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North Manchester General Hospital Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 12 August 2016

 

North Manchester General Hospital is one of the main locations providing inpatient care as part of The Pennine Acute Hospitals NHS Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

 

The Pennine Acute Hospitals NHS Trust provides services for around 820,000 people in and around

the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham, Rochdale and parts of East Lancashire. There are approximately 1191 inpatient beds across the Trust with the  North Manchester General Hospital having 481 inpatient beds.

We carried out an announced inspection of North Manchester General Hospital between the 23 to 3 March 2016 as part of our comprehensive inspection of The Pennine Acute Hospitals NHS Trust.

 

Overall, we rated North Manchester General Hospital as Inadequate. Improvements were needed to ensure that all services were safe, effective, well led and responsive to people’s needs.

However, we found that the majority of services apart from Children and Young people services  were provided by dedicated, caring staff, and patients were treated with dignity and respect

Our key findings were as follows:

 

Incident Reporting  

 

  • There was not a strong culture of reporting and learning from incidents in the hospital. This was evidenced by practice we saw in the;

  • Urgent and emergency, medicine, maternity and gynaecology and children and young people departments.

  • There was an unacceptable level of serious incidents with delays in investigations including those resulting in severe harm.

  • Some staff said that they did not always report incidents because they felt that little was done when they reported them. When staff did report incidents they told us that they did not always receive feedback.

  • There were occasions when we had to prompt members of staff to report incidents for things such as equipment that was overdue a service, inappropriately stored drugs and out of date disposable equipment. Staff did not demonstrate awareness that these needed to be reported and required several prompts throughout the inspection to report incidents.

  • Incidents were not always investigated in a timely way and staff did not always receive feedback from incidents.

  • Risks were not escalated appropriately and therefore did not gain robust executive scrutiny or the required response to mitigate risks in the longer term.

  • Learning was not shared through established systems and channels with a lack of openness about outcomes.

  • There was a lack of learning from complaints and a lack of learning and sharing of knowledge from discussions about mortality and morbidity.

  • However within the surgical, critical care, end of life and outpatient and diagnostic departments we saw evidence of a safer culture where systems were in place to ensure incidents were reported, investigated and lessons learnt.

Cleanliness and infection control

  • There were a number of departments in the hospital where there were concerns regarding cleanliness and infection control. These included medicine, surgery, maternity and gynaecology and Children’s and young people’s services
  • The environment posed an issue on a number of the medical wards we visited. Wards shared facilities or patients were co-located on medical wards meaning staff had to walk through different wards and departments to access the dirty utility or care for patients.
  • There was no risk assessment completed to address this issue or minimise any potential risks.
  • There were also no plans in place to manage the issues on the medical wards if there was an outbreak of norovirus, MRSA, C-difficile or carbapenemase producing enterobacteriaceae (CPE).
  • There were no hand washing facilities when walking between some wards. There were no toilet facilities on some patient bays. This meant that patients shared toilet and washing facilities with patients from different bays. There were no plans in place to manage this if there was an outbreak of infection.
  • There were few side rooms available on medical wards which meant that it was not always possible to isolate patients as required.
  • A number of wards were 'Nightingale' style wards which limited the ability to isolate or cohort groups of patients with infections to prevent the spread of infection
  • Within maternity and gynaecology there were incidences of puerperal sepsis at a higher rate than would be expected for a service of this size. 
  • On the labour ward there was no infection control information displayed such as results of hand hygiene audits or infection rates. This should be displayed as part of the safety thermometer data
  • Within the children’s and young people’s service hospital audits for MRSA and C.Diff were reactive. From June 2015 to October 2015 the children’s wards, Koala unit and the neonatal unit were not audited for C.diff or MRSA.
  • The paediatric wards at NMGH were audited in August 2015. They were found to be 67% compliant with hand hygiene. We saw no evidence there was a re-audit in the information we were provided and saw no action plan to address this.

However

  • The hospital had infection prevention and control policies in place which were accessible to staff.

  • We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.

  • ‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.

  • In the Emergency and urgent care department all areas were visibly clean, with no reported occurrences of methicillin-resistant staphylococcus aureus (MRSA) or colostrum difficile (CDIFF).

