New Royal Liverpool University

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. People always had enough to eat and drink to stay healthy. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well.

Patients told us staff had informed them about their plan of care. Patients said their nutrition and hydration needs had been met during the course of their wait in the emergency department, regardless of the area they were boarded or waited. Patients and their relatives who were waiting for treatment in the waiting area had access to jugs of water and hot drinks. All patients had access to hot food.

Staff told us they followed care pathways based on national guidelines in order to provide appropriate care and treatment to patients. They knew how to access clinical pathways and guidance when needed. Senior managers told us they participated in local and national clinical audits and findings were reviewed and shared.

Managers checked to make sure staff followed guidance. Staff protected the rights of patients subject to the Mental Health Act 1983. Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. Staff had access to policies and treatment guidelines, stored electronically. Policies and procedures were based on best practice from NICE and Royal College of Emergency Medicine guidelines (RCEM). These were regularly reviewed and updated. Staff protected the rights of patients subject to the Mental Health Act and followed the Code of Practice. The trust had an agreement in place with the neighbouring mental health trust to provide psychiatric and mental health support to patients in the department. This enabled staff to protect the rights of patients subject to the Mental Health Act and followed the Code of Practice. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives, and carers.

Patients’ mental health was assessed during the initial assessment/triage and throughout their stay in the department if risks were identified. The proportion of patients who had a complete mental health triage and risk assessment within 15 minutes of arrival at the department was 40.37% which was an improvement of 24.9% from the previous year. Patients triaged and risk assessed within 30 minutes of arrival was 67.63% which was a slight improvement from 61.02% the previous year. The number of parallel assessments (joint assessment) completed were 57% which was an improvement from 35.5% from the previous year. The 2nd Year RCEM (Royal College of Emergency Medicine) Mental Health Self Harm) audit was ongoing at the time of the assessment. Figures showed an improving picture from the 1st year with risk assessment completion at 65%. Parallel assessment (joint assessment) completion rates were at 57% (versus 35% year 1), and appropriate physical health reviews were at 94%. The audit showed that safeguarding was considered in 46% of cases which was worse than 71% in year 1, but an improvement on the 13% in 2019). Drugs and alcohol concerns were considered and addressed in 47%, which was worse that 58% in year 1.

Patients presenting with poor mental health were referred to the Hub within the department. This was staffed by 2 mental health nurse practitioners and assistants in a separate, quieter environment and supported by the hospital’s psychiatric liaison service. There was a mental health lead consultant in post with a dedicated PA (a PA is a work session) for this work. There was also a substance misuse liaison service staffed between 8am – 8pm daily.

Guidelines and protocols were available to staff to follow for the most common symptoms patients would attend the emergency department for. These were noted to be in date in terms of review. The staff were able to find and access clinical guidelines on the electronic record system and print them out as required to use as a source of reference. For example, patients presenting with diabetic emergencies.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide safe care. Staff held regular and effective multidisciplinary meetings to review patients and improve their care. We saw multidisciplinary working with services, such as occupational therapy, psychiatric liaison, and diagnostics to identify the most appropriate care and treatment for patients.

Staff told us when a patient required admission, sometimes admission to the appropriate ward or clinical area was not possible as the ward was full. Patients had to wait either in the emergency department or in a temporary escalation space on the ward. Staff reported good access to specialist teams of staff who would be contacted to review patients. Generally, patients were assessed on a risk basis and patients with a higher acuity were reviewed first.

Staff were observed working well together as a team within the department and putting the patient’s needs first. Delays were sometimes experienced for patients who were referred to some specialties and required speciality review. Nevertheless, it was seen that the medical team were working collaboratively by seeing patients who had waited in the emergency department for a long period of time as part of regular ward rounds. Staff highlighted that this was not consistent amongst all specialities, particularly surgical, which led to surgical patients experiencing delays of specialist care and treatment.

Once patients had been seen by the specific speciality, they became the responsibility of that team, with the ongoing support of the emergency department staff. The interprofessional standards of the RCEM were described to be in place however it was not evidenced that these were upheld in practice. For example, any investigations ordered by the speciality team whilst the patient remained in emergency department, remained the responsibility of the emergency department to follow up.

Whilst there was multidisciplinary working across the emergency department, there was lack of collaboration between emergency department and Same Day Emergency Care (SDEC). SDEC allows specialists, where appropriate, to assess, diagnose and treat patients on the same day of arrival who may otherwise be admitted to hospital.

