff handovers.Patients and relatives that we spoke to confirmed thatthey felt their pain had been well controlled.

• There were examples of studies being undertaken bymembers of medical staff to improve the effectivenessof pain medications that were administered for specificconditions. An example of this was a study that wascompleted measuring the effectiveness of gabapentin inreducing acute pain scores following a tonsillectomy.However, there was limited evidence of regular auditsbeing undertaken across the hospital measuring theeffectiveness of general pain management. This meantthat there was potential for areas that requiredimprovement to be missed.

Nutrition and hydration

• There were procedures in place to provide fastingguidance to patients and relatives at the pre-operativeassessment stage. However, there were currently noaudits being undertaken measuring if patients werecompliant with the fasting guidance before undergoinga surgical procedure.

• Nutrition and hydration assessments were undertakenas part of the pre-operative assessment and foradmissions to the inpatient wards. There was access toa dietitian during normal working hours betweenMonday and Friday if needed. Staff informed us thatthere were no issues in accessing this service whenneeded.

• Fluid balance including input and output wasmonitored on the electronic records system. Wesampled seven patient records, finding that these hadbeen completed correctly on all occasions.

• Patients who required total parenteral nutrition (TPN)regimes were reviewed by medical staff and this wasprescribed when needed. TPN regimes provideappropriate levels of intravenous fluids and nutrition.

• We found that breast milk was clearly labelled andstored appropriately.

Patient outcomes

• The hospital had limited opportunity to benchmarkresults against similar services nationally as there werenot many national audits for paediatric surgerycurrently available.

• Records between April 2016 and March 2017 showedthat measurable outcomes for patients who hadundergone cardiac surgery were slightly better thansimilar services nationally. The survival rate had been98.4% in comparison to a predicted rate of 97.7%.

• The Trust were one of only two paediatric centresnationally who were able to provide extracorporealmembrane oxygenation (ECMO). ECMO is used tosupport patients whose heart or lungs are unable toprovide an adequate amount of gas exchange tosupport life. The hospital had undertaken a yearlyInternational audit which benchmarked them againstother similar providers. Results indicated that in 2016,for children receiving cardiac support, survival rateswere better than International survival rates (80% incomparison to 50%). For the same period, results forchildren receiving respiratory support were slightlyworse than International survival rates (40% incomparison to 50%).

• An audit had been undertaken in 2016 to review theeffectiveness of patients who had requiredcardiopulmonary resuscitation (CPR). Results from thisshowed that there had been a 91% success rate inachieving a return of spontaneous circulation. This wasout of 57 cases reviewed. The hospital monitoredreadmissions that had occurred within 28 days ofundergoing surgery. Between April 2016 and March 2017the monthly percentages varied between 2% to 3.8% ofall patients who had undergone a surgical procedure.We were unable to compare this to similar servicesnationally.

Competent staff

• The hospital employed practice education facilitatorsacross most departments. They were supported by atrust-wide education team. The only exception to this insurgery was on ward 3A where training was facilitated bythe ward manager.

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• In theatre, there was one whole time equivalent (WTE)practice education facilitator, who was supported by anadditional three members of staff who also undertookclinical duties. They were responsible for organisingtraining, as well as monitoring mandatory trainingcompliance and appraisals.

• There was an induction policy and an inductionprogramme for new staff to complete. All new staffcompleted a corporate induction and were assigned anamed mentor, had a list of key competencies tocomplete and were given a supernumerary period (thismeant that they were not included in the daily staffingnumbers to look after patients so that they could learn).

• We were given examples of when theatre staff had beensupported to complete additional qualifications eitherinternally or externally. For example, eight scrub nurseshad undertaken training to become first surgicalassistants. This meant that they were able to undertakeadditional duties during a surgical procedure under thesupervision of a consultant.

• Members of the theatre team undertook 10 half daytraining sessions per year. Surgery was not scheduledduring these times so that all staff were able to attend.The topics covered as part of these sessions was basedon any gaps in knowledge that had been identified, if anew practice had been introduced or if staff required tocatch up with training updates such as paediatric lifesupport. A positive example of the way that this timewas used included the provision of human factorstraining, which was a key action following a ‘never event’that had occurred.

• On surgical wards, a training needs analysis had beenundertaken for nursing staff. This was important aswhen the service moved to the new hospital, a numberof specialist wards had been amalgamated together. Forexample, on ward 4A, staff looked after patients whohad undergone both orthopaedic and neurosurgery.Staff informed us that this had been challenging as theyhad not always felt comfortable manging patients withconditions they had no experience of dealing with.

• A number of education days that were held throughoutthe year had been designed to support staff with key

competencies and skills for the area that they wereworking in. However, we were informed that due tooperational demand not all of these had beenfacilitated.

• On ward 1C, the practice education facilitator haddevised a competency book which covered coreintensive care competencies as well as a number ofothers that were specific to caring for cardiac surgerypatients.

• Staff were able to complete a self-review of theircompetencies as part of the appraisal process whichwas an opportunity for them to raise any concerns ortraining needs that they had. However, we found thatappraisal rates varied across the wards and that in somecases, there was limited documentation to evidencethat a full appraisal had taken place.

• Overall compliance with appraisals for all nursing staffwas only 41%. On ward 4A, we found that no staff hadcompleted an appraisal between April 2016 and March2017. On ward 3A, records indicated that 84% of staffhad undergone an appraisal during the same timeperiod; however, we reviewed a number of staffappraisal forms and found that they had only partlybeen completed. The ward manager informed us that ithad been difficult getting staff to complete these fullyand in a timely manner.