Medicines management

  • Overall we found the medicines were well managed across departments with some issues in the End of life department
  • Medicines including controlled drugs were stored securely in line with legislation.

  • Staff carried out checks on controlled drugs to ensure compliance with their medicines policy and records indicated that checks were completed correctly on the majority of occasions.

  • We saw that medication was in date and stored appropriately.

  • Medicines requiring cool storage at temperatures between two and eight degrees centigrade were appropriately stored in fridges. However, records indicated that daily checks had been missed on a number of occasions.

  • We checked a sample of patient medication charts which had been correctly documented and signed for.

  • Pharmacy staff were responsible for maintaining stock levels across the hospital.

  • There was a trust wide antibiotic policy for adults in place. The most recent audit in July 2015 showed that 98.6% of antibiotics prescribed at NMGH were compliant with this policy. Staff told us the policy was clear and easy to follow.

  • We observed a nurse giving a patient medication that was due to be transferred to another hospital. The medication was given so that it was not delayed by their discharge. The medication was given and documented on the electronic prescribing system so that the medication could not be given again at the new hospital.

  • In the surgical department staff told us that they tried to pre-empt patients for discharge at weekends and where necessary they could dispense patient’s medication to take home from the ward.

  • Children were weighed and this was documented within their medical records.

However

  • In the End of life department we reviewed prescription charts for seven EOL patients spread across different wards. Three patients had not been prescribed all of the recommended anticipatory medication. We returned and reviewed one of these charts 24 hours later, but the anticipatory medicine prescriptions were still not in place.

Nursing staffing

  • There were a number of departments in the hospital where there were concerns regarding nurse staffing. This was particularly significant within the medicine, maternity and gynaecology and children’s and young people’s services (CYP)
  • Consideration of the safer staffing guidelines produced by the National Institute for Health and Care Excellence (NICE) had been taken when determining the nursing staffing required in most departments apart from CYP.

  • The use of bank and agency staff was high and they were used on most days to fill vacancies and cover sickness. This had recently been stopped for one agency in the CYP due to the agency not complying with the national agency cap. However the use of agency staff from that agency had been reintroduced since our inspection.

  • We found that the average sickness rate and staff turnover rate in a number of departments was above the trust target of 5%

  • On some medical wards the acuity and dependency of patients on this ward was high. Staff told us that staff shortages meant that essential nursing tasks could not be undertaken in a timely way. For example, intravenous (IV) medications or fluids were given late, dressings were not completed and that there had been an increase in the number of hospital acquired pressure ulcers due to late or incomplete pressure area care.

  • The critical care unit did not meet the standard for supernumerary cover. The nurse in charge of the each unit was working clinically to care for patients. This issue was well known to the trust and was highlighted as a concern in the May 2015 review by the GMCCN.

  • Within CYP department we found that 19 out of 20 shifts (95%) were not staffed in accordance with RCN guidance in terms of the recommended staff: patient ratio. On average each shift was understaffed by two registered nurses.

  • We reviewed the planned vs actual staffing figures on the CYP ward. In 32 out of 92 shifts (34.78%) nurse staffing was at least one registered nurse short.

  • Royal College of Nursing (RCN) standards (August 2013) recommends that a nursing staff member has advanced life Support (APLS) training at all time throughout the 24 hr period. The trust did not have any APLS trained nursing staff members in paediatrics. They informed us that 13/46 (28.3%) nurses had current paediatric life support (PILS) certification on paediatrics.

  • Nursing staff told us that regularly they did not take all their breaks.

  • High dependency patients are nursed on the paediatric ward where staff had not received additional training for this this dependency of patient. This is against Paediatric Intensive Care Standards.

However

  • On CCU, the average fill rate was lower for RNs during the day at 90% however; this remained above the trust target and national benchmark of 80%.

  • A paediatric advanced nurse practitioner and paediatric nurses were employed by the urgent and emergency care department.

  • The department always had at least one paediatric nurse on duty at all times which met the royal college of nursing (RCN) guidelines.

  • A letter dated 17 February 2016 was seen addressed to the staff from the chief nurse in response to their recent concerns about staffing shortfalls within the surgical department. The outcome was to arrange a staff meeting with the chief nurse. Staff said they felt assured by the chief nurse’s involvement and the staffing proposals to recruit two healthcare support workers in the future.