Staff told us they had a mental health hub where patients could be streamed to received specific care for mental health needs. The patient had to remain in an unsuitable area with additional staff as support. Another member of staff told us the processes had recently been reviewed and improved, but that sometimes they received resistance from the Hub where patients also needed medical care. Medical nursing staff were allocated to the Hub when capacity allowed to complete routine observations and administer medicines.

Information packs were available to support patients living with learning difficulties or autism and staff sought to allocate them to quieter areas of the department whenever possible.

The region had a high population of homelessness and substance misuse; staff worked with the homelessness outreach and drug / alcohol misuse teams regularly to support people appropriately.

The SWAN (Palliative care - Signs, Words, Actions, Needs) team supported the emergency department to help advise end of life care planning and information about the team was available to people via notice boards.

Emergency nurse practitioners received additional training to enable them to triage and treat patients with minor injuries. This diverted patients away from the emergency department and reduced overall wait times.

The frailty team attended the emergency department as required to review and assess patients who could be cared for in the frailty unit. Chronic pain teams, learning difficulties teams and dementia support was available.

We observed that there was a triage nurse and observation guardian in the waiting room at all times performing intentional rounding.

The system to share patient information with other health and care providers was easy to use and GP discharge letters were created and sent within 24 hours of attendance at the department.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. The service participated in relevant national clinical audits. Outcomes for patients were mostly positive, consistent, and met expectations, such as national standards.

We found evidence that managers and staff carried out a programme of repeated audits to check improvement over time. Regular support was provided to the department by the clinical educators and the information gathered from audits was shared with staff and used to improve care and treatment.

The department followed NICE (National Institute for Health and Care Excellence) guidance and hosted a GIRFT (Getting it right first time) visit. There was a consultant research lead who worked actively with NIHR (National Institute for Health and Care Research) and other hospitals and universities, with dedicated PA for this activity. The emergency department hosted intercalating emergency medicine undergraduates.

Despite not being a major trauma centre, the emergency department collected data on trauma. There were quality improvement projects underway including the rib injury pathway involving the pain team, rehabilitation services and physiotherapy. There was a quality improvement and audit lead who involved staff in audits and quality improvement projects to improve patient care and experience. One of the consultants was the regional lead for simulation training.

An audit of the Ottowa Knee Rules was undertaken in October 2024. Results found that 61% of imaging requests met at least one Ottowa Knee Rule indication and when repeated, 70% of requests met the standard in cycle 2. This was worse than the target of 95%.

All patients diagnosed with fragility fractures over 50 should get a bone density scan or be started empirically on treatment (bone protection). Findings in the February 2024 audit of Fragility Fractures showed that 50% of patients got appropriate follow up/investigation.

A Pabrinex Prescribing audit was completed in June 2024. Pabrinex should be prescribed to those attending the emergency department with a history of harmful/dependent drinking who are at risk of being malnourished or have a history of Decompensated alcohol related liver disease. Findings were 67% compliance rate which was worse than the 90% target rate.

In September 2024 pregnancy testing in the emergency department audits were undertaken for women of childbearing age presenting to the emergency department with abdominal pain. The audit showed that 38/52 eligible patients had a pregnancy test done (73%).

The RCEM Time Critical Medication (TCM) quality improvement project set out to ensure that Patients on TCM were identified within the emergency department early and aimed to ensure all of patients’ TCM were administered according to their usual regime. Results showed that 57% of patients were identified to be on TCM within 30 minutes of arrival, TCM dose administered within 30 minutes of expected time was 33% and 68% of patients did not miss any TCM doses during their ED stay.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Consultants were able to describe the process of consent according to trust and RCEM guidelines. They explained that this was used for any procedure performed in the department, including chest drains and fascia iliac blocks. Consent was recorded within the patient record and there were provisions and protocols in place pertaining to patients who did not have capacity to consent. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They supported patients who lacked capacity to make their own decisions or when experiencing mental ill health. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.

Staff gained consent from patients for their care and treatment during triage in line with legislation and guidance and this was clearly recorded in the patients’ records.

The service had effective systems to ensure staff assessed and managed the risks to people in relation to their mental health. A review of patient records showed a risk assessment of the patient’s mental health needs was completed or an appropriate plan to manage their mental health risks recorded.

When patients could not give consent, staff made decisions in their best interest, taking into account patients’ wishes, culture and traditions. The service had effective systems to ensure staff assessed the mental capacity of patients and recorded decisions made in service users’ best interest when applying to deprive the service user of their liberty. Managers monitored the use of Deprivation of Liberty Safeguards and made sure staff knew how to complete them.