• In addition, records indicated that only 26% of clinicalfellows and junior doctors within the surgery divisionhad completed their appraisals. However, we also notedthat 99% of consultants were up to date with this.

Multidisciplinary working

• There was evidence that surgical staff worked well witheach other and that they had good relationships withdifferent groups of staff throughout the hospital.

• There were a number of nurse handovers and safetyhuddles that were held daily on both the wards and intheatre. These were used to discuss patient informationand disseminate any important information to staff. Weattended two of these and found them to be wellorganised and informative.

• A member of the management team attended bedmeetings which were held three times per day. Staffinformed us that these meetings were effective in

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managing access and flow and responding to any newadmissions or patients who had changed in acuity. Also,the management teams were able to discuss if they hadstaffing shortfalls in their areas.

• Referrals were made for physiotherapy, occupationalhealth and speech and language therapists whenrequired. Members of these teams did not attend thedaily ward rounds, but we saw examples of themworking well with nursing and medical staff whencontributing to care and treatment that was beingdelivered. We also saw examples of this beingdocumented in patient records.

• Staff were also able to make referrals to a microbiologistif needed. Microbiologists review patients and ensurethat appropriate antibiotics and treatment plans areimplemented for different conditions.

• Each surgical speciality held a number ofmultidisciplinary team meetings through the week.These included different groups of staff, sometimesincluding staff from external organisations. This was sothat all cases in the local area were reviewed and adecision could be made to whether a patient should betransferred for treatment.

• Staff informed us that there were occasions whenmedical patients were present on the surgical wards.This was mainly because they were being treated for amedical condition as well as requiring a surgicalprocedure. Staff informed us that organising medicalreview was sometimes difficult, although they felt thatthere were good working relationships with medicalstaff.

• We found that on some wards there were reducednumbers of play specialists. We were told by some staffthat this sometimes compromised the level of inputafforded to some patients and reduced the amount oftime the children spent in play areas, particularlyoutdoor areas, as they required supervision, which wasnot always available. Staff reported that the playtherapists were sometimes overstretched and coveredvarious areas which made it difficult to provide full coverfor wards all of the time. We were advised that there wasactive recruitment of plaly specialists who were due tostart working imminently.

Seven-day services

• There was an emergency resident theatre team whowere on site 24 hours a day, seven days a week. Thisteam included an operating department practitioner, ascrub nurse and a healthcare assistant. There was alsoan on call consultant anaesthetist who was able toattend if needed.

• Out of hours, there were a number of on call consultantsavailable from different surgical specialities. Medicalstaff informed us that there were no problemscontacting them for advice and they would attend ifrequired.

• Staff had access to pharmacy, diagnostic imaging aswell as other diagnostics such as blood testing sevendays a week. Out of hours, each of these services had anon-call facility and a member of an appropriate teamwas able to attend in the event of an emergency.Additionally, there was 24 hour, seven day a week accessto endoscopy and bronchoscopy.

• The hospital provided a seven day physiotherapyservice that were available to review surgical patientsand were responsible for introducing rehabilitationplans. There was also an on call physiotherapy serviceavailable out of hours.

• Other allied health professionals such as speech andlanguage therapists as well as occupational therapistswere available five days a week during normal workinghours.

Access to information

• All staff had access to the intranet and were able toaccess a range of information including policies andprocedures, clinical guidelines and the incidentreporting system. However, in theatre we found that notall standard operating procedures had been added tothe intranet. This was because most paper copies wereout of date and were currently in the process of beingreviewed. This meant that in these cases, staff were notalways able to access the most up to date guidance.

• Pre-operative assessments were paper based and wereavailable as part of the patients medical notes on theday of admission. Staff were able to print out clinicalpathways and add them to patients’ medical noteswhen required.

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• The electronic system was used to record things such aspatient observations and risk assessments, and able toaccess diagnostic results such as x-rays and blood testsusing the same system.

• Discharge information was inputted into the electronicsystem and a print out of a discharge sheet was given topatients and their relatives prior to leaving.

• Staff were also able to submit an electronic dischargeletter to a patient's GP using the electronic recordssystem.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• The hospital had policies for consent, mental capacityand deprivation of liberty safeguards (DoLS) which wereavailable on the intranet. Staff knew of these and knewhow to access them if required. However, we found thatmental capacity act and deprivation of liberty trainingwas not currently included as part of the mandatorytraining programme.

• Staff understood how to assess if children were able toconsent to treatment themselves. We were informedthat as children became older, they were involved asmuch as possible in their care and treatment.

• Information about the procedures that were to becompleted were given to the patient and families duringthe pre-operative consultation. Signed consent wasusually completed on the day of surgery. We sampledseven medical records and found that discussions withthe family had been documented appropriately andconsent had been obtained prior to surgical proceduresbeing undertaken.

• Staff had knowledge of gillick competence. Gillickcompetence is a term used to describe if a child under16 years of age is able to consent to their own medicaltreatment without the need for parental permission orknowledge. However, staff that we spoke to were unableto articulate what the Fraser guidelines were. Fraserguidelines relate to whether young people have thematurity to make their own decisions and consent insexual health discussions and contraception.

Are surgery services caring?

Outstanding –

We rated surgical services as ‘outstanding’ for caringbecause;

• We found a strong, person-centred culture. Holistic carewas provided by kind and caring staff who made everyeffort to provide support to patients and their parents.