Midwifery staffing

  • The numbers of midwives to birth ratio was worse than the England average.

  • Information provided by the trust showed one to one care in established labour did not meet the 100% of births target between April and October 2015. The lowest was 96.5%.

  • All the midwives and managers we spoke with stated staffing issues were their major concern for the maternity services. This had been recognised by the trust and the “failure to achieve safe staffing levels” was on the risk register.

  • Managers on the wards were unsure how their staffing establishment had been calculated and why there were variations.

  • Measures to improve midwifery staffing such as recruitment had been less successful than expected.

  • On the rota for 7 March to 3 April 2016 there were 204 vacant shifts in the labour ward

  • Midwife numbers were significantly below those planned on the labour ward. For week commencing 22 February 2016 nine shifts were not staffed to the planned level of eight midwives with weekends having six per shift. One day there had been four midwives instead of eight. This had been escalated and the managers worked in a clinical capacity.

  • We saw staff who had worked since 7.30am and had no break at 3.45pm.

  • Between 1 December 2014 and 30 November 2014 there were 46 incidents of shortage of staff reported.

  • There was a high level of sickness among the midwives.

  • Information provided by the trust showed the turnover rate was 13.4% between 1 February and 31 January 2016.

Medical staffing

  • There were a number of departments in the hospital where there were concerns regarding medical staffing. This was particularly significant within the Urgent and Emergency Care, medicine, maternity and gynaecology and children’s and young people’s services (CYP)
  • Within the Urgent and Emergency (U&E) care department an establishment of nine consultants had been commissioned. Only one of these was employed substantively at the time of the inspection. However, consultants from other areas of the trust worked in the department on a rotational basis to provide support.

  • The paediatric consultant did not currently work in the department due to being seconded into another role within the trust, support was provided by a paediatric advance nurse PR actioner.

  • The U&E department were established for seven middle grade positions and 13 junior doctor positions. However, only three middle grade doctors and five junior doctors were employed substantively at the time of the inspection. As a result, the department relied heavily on locum doctors of all grades

  • The U&E department had received funding for additional doctors due to winter pressures. However, we found that these had been filled on only a minority of occasions during the same period.

  • There was limited assurance that the performance of locum doctors with U&E was being reviewed on a regular basis. This was important as locum doctors formed a large percentage of the medical workforce within the department.

  • Medical handovers within the U&E department were not always facilitated on a daily basis. On one occasion that the senior doctor in the department had to request information from the nursing staff to find out about patients who were currently in the department.

  • There were high levels of locum use on Medical Emergency Unit (MEU) in particular for junior, middle grade and consultant cover. 70 percent of medical shifts had been filled by a locum doctor between October 2014 and March 2015. Locum usage for general medicine was 51% and care of the elderly was 39%.

  • One junior doctor told us that shifts and staffing on MEU did not always meet the needs of patients. For example, there were always more admissions to be clerked during the afternoon but these admissions were often left waiting for the night team to clerk them. This meant that patients could wait for long periods to be seen by a medical doctor.

  • On the maternity unit doctors of various grades told us some consultants who were on call from home over the weekend were reluctant to attend if called for support. An example was given of when support was requested with the delivery of a baby; however the consultant did not attend. This concern was raised with the trust and assurance given that all consultants worked within the guidance.

  • Consultant presence was not in place on the paediatric wards during peak times as per the facing the future standards. The trust advised us that consideration had been given to new rotas as part of the paediatric improvement plan. However, no implementation date had been set at the time of our inspection.

  • Facing the Future Standards also recommend that every child who presents with an acute medical problem is seen by a consultant, or equivalent, within 24 hours. In one paediatric serious incident investigation we reviewed this had not occurred and was deemed a causal factor in the delay of diagnosis. The trust did not monitor this standard at the time of our inspection.

However

  • The surgical service had similar levels of junior grade doctors and higher levels of consultants compared to the England average.

  • The surgical wards and theatres we inspected had a sufficient number of medical staff with appropriate skill’s to ensure that patients received safe care.

  • The SPC team was clinically led by a full time consultant in palliative medicine.

  • Within the OPD department consultants reported no gaps at consultant level and clinics were consultant led.