• We found that patients and their parents were activelyinvolved in decisions about care and treatment. Theirviews and wishes were respected and valued.

• Feedback from people who used the services wascontinuously positive. They reported that staff werealways available, kind and supportive. They stated thattheir privacy and dignity was maintained at all times.

• Relatives told us that staff gave them the opportunity totalk about the care of their child, were given time to askquestions and they felt involved in decisions about care.

• The service recorded very positive friends and familytest and patient satisfaction survey results.

• We observed positive, compassionate and considerateconduct from staff towards their patients and families.

• Staff were fully aware of children and parents emotionalneeds and ensured this was embedded in the care thatwas provided. The emotional needs of patients andparents were assessed and this was supported by themultidisciplinary team.

• Staff were motivated and committed to working withparents and children to deliver the best care they could.

Compassionate care

• During our inspection we saw interactions between staffand children and between staff and parents. We sawthat these interactions were kind, courteous andinclusive.

• We saw that staff demonstrated a compassionate andcaring attitude towards children, young people andtheir parents.

• We spoke with six patients and their parents and wewere told that they were very satisfied with the care andtreatment they had received and they found the staffcaring, approachable and supportive.

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• One child spoke of how they were unable to eatchocolate eggs but staff ensured they were not left outand ensured they received an alternative gift.

• Friends and Family test results for Alder Hey hospitaloverall showed that 98% of respondents wouldrecommend the hospital to their family and friends,which was better than the England average of 96%. Only1% said they would not. However, the response rate forthe trust was only 20% compared to an England averageof 25%.

• Individual results for surgical wards and areas show aresponse rate of 29% for the surgical day-case unit; 99%of respondents stated they would recommend theservice to their family and friends. For Ward 4A theresponse rate was 36% with 93% recommendation and5% would not recommend.For Ward 3A the responserate was 36% with 100% recommendation. For Ward 1Cthe response rate was 27% with 100% recommendation.

• The hospital received a low response rate as to whetherstaff would recommend the hospital to friends andfamily as a place to receive care as of September 2016.Only 8% of staff (256 from a total of 3095) completed thefeedback; the results showed 88% of staff wouldrecommend the hospital as a place to receive care and4% would not. The remaining 8% did not express arecommendation or non-recommendation.

• Alder Hey’s own patient satisfaction survey recordedthat in February 2017, 100% of surgical inpatients statedthey were treated with respect.

Understanding and involvement of patients and thoseclose to them

• Parents with children who were inpatients were assistedto remain involved with their care by provision ofovernight accommodation at a nearby location.

• Parents told us that staff involved them in their care,and provided information and support in order to makedecisions about the child’s care and treatment.

• We observed staff involving and including patients andtheir families during discussions and planning for careand treatment.

• We saw instances of staff supporting parents to feedtheir baby and other staff providing guidance to parentson how to use equipment.

• We saw examples of care contracts drawn up inconsultation with patients, these expressed what theydid and didn’t want from their encounters with staff andwhilst at the hospital.

Emotional support

• Staff supported the emotional needs of patients andtheir families and took their emotional needs intoaccount when planning care and delivering information.We saw examples of this and observed this in practiceduring our inspection.

• Patients were assessed for anxiety and depression,phobias and fears. Staff (in particular, play specialists),sought information from patients and their parentsabout reactions to the hospital environment andtreatment. They listened to what the child wanted andwhat might increase anxiety. They provided coaching,confidence building, de-sensitisation and distractiontherapies for them in order to ensure they could receivethe treatment they required and had the least stressfulexperience.

• Counselling and psychological services were availablefor children and/or their parents on request or if a staffmember requested input. We saw examples of when apatient received psychologist input due to theemotional and psychological needs they demonstratedwhilst an inpatient. These services remained accessibleto the patient and their parents after their discharge. Wesaw examples of families who had continued to use theservices long after the period of inpatient stay due to thestresses of caring for a child with long term complexhealth concerns.

• Clinical nurse specialists were available to providecondition specific emotional support to patients

• Bereavement services were available to parents whohad lost a child. This service provided counselling,support groups, befriending schemes, therapeuticbreaks and a telephone helpline.

• We were told by one parent “the staff here have got methrough a very difficult period, I don’t think I could havedone this without them”.

• The cardiac team had arranged a family day so thatfamilies were able to share their experiences and receiveongoing support from the cardiac medical team.

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• The burns department had introduced a burns camptwice annually to give patients an opportunity tonetwork with their peers.

• Children we spoke with were positive in how staffinteracted with them and helped them overcome fearsaround surgical procedures they were having.

• There had been consideration to the design of the daycase waiting room to provide an interactive area forchildren so that they don’t feel they are in a clinicalenvironment, this included a giant interactive fish tankwhere children could design their own sea creaturesand see them come to life.

Are surgery services responsive?

Good –––

We rated surgical services as ‘good’ for responsive because;

• Services were planned with the needs of patients andparents in mind. The services were based on bestpractice guidance and from information gained frompublic and staff consultation.

• The environment and facilities were suitable andpleasant and met the needs of patients and parentsattending for surgery or being cared for on the wards.

• Access to surgical services was good with over 91% ofpatients gained access to treatment with 18 weeks ofbeing referred.

• The operating theatres were utilised effectively,enabling more patients to receive their treatment.

• There was access to an emergency operating theatrewhich was available 24 hours a day, 365 days a year.

• The average length of stay for surgical patients at AlderHey from April 2016 to March 2017 was shorter (better)than the England average.

• Bed occupancy levels were not too high which meantthere was usually beds available for patients beingadmitted and there was good access and flow in thedepartment.

• The individual needs of patients were met, such asthose with complex needs, those who were anxious orthose living with a learning disability.

• The spiritual, cultural and religious needs of patientswere taken into account and facilities were provided toaccommodate those needs.

• Feedback from patients was sought and complaints andconcerns were dealt with appropriately and in a timelymanner.

However,

• There were high levels of cancelled operations fornon-clinical reasons.

• When operations were cancelled, a large proportionwere not subsequently treated in 28 days.

Service planning and delivery to meet the needs oflocal people

• Alder Hey is one of four specialist paediatric trustsnationally. The surgical services provided were availableto paediatric patients from across the country. However,most were patients from the local region which coveredthe North West of England, North Wales and the Isle ofMan.

• The new surgical premises were designed and purposebuilt to facilitate effective surgical practice. There wasconsultation with both patients and surgicalprofessionals to determine the requirement of the newfacility and this was planned to meet the needs ofservice users.

• Suitable facilities and premises were available to theparents of children undergoing surgery. Waiting roomswere pleasant and well equipped and there was accessto food and beverages.

• There were facilities and play areas on all wards and inoperating theatres, waiting areas and in the day surgeryunit. There was a sensory room in the day surgery unitthat was equipped with lights and soft furnishings.There was portable sensory equipment and 3Dtelevisions that could be brought to the bedsides ofthose who might benefit from it.

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• The environment had been created to ensure it wasfriendly to children and young people. The wards hadelectronic game stations and rooms for older childrenwhich were away from younger children’s areas.

• There were facilities on the wards for parents to preparefood and drinks and there were rooms available if theyneeded somewhere quiet away from their child’sbedside. There was access to fold down beds for themto sleep on if they wanted to stay with their childovernight although some parents told us these wereuncomfortable.

• The facilities and premises for surgery at Alder Hey wereplanned by reference to best practice research andthrough consultation with staff, experts and members ofthe local community. The facilities were appropriate forthe surgical services provided. For example the facilitiesfor day surgery were compliant with therecommendations of the ‘day case and short staysurgery guidelines’ by the Association of Anaesthetistsof Great Britain and Ireland and the British Associationof Day Surgery. Day case surgery was provided in aself-contained unit separate from inpatient wards andtheatres with its own reception, consulting rooms, ward,operating theatres and recovery areas.

• Parents with children who were inpatients could accessovernight accommodation at Ronald Macdonald house,operated by a charity, which could house 84 families onsite.

Access and flow

• During the period April 2016 to March 2017, surgicalservices carried out 9,018 day case procedures, 3,480elective procedures and 999 unplanned procedures.This totalled 13,497 procedures for the year.

• Patients were admitted to Alder Hey surgical servicesthrough various means. They may have attended theemergency department and have been deemed torequire surgery for their condition. They may have beenreferred to the hospital via their GP for a consultation ona suspected surgical condition. They might also havebeen referred from their own local hospital for a surgicalprocedure only undertaken at this regional centre; forexample Alder Hey was the specialist cardiac surgerycentre for children in the region. They might also havechosen to have their surgery carried out at the hospitalthrough the NHS ‘choose and book’ system.

• Between April 2016 and March 2017, on average 92% ofpatients received treatment with 18 weeks of the datethey were referred for that treatment. This ranged from73% for patients waiting for spinal procedures to 100%of patients waiting for orthodontic treatment. Overallthis was better than some other specialist paediatrictrusts but not as good as others nationally.

• Weekly surgical planning meetings were held andattended by multidisciplinary staff, this facilitated themanagement of patient admission times, theatrescheduling, safe staffing and the need for furtherspecialist or diagnostic support.

• Theatre utilisation was 84.9% on average across alloperating theatres. This ranged from 76.6% utilisationfor the gynaecology theatre to 90.2% utilisation for theurology theatre. Most other theatres had utilisation ataround 85% which reflects good use of operatingtheatres, enabling greater numbers of patients to betreated.

• Bed occupancy across all surgical wards was 76.1%,which meant that surgical services did not usuallyexperience a problem with lack of available beds.However, staff did tell us that sometimes there washigher demand for some surgical specialities thanothers for example cardiac surgical beds, but stated thatthis did not usually result in the cancellation ofoperations.

• The average length of stay for patients following surgicalprocedures at Alder Hey from April 2016 to April 2017was 1.7 days, which was shorter (better) than theaverage across other children’s trusts in England whichis 2.6 days.

• Surgical services provided an emergency theatre whichwas available 24 hours a day, seven days a week forunplanned and unscheduled procedures for patientsadmitted via the emergency department and surgicalassessment unit and those who develop the need forsurgery as an inpatient.

• Patients on the day surgery ward were discharged bynurses who were trained in this practice. Patients had tomeet a minimum criteria before they were safe to bedischarged. Nurses had the support of senior staff andan on-site anaesthetist if they needed any further inputor advice on suitability for discharge.

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• On the inpatient wards, patients were discharged bysurgical doctors, which was based on clinical judgementand examination.

• A print out of the summary of care and treatmentprovided for the patient was given to the patient andparent on discharge and an electronic dischargesummary was sent to the GP within 48 hours ofdischarge. We saw examples of these summaries andthey contained all relevant information.

• Pharmacists were present on wards for a half a day eachday, which facilitated the timely dispensing ofmedication for patients to take home. The pharmacistcould supply medicines from a stock of items on theward or could collect items from pharmacy stockthemselves. This prevented delayed discharges due towaits for medications in the majority of cases.