  • Consultant radiology cover was provided on site Monday to Friday 9am to 5pm. Radiology on call services were provided weekday evenings 5pm to 9pm on a trust wide rota supported by the trust consultants and between 9pm to 9am general on call services were provided by an on call contractor.

Access and Flow

  • There were a number of departments in the hospital where there were concerns regarding access and flow. These included Urgent and Emergency care medicine, critical care, maternity and gynaecology and Children’s and young people services
  • The Urgent and Emergency department had continuously failed to meet national targets to see, treat, discharge or admit patients within 4 hours. Records showed that between July and November 2015, performance had continually deteriorated.

  • The department also failed to meet the department of health 1 hour target which measured the time of arrival to the time of definitive treatment within the same period.

  • Records indicated that there had been a high number of patients waiting for over 12 hours in the department. As a result of the trust’s decision to admit policy these were not always recorded appropriately potentially providing and inaccurate picture of performance and limiting the ability to improve the service.

  • Information provided by the trust showed there were a large number of patients being cared for in non-speciality beds which may not be best suited to meet their needs (also known as outliers).

  • There were total 1,002 patients moved overnight between November 2014 and October 2015. The majority (871) of these moves were from MEU. Trust policy was that patients should not be moved between 8pm and 8am. Large numbers of patients experience multiple ward moves during the night

  • Some wards had very high bed occupancy rates, for example in October and November J3 had a bed occupancy rate of 98.3% It is generally accepted that, when occupancy rates rise above 85%, it can start to affect the quality of care provided to patients and the orderly running of the hospital.

  • Patients waited on MEU for longer than necessary due to bed shortages. One patient had been waiting for a medical speciality bed for seven days.

  • Staff on Coronary Care Unit (CCU) told us that there was often a wait to step patients down from this unit to beds on other medical wards. On the day we visited this unit, two out of six patients no longer required the level of care provided on CCU and were awaiting medical beds. This meant that patients needing admitting to CCU may not be able to access the care they need although bed occupancy rates were lower on CCU, at an average of 86.6% between October and December 2015.

  • Beds on the Infectious Diseases (ID) ward were often filled with outlying medical patients. This meant that patients requiring bronchoscopies for suspected tuberculosis (TB) waited for up to 12 weeks for this investigation. Specialist negative pressure rooms could not be used for their intended purpose. There had previously been a trolley area that was used to provide specific specialist treatment to patients with HIV but this was now in use as a medical bed.

  • Discharge plans were discussed during nursing handovers. There was a patient flow team available Monday to Friday who supported staff with issues regarding access and flow. Staff told us there were often long delays for packages of care to be arranged. Divisional leads told us that approximately 20% of medical beds across the trust were filled with delayed discharges.

  • On the day of our visit to the treatment centre, there were two male patients who had undergone lung biopsies on the unit. Staff told us that usually these patients were admitted to ward C3 following the procedure for monitoring, but on this day there were no available beds. The centre was therefore being used inappropriately due to a lack of surgical beds.

  • Challenges with access and flow within the wider hospital impacted on patients’ discharge from the critical care units. Once a clinical decision has been made that a patient was fit for step down or discharge from critical care there was often a delay in discharge.

  • There was a problem with delayed and out of hours discharges. Access and flow performance was tabled at the monthly critical care directorate meetings; though it is not clear from the minutes what actions, if any, the unit are taking to try improve the position for patients.

  • During the 12 months from December 2014 to December 2015, 6 patients had been ventilated outside the critical care unit.

  • Both the outpatient department (OPD) and the radiology department had high levels of patients who did not attend and there were no plans in place to address this.

  • Due to capacity and staff shortages on the labour ward we saw delays in transfers from the antenatal ward or maternity assessment unit did occur. Between January and November 2015 there had been 10 births in areas of the maternity unit other than the labour ward. There was no record of emergencies transfers following delay.

  • We saw nine patients waiting for their inductions to be progressed and were told at least three had waited beyond two hours which had been raised as a staffing red flag incident due to lack of midwives.

  • On the paediatric unit beds were not permitted to be closed to GP admissions. This meant that even when the escalation policy had been followed and risks agreed, the ward would not be fully closed.