• From January 2016 to December 2016, 304 pre-plannedsurgical procedures were cancelled for non-clinicalreasons, of these 61 (20%) were not subsequentlytreated within 28 days. This was higher than the Englandaverage which was 6% of patients not treated within 28days. Examples of cancellations for non-clinical reasonsincluded, ward beds unavailable; surgeon unavailable;emergency case needing theatre; theatre list over-ran;equipment failure; administration error; anaesthetistunavailable; theatre staff unavailable and critical carebed unavailable. NHS England considers that failing totreat patients within 28 days of a procedure which wascancelled for non-clinical reasons to be a breach of thestandard.

• The hospital did not have any surgical outliers (patientsthat were on a medical ward as opposed to a surgicalward), surgical patients were always accommodated onsurgical wards, however there were 402 medical (outlier)patients cared for on surgical wards between April 2016and March 2017, which equated to approximately 8patients per week on average.

Meeting people’s individual needs

• The parents we spoke with said that the individualneeds of their child were taken into account and thatcare was individualised.

• Surgical services could arrange interpreters in person orvia a telephone service for those patients whose firstlanguage was not English.

• British sign language interpreters were available to bebooked in advance.

• Leaflets and information packs were available in a rangeof languages and accessible formats such as easy read,large font and plain English.

• The trust’s website was equipped with accessibleadjustments such as increased text size and highcontrast options.

• There was a lift available to the upper floors and wardsareas and surgical admissions unit. The environmentwas accessible by wheelchairs. The environment wassuitable for use by those with mobility, visualimpairments and for those using pushchairs.

• A range of menus were available to all patients. Wespoke to several patients and relatives, who told us thatthe food was excellent and that there was a lot ofchoice. Chefs were located on each ward and food wasmade to order, this gave patients a range of options tosuit their individual choices and needs. Relatives werealso able to order food for a nominal fee.

• The was a multi faith spiritual care service team whowere available on site at the hospital during core hoursand available 365 days a year, 24 hours a day, sevendays a week through an on call service. There was apleasant sanctuary with quiet area that provided for arange of faiths, with ablution facilities and access tomaterials to meet the needs of different faiths.

• The departments demonstrated a knowledge andexperience of caring for patients with living with alearning disability and other individual needs. Therewere play therapists available in every department whowere able to offer distraction and play techniquesshould it be required.

• Those with more complex care needs had their careplanned by multidisciplinary teams who createdinnovative ways to best care for the patient and meettheir needs. The departments had arrangedfamiliarisation visits, given patients equipment to takehome and get used to, worked hard to educate andde-sensitise children to their fears by gradual andrepeated exposure to the things they were apprehensiveof, distraction therapies and allowed patients to weartheir own clothes for theatre.

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• Staff tried hard to understand the needs of their patientsand their parents in order to formulate a tailor madecare plan to meet the specific needs of that patient. Wesaw various examples of such care plans and staffstrived very hard to make sure everything was in placefor their patients. They undertook best interests andreasonable adjustments meetings with multidisciplinaryteams and families to ensure the treatment was asuccess.

Learning from complaints and concerns

• There was comprehensive information and adviceregarding the various methods of communicating andfeeding back complaints and concerns to the hospital.Patients and parents were given a range of options suchas the patient advice liaison service (PALS), written orelectronic complaints, informal feedback, telephonecontacts, directed to NHS choices or the friends andfamily test.

• There were leaflets explaining the various optionsaround the hospital, on posters and via the website.

• Staff demonstrated they understood how to supportpatients and relatives to make complaints. We observedthat staff actively sought feedback from thoseexperiencing their care in order to put right anythingthey had immediate control over.

• We reviewed a selection of complaints and found theywere all responded to in appropriate timescales.Complaints were addressed in an appropriate mannerand investigated in sufficient detail.

• Staff stated that complaints were discussed andhighlighted at team meetings and shared via emails andbulletins. We saw from minutes that managersdiscussed them at governance and departmentalmeetings.

• We saw evidence of when action had been taken toimprove services following the receipt of feedback orcomplaints. For example, the kitchen facilities wereimproved for relatives following a complaint andstickers were used to brighten up areas of the wardfollowing feedback.

Are surgery services well-led?


We rated surgical services as ‘requires improvement’ forwell-led because;

• We found that the governance framework for surgicalservices was relatively new and was still beingembedded at the time of inspection.

• We found that on surgical wards, there was no evidenceof risk assessments being completed. We were thereforeunsure if all risks had been identified and mitigatedappropriately. This was not line with the hospital’s riskmanagement strategy. However, we did note that intheatre this process was being followed.

• There was no evidence of ward managers attendingregular meetings with the clinical business unit (CBU) forsurgery. This meant that it was unclear how risks werebeing escalated and improvements were being made. Incontrast, there was evidence that the theatremanagement team attended regular meetings with theCBU.

• We sampled risk registers and found that in a number ofcases, there was limited or no evidence that the riskshad been reviewed fully or details of how the level of riskhad been mitigated appropriately.

• Staff raised some concerns that they were sometimesunder pressure to complete their roles and gaveexamples of when they felt that the management teamhad not always listened to their concerns or made anyimprovements.

• A monthly staff engagement temperature check wasundertaken for surgical services. Results from this hadshown an improvement from January 2016, when only39% of staff had recommended the hospital as a placeto work. Results In November 2016 were still low at 67%.

However,

• There was a clear vision and strategy for surgical service.This was underpinned by a number of strategicobjectives.

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• In theatre, a matron had been employed to manage risk,quality and infection control. We found that this workingwell and we saw evidence where improvements hadbeen made.

• Staff informed us they felt that there was an open andhonest culture within surgical services. We observed allteam members working well together during theinspection. All staff were proud of the job that they weredoing and felt that they provided a fantastic service topatients and their relatives.

• We saw examples of innovation, including the openingof the first paediatric hybrid theatre in Europe and thehospital innovation team have worked collaborativelywith a local university to develop ‘virtual surgery’ and touse high definition 3D printing so that organs can beviewed in much more detail.

Leadership of service

• Surgical services were run by a CBU which also includedcritical care, anaesthesia and neonatal services. TheCBU had a director of services and was supported by ateam including an associate chief of operations, anassociate chief nurse as well as a quality and riskmanager. The management team informed us that thisstructure had been implemented to shadow thestructure at executive level and so that it could functionwith more autonomy.

• Each member of the CBU had different responsibilities,for example, the associate chief nurse was responsiblefor supporting the ward managers with staffing issues,while the quality and risk manager supported staff withinvestigations into reported incidents and clinicalaudits.

• Within the CBU, there was a chief of operative care whowas supported by a lead consultant for every speciality,including burns and plastics as well as neurosurgery.They were responsible for providing supervision toconsultants and developing surgical services.

• At departmental level, there was a theatre manager whowas supported by an education team and a number ofstaff who had different responsibilities, such as leadinginfection and prevention control for the department. Amatron had also been recruited to support risk

management and quality within the theatreenvironment. In addition, each ward had its ownmanager who had a number of responsibilitiesincluding staffing and incident investigation.

• The theatre and ward management teams weresupported on a day to day basis by supernumeraryco-ordinators who were available on every shift. Forexample, in theatre there was always a band 7 staffmember on duty who was responsible for ensuring thatall theatres were staffed correctly. However, we found onsome surgical wards, this was not always facilitated. Forexample, on ward 1C, at night time, a band 5 nurse wasresponsible for supporting staff and ensuring that careand treatment was delivered appropriately. Staffinformed us that they did not feel that they were able toundertake this role effectively as they had patients tolook after on a regular basis. Additionally, they had notbeen provided with any extra training to undertake thisrole.

Vision and strategy for this service

• There was a clear vision for surgical services which hadbeen devised as part of a two year forward plan. Therewere three key elements to this, which included havingworld class clinical outcomes, providing safe care andtreatment to all patients and teamwork being anintegral part of surgical services.

• Members of the management team were able to identifywith the vision. However, other surgical staff, includingnurses and doctors were unclear about this.

• The vision for surgical services was underpinned by anumber of strategic objectives. Examples of these wereproviding systems and an environment that promotedexcellent care as well as ensuring that the workforce wasthe right size and had the appropriate skills.

• Although there were examples of how these objectiveswould be met, we did not see evidence of a serviceimprovement plan setting time frames in whichimprovements were to be made. Additionally, therewere examples when strategic objectives had been setfor the previous year, but results from this had beenmixed. Examples of improvements that had beenachieved included the percentage of familiesrecommending the hospital as a place of care exceeding95% (98% in December 2016) and a 50% reduction inthe short notice cancellation of theatre lists. However,

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there were areas that had not been achieved whichincluded a 25% reduction in surgical site infections, a5% reduction of day case to inpatient stays (there hadbeen a 1% increase) and 95% of staff recommending thehospital as a place to work (67% as of January 2017).

Governance, risk management and qualitymeasurement

• We found that the governance framework for surgicalservices was relatively new and was still beingembedded at the time of inspection. The hospital had arisk management policy that was located on theintranet. Members of the management team knewabout this and were able to locate it.

• Risks that had been identified for both theatre and theward areas were monitored and managed through anelectronic risk register. We found risk registers wereavailable for all areas of surgical services. Departmentmanagers were able to locate these on the electronicsystem. However, managers in two ward areas wereunsure of what was highlighted on their risk registers.

• We found that on surgical wards, there was no evidenceof risk assessments being completed. We were thereforeunsure if all risks had been identified and mitigatedappropriately. Examples of this included that a riskassessment for children absconding or being abductedfrom the ward areas had not been completed. Also, therisk of the resuscitation equipment being located indifferent areas of the ward and not being checked in linewith the resuscitation policy had not been assessed.The latter was a particular concern as an external reviewhad been undertaken at the beginning of 2016 whichhighlighted that this was a risk.

• In addition, the risk management policy stated that if apotential risk had been identified, a risk assessmentmust be completed so that the level of risk was properlyassessed. We raised this with the management teamwho informed us that an informal weekly discussionwas held between the ward managers and the riskmanager for the clinical business unit (CBU) for surgery,although they acknowledged that the formal processwas not being followed and that there was nodocumentation to recording this.

• In contrast, we saw evidence of risk assessments beingundertaken in theatre. When the level of risk reached acertain level, the risk was escalated to the risk register inline with the risk management policy.

• We reviewed a sample of risk registers across alldepartments. We found that individual members of staffhad been allocated to manage individual risks, an initialrisk score had been documented in all cases andcontrols to manage the risk were documented in mostcases. There was a date for further review, which wasdependant on the level of risk and in some cases; thereview had been documented appropriately. However,in a number of cases there was limited or no evidencethat the risks had been reviewed fully or details abouthow the level of risk had been mitigated further.