However

  • Between November 2014 and October 2015 referral to treatment times (RTT) for all medical specialities including cardiology and gastroenterology were above the England average and the trust target of above 92%. General medicine and geriatric medicine were 100% compliant with the 18 week RRT.

  • The average length of stay at NMGH for the top surgical three specialities identified by HES data (July 2014 – June 2015) confirmed that the average length of stay for elective urology and trauma and orthopaedics was lower than the England average.

  • The referral to treatment times (RTT) and the cancer waiting times were better than the England average

  • There was no reporting backlog for any of the modalities for radiology. The patient tracking list group was chaired by a clinician and addressed individual patient issues along the cancer pathways.

  • The maternity assessment unit provided open access for patients who were 16 weeks pregnant and above. Patients could self -refer if they had concerns, or be referred by their GP or the emergency department.

  • Midwives could discharge patients from the maternity assessment unit without medical review. This meant there were no delays in discharge from this area.

  • Within the end of life service there were two rapid discharge initiatives in place. One was the rapid transfer pathway, which referred to EOL patients under the care of the SPC team who wished to leave hospital to their preferred place of care.

  • Staff told us pharmacy prioritised anticipatory medication when identified it was needed for rapid discharge, and that an agreement was in place with North West Ambulance Service (NWAS) for them to attend within two hours.

Leadership and Management

  • There were a number of departments in the hospital where there were concerns regarding leadership and management. These included U&E medicine, surgery, maternity and gynaecology and Children’s and young people’s services.
  • The leadership for the departments had a clear structure. However, the majority had only been implemented three months before the inspection and some senior members of the teams had only been in post a few weeks.
  • We saw that leaders were visible within the majority of departments and that they interacted well with staff. However midwives told us they saw the midwifery lead “never”, “rarely” and “occasionally” on the wards and departments. Although they reported having seen other leaders in the service more frequently.
  • Some band seven and six nurses felt that the leadership was blame focussed and not supportive and that that they felt they could not be honest during the inspection team staff focus group.
  • Senior nurses told us that they rarely received positive feedback.
  • Staff identified some concerns about the lack of senior support for the dietetic service as the previous manager left in January 2016
  • Human resources issues were not managed in a timely way to ensure the right people were in the right job. Senior medical staff discussed some concerns regarding the employment of seven locum consultants where integration into the substantive team, or their replacement with permanent staff had not progressed for four years.

However

  • Staff told us that there had been a positive change in the overall leadership of the trust in the past 18 months. The chief nurse regularly visited wards and departments

  • A new ‘Transforming Leaders’ course was open to all senior managers and clinical directors

We saw several areas of outstanding practice including:

  • The introduction of PCR testing for clostridium-difficile ensured rapid results were available to medical teams to reduce the potential spread of infection within inpatient areas.

  • The paediatric unit had created specific packs to support parents whose children were having specific procedures for example a DVD and self-help pack had been created for children having spiker surgery. This included contact details for parents who had had a similar experience.

  • The neonatal unit had a range of leaflets that complemented their ‘baby passport’. The leaflets were staged depending on the baby’s development. Parents were prompted via the ‘baby passport’ and nursing staff to know which information leaflets were relevant to them at a particular point in time.

Importantly, the hospital must:

Urgent and Emergency Care

  • Ensure that the staffing recommendations made by the peer review are considered and that the staffing establishment is correct for the department.

  • Ensure that there are sufficient numbers of trained staff within the department who can resuscitate adults and children when necessary.

  • Ensure that staff has access to and receive a yearly appraisal in a timely manner so that their training needs can be identified and so that their skills and knowledge can be developed.

  • Ensure that a site induction and a sufficient level of clinical supervision are provided to locum staff who work in the department.

  • Ensure that newly qualified nursing staff receive the appropriate supernumerary period in line with trust policy in order to ensure patient safety.

  • Ensure that is made clear how the minor injuries area is used and make sure that if high acuity patients are managed in this area it is done by the correct level and numbers of staff.

  • Ensure that daily checks and relevant documentation of controlled drugs are completed correctly and accurately in line with legislation and trust policy on every occasion.

  • Ensure that staff check resuscitation equipment on a regular basis so that out of date equipment is identified in a timely manner.