• The management team from theatre attended severaldepartmental and clinical business unit (CBU) meetingson either a monthly or a bi-monthly basis. There was aclear structure of how concerns were escalated. Forexample, there were monthly departmental risk andgovernance meetings and a bi-monthly theatre safetyboard. This fed into the monthly CBU risk andgovernance meeting. However, we did not see anyminuted evidence of the ward managers attendingmonthly meetings with the CBU.

• Each department submitted information to form amonthly quality dashboard. The results from thisformed the overall quality dashboard for surgery.However, this was primarily performance orientated.There were plans to introduce further clinical indicatorsso that compliance in these areas could be monitoredmore effectively.

• Minutes of meetings that we reviewed indicated thatmembers of the executive team attended CBU meetingson a regular basis, meaning that they were aware ofagenda items that were discussed or issues that hadbeen raised. In addition, an integrated performancedashboard was used to monitor compliance with itemssuch as mandatory training or personal developmentreviews.

• Surgical services had developed an audit plan for 2017 /2018. This was based on a number of audits measuringthe effectiveness of clinical services. The senior

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management team informed us that it was difficult tobenchmark results against similar Trusts nationally asthere were only a limited number of specialities thatwere eligible for data submission.

• The hospital had a central audit team who wereresponsible for measuring compliance against a varietyof best practice guidelines. However, the managementteam were unable to articulate what they hadundertaken. This meant that if audits had beencompleted, we were unclear about the process forlearning and making improvements.

• In theatre, we found that most standard operatingprocedures were out of date by either two or threeyears. These were currently being reviewed and were inthe process of being added to the electronic system.However, in the meantime, we had concerns that therewas a risk of staff following guidance that did not reflectcurrent practice.

Culture within the service

• Staff informed us they felt that there was an open andhonest culture within surgical services. We observed allteam members working well together during theinspection. Staff told us that patient care was thepriority and that they felt this view was shared by staffthroughout the department.

• All staff were proud of the job that they were doing andfelt that they provided a fantastic service to patients andtheir relatives.

• Staff informed us that most leaders were visiblethroughout the hospital, and that they generally feltsupported. However, staff raised some concerns thatthey were sometimes under pressure to complete theirroles and gave examples of when they felt that themanagement team had not always listened to theirconcerns or made any improvements. Examples of thisincluded when staff had raised concerns aboutmanaging the new environment since the move fromthe old hospital and the feeling of being understaffedand under pressure to do their jobs in difficultcircumstances. Some staff also felt under pressure as aresult of the amalgamation of specialist wards, forexample, staff who had experience of working onorthopaedic wards were also responsible for managingpatients who had undergone neurosurgery.

• Despite this, turnover levels had been consistently lowbetween April 2016 and March 2017. Turnover fornursing staff had varied between 0.2% and 1.9%. For thesame period turnover rates for medical staff variedbetween 0.8% and 3.4%.

• Sickness rates had varied between 0.3% and 2.5% formedical staff. Sickness rates for nursing staff had beenhigher, ranging between 4.7% and 7.3%.

• Staff knew how to access policies in relation towhistleblowing and bullying and harassment. Thesewere available to staff via the intranet.

Public engagement

• All patients and relatives were encouraged to givefeedback about the care and treatment that they hadreceived during their stay in the hospital.

• The hospital operated an online patient feedback forumwhich was open and visible to website visitors. Therewas an option to raise concerns or poor experiences andprovide positive feedback. The posts were reviewed andresponded to by Alder Hey ‘post authors’ and individualposts were referred to the relevant service managers.

• Share your experience online feedback could bedirected to specific departments as each departmenthad a feedback option on their website page, such asday surgery, neurosurgery and orthopaedic and traumadepartments.

Staff engagement

• The hospital had appointed a lead to facilitate ‘listeninginto action’ groups.They had been in post since April2016. ‘Listening into action’ was used to engage with asmany employees as possible, to listen to concerns orideas that they had, and to make improvements fromthese.

• The hospital had held six ‘big conversation’ events in thelast 12 months. We were informed that these had beenwell attended, with up to 80 staff taking part.

• A monthly staff engagement ‘temperature check’ wasundertaken for surgical services. Results from this hadshown in January 2016 only 39% of staff hadrecommended the hospital as a place to work. InNovember 2016, this was 67%.

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• The same survey also showed that in November 2016,90% of staff would recommend the hospital as a placeto receive care and treatment.

Innovation, improvement and sustainability

• A review of all nurse staffing had been recentlyundertaken by the senior management team. This wascompleted to help review current gaps, review financialimplications and suggest ways in which the workforcecould be improved and sustained in the future. This wascurrently in draft format and was due to be presented atthe next board meeting.

• The senior management team had recently created amatron role in theatre. Initial reviews showed that thisrole had been beneficial to the improvement of theservice. The senior management team had identifiedthe need for a matron in each CBU to ensure that therewas a direct link between each department andmembers of the CBU.

• A hybrid theatre had recently been opened in theatreswhich was the first paediatric hybrid theatre to beopened in Europe. Hybrid theatres are equipped withadvanced medical imaging devices such ascomputerised tomography (CT) or magnetic resonance

imaging (MRI) scanners. The aim of this is to increaseeffectiveness and to reduce the number of occasionsthat patients have to undergo surgery, including generalanaesthesia.

• The hospital innovation team had workedcollaboratively with a local university to develop ‘virtualsurgery’ and to use high definition 3D printing so thatorgans can be viewed in much more detail. This allowedstaff to ‘virtually walk around’ organs.