  • Ensure that patients receive a full assessment and appropriate treatment in a more timely manner so that patient risk is better managed.

  • Ensure that staff are always escalating patients who trigger the sepsis pathway for immediate medical review.

  • Ensure that call bells are available in all cubicles and that patients are given call bells to alert staff if they require assistance when needed.

  • Ensure that an up to date escalation plan is used in managing the department. This must identify all of the risks that the department faces and support staff in managing those risks.

  • Ensure that all incidents of patients waiting for more than 12 hours are reported as serious incidents and are investigated using the appropriate serious incident framework.

Medical Services

  • Ensure that patients staying overnight at the Manchester treatment centre have facilities to wash and store personal belongings.

  • Ensure that records are completed in line with best practice guidance and are maintained and stored securely.

  • Ensure that incidents are investigated promptly and learning is shared through formal, established channels. Mortality and morbidity must be discussed and learning shared.

  • Ensure that plans are in place for wards sharing facilities and staff in the case of an outbreak of infection.

  • Ensure that staff receive training on and understand how to apply the Mental Capacity Act and deprivation of liberty safeguards.

  • Ensure that staff follow the hospital standard for adult patient observation practice

  • Ensure that intentional rounding is completed in a timely and effective way.

  • Ensure that assessments of nutrition and hydration are completed for all admitted patients.

  • Ensure that mental capacity and deprivation of liberty is considered and documented on the bed rail assessment document.

  • Ensure that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.

  • Ensure that processes are in place to share and respond to patient safety alerts.

Surgical Services

  • Ensure that staff understand and act in line with the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards.We spoke with five staff. Two staff had no knowledge and two staff were waiting to receive training.

  • Ensure that patients do not attempt resuscitation documents and supporting documentation is fully completed and review dates identified.

  • Ensure all nursing and medical staff have annual appraisals completed.

  • Ensure that staff complete training in ‘Sepsis six’ so staff are aware of the process to follow when a patient is put on a ‘Sepsis six’ treatment pathway.

  • Ensure that critical care beds are available for surgical patients who require their initial post-operative care to take place in a designated critical care unit so that they receive treatment and care from staff who have the skills and training in this area.

  • Ensure that patients who are outliers on wards have the appropriate care, review and support to ensure a positive outcome results from their treatment.

  • Ensure that all yellow clinical waste bins when in use are locked.

  • Ensure formalised surgical service strategies are put in place.

  • Ensure incidents are reported in accordance to trust policy

  • Ensure that monitoring of drugs fridges take place as per hospital policy.

Critical care

  • Ensure action is taken to reduce the numbers of delayed and out of hours discharges from critical care.

  • Ensure that the management of sharps complies with infection control and health and safety guidance.

Maternity and Gynaecology

  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed in the maternity services.

  • This includes sufficient consultant resident cover in the labour ward.

  • Assess the risks to the health and safety of patients of receiving the care or treatment.

  • (To complete EWS / neonatal EWS / ante-natal risk assessments)

  • Assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.

  • (Investigate incidents within agree timescales and take action to prevent recurrence)

Children and young People

  • Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed in the paediatric and neonatal services.

  • This includes sufficient medical cover.

  • Ensure risks are assessed with regard to the health and safety of patients of receiving care or treatment.

  • Ensure they assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.

  • Ensure that electrical equipment is appropriately maintained and fit for purpose.

End of Life Care

  • Ensure patients are prescribed all of the recommended anticipatory end of life medications.

In addition the hospital should:

Urgent and Emergency care

  • Encourage staff to report all incidents in line with the trust policy.

  • find ways in which incidents and complaints are disseminated back to all staff so that learning and service improvement is facilitated.

  • check that unused equipment is stored in clean areas and that used equipment and waste is kept in appropriate areas.

  • consider keeping the doors to the children’s area locked at all times so that unauthorised people do not enter.

  • consider the safe storage and accessibility of resuscitation equipment, particularly in the children’s department.

  • Keep records for safeguarding peer reviews in a way that can be measured and used to inform service improvement.

  • Use all appropriate resources in supporting patients living with dementia in line with the trust policy.

Medical Services

  • Consider implementing an action plan into improve performance on the national heart failure audit.

  • Consider that patients are discharged from hospital as soon as they are medically fit.

  • Consider that the use of escalation beds and additional bed capacity is monitored and reviewed.

  • Consider that complaints are managed in a timely way.

  • Consider how to make changes to the layout and design of wards and departments to reduce the risk of spread of infection, including the abolishment of Nightingale style wards and the provision of additional side room capacity.

  • Consider how nursing skill mix is determined on wards where bank or agency staff are regularly being used.

  • Consider how to ensure specialist beds on the infectious diseases ward can be used for their intended purpose.

  • Consider how to reduce the risk of mixed sex breaches in the Manchester treatment centre.

  • Consider how to ensure that there is an open, honest and supportive culture within medical services.

Surgical Services

  • Consider improving staff understanding of the trust core values and what they involve.

  • Consider a better staff knowledge of the ‘Duty of Candour’ is developed.

  • Consider ways to ensure that patient’s meal times remain protected.

  • Consider that medical staff receive sufficient supervision and that work-based assessments are completed.

  • Consider ways to improve staff attendance at infection control (patient handling) training

  • Consider introducing a mandatory training summary for the surgical service that is available which identifies compliance levels for mandatory training sessions for all staff groups. Where there are, shortfalls in mandatory training noted then actions should be taken to identify how to improve compliance.

  • Consider introducing a system where all resuscitation equipment has expiry dates identified and that this information is noted on the resuscitation equipment checklist.

  • Consider introducing a formalised and documented induction checklist which are in place for bank or agency staff who are working on the clinical area for the first time

Critical care

  • Consider that there is a supernumerary band 6/7 shift co-ordinator on duty 24/7.

  • Consider updating and reviewing the critical care risk register on a regular basis ensuring all risks with actions are included.

  • Consider how it can embed training on Duty of Candour to all staff.

  • Consider how it is going to embed the delirium strategy into the day to day care of patients receiving critical care.

  • Consider how it is going to meet the intensive care society standards for the provision of pharmacy and allied health professional support to the critical care service.

Maternity and Gynaecology

  • Consider including actions and sharing lessons learned following the mortality or morbidity meetings to use them to improve practice.

  • Consider having a system to provide feedback, develop actions and share learnings from complaints.

  • Consider introducing a system to check the completion of fluid intake and output charts.

  • Consider introducing a system to protect community midwives when they are lone working.

  • Consider keeping staff mandatory training and that specific to the role they completed up to date at all times.

  • Consider a safety message being delivered at handover

  • Consider multidisciplinary handovers on the labour ward

  • Consider how consultants on call from home respond to requests to attend the labour ward in order to meet the RCOG recommendations.

  • Consider introducing mechanisms to reduce the delays in induction of labour.

  • Consider implementing actions from audits.

  • Consider how the information on the maternity dashboard can be used to inform and improve practice.

  • Consider making sure all staff appraisals are up to date.

  • Consider training all staff in the application of the principles of the Mental Capacity Act.

  • Consider whether the location of the maternity assessment unit is suitable to meet its purpose.

  • Consider how risks are managed.

  • Consider improving the engagement with staff and the public.

Children and young People

  • Consider including actions and sharing lessons learned following the mortality or morbidity meetings to use them to improve practice.

  • Consider having a system to provide feedback, develop actions and share learnings from complaints.

  • Consider keeping staff mandatory training and that specific to the role they completed up to date at all times.

  • Consider nursing staff presence at morbidity and mortality meetings.

  • Consider how it is going to meet the facing the future standards

  • Consider implementing actions from audits

  • Consider how the information on the paediatric and neonatal dashboards can be used to inform and improve practice.

  • Consider making sure all staff appraisals are up to date.

  • Consider how risks are managed.

  • Consider improving the engagement with staff and the public.

End of life Care

  • Consider developing a clear policy that defines the different rapid discharge processes with targets for the time taken.

  • Consider implementing a seven day service is in place and the risk to patients is mitigated

  • Consider implementing the IPOC and it is disseminated to the wards and fully embedded.

  • Consider the completing uDNACPR documentation so it meets the required standards.

Outpatients and Diagnostics

  • Continue to reduce the waiting times for the diagnostic procedures of colonoscopy, gastroscopy and sigmoidoscopy.

  • Consider