• There was evidence of innovation within cardiacsurgery. The hospital had developed an early extubationpathway for patients who had undergone this type ofsurgery and were the only children’s cardiac servicenationally to work with the Public Health Englandsurgical site infection surveillance team in reducing thenumber of surgical site infections within this speciality.

• The Trust had pioneered a headspace project which hadcreated the world’s first normal equivalent model of thehuman head. This enables comparison of pre-operativeand post-operative 3D images of craniosynostosispatients.

• The orthotics department had a specialist scannerwhich produced specialist braces for patients withoutexposing them to x-rays.

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Outstanding practice

• Each ward had their own dedicated pharmacist andmedication was accessed by fingerprint technologythis ensured that medication was secured and stocklevels were adequately controlled.

• There was a chef allocated to each ward and all foodwas prepared on the ward.

• A hybrid theatre had recently been opened and asmall number of operations had been undertakenusing this facility. This was the first paediatric hybridtheatre to be opened in Europe.

• The hospital innovation team had workedcollaboratively with a local university to develop‘virtual surgery’ and to use high definition 3D printingso that organs can be viewed in much more detail.This allowed staff to ‘virtually walk around’ organs.

• The Trust had pioneered a headspace project whichhad created the world’s first normal equivalentmodel of the human head. This enables comparisonof pre-operative and post-operative 3D images ofcraniosynostosis patients.

Areas for improvement

Action the hospital MUST take to improve

• The trust must take action to ensure all staff who areinvolved with assessing, planning, and evaluatingcare for children and young people are trained tosafeguarding level three in line with the safeguardingchildren and young people: roles and competenciesfor health care staff Intercollegiate Document (2014).

• The trust must take action to ensure all children andyoung people receive treatment in relation tosepsiswithin appropriate timeframes and have aprocess tomonitor adherence to policy for patient’streated for sepsis.

• The trust must ensure that there is a member of stafftrained in advanced paediatric life support availablein every department at all times as outlined in theRoyal College of Nursing guidelines.

• The trust must ensure that compliance withmandatory training is improved, particularly formedical staff.

• The trust must ensure that formal risk assessmentsare undertaken in all departments and all identifiedrisks are captured on the risk register where needed.

Action the hospital SHOULD take to improve

• Review the systems in place to enable staff to beclear about their roles and responsibilities during anemergency resuscitation scenario.

• The trust should ensure that all resuscitationequipment on inpatient ward is checked fully in linewith the hospital resuscitation policy.

• Review the systems in place to mitigate the risk ofchildren and young people absconding or beingabducted from the ward areas.

• Expedite plans and actions to enable all staff toimprove compliance with mandatory training to thetrust’s target of at least 90%.

• Have safe storage facilities in place for medicalrecords on all wards to protect children and youngpeople’s confidentiality.

• Have disease specific pathways in place that arebased on up to date evidenced based practice and asystem for assurance during the period of transitionfrom paper to electronic pathways.

• Improve staff appraisal rates to reach the at least thetrust’s target of 90%

• Consider training on the Mental Capacity Act forclinical staff being part of the mandatory training.

• Ensure visual display screens on the wall behind thedesk to the entrance of wards do not compromisepatient confidentiality.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• Identify review dates on all risk registers and reviewmonitor that actions identified to mitigate risk are inplace in medical services and surgical services

• Consider implementing a schedule for replacingcurtains in the ward areas.

• The management team should consider ways inwhich to improve monitoring of surgical siteinfections for patients who have undergonenon-specialist surgery.

• The management team should make sure thatdiscarded controlled drugs across all departmentsare recorded appropriately.

• The management team should consider ways inwhich to improve the meditech system so that itaccurately reflects the time that medicines had beenadministered, reducing the potential risk of amedication overdose.

• The hospital should find ways in which to make surethat there is always a supernumerary co-ordinatoravailable in all areas, at all times to support staff.

• The management team should ensure that all staffreceive a full annual appraisal in line with the trustsupervision policy.

• The hospital should consider ways in which to reducethe number of cancelled surgical procedures, andwhen this does happen to facilitate a furtherappointment within 28 days of the cancellation.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment

How the regulation was not being met:

Not all clinical staff who contributed to assessing,planning, and evaluating the needs of a child or youngperson had completed a mandatory training update insafeguarding (level 3). Regulation 13 (2)

Regulated activity

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance


Systems and processes did not fully mitigate risk ofcomplications of sepsis. Records for two children with ahistory of sepsis were reviewed and both highlighteddelays in treatment. Both these children had alerts onthe electronic system saying ‘high risk of sepsis,immediate review’ however there were delays of 12 and18 hours for review which delayed ongoing treatment.Not all clinical staff had received sepsis training andthere were no audit indentified following the pilot tomeasure if the pathway was robust.

We found at ward level, formal risk assessments werenot being undertaken and as a result, there wereexamples of risks that had not been captured on the riskregister.

We found examples of when serious incidents were notreported within the set timeframe, which meant that an

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


initial investigation to identify immediate learning hadnot taken place in a timely manner. We also found thatthere was limited learning from incidents recorded tomitigate the risk of the incident happening again.Regulation 17 (2) (b)

Regulated activity

Regulation 18 HSCA (RA) Regulations 2014 Staffing


The hospital was unable to provide a member of staffwho was trained in advanced paediatric life support inevery department at all times. Regulation 18 (1) (2) (a)

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


alder hey children's hospital newapproachfocused report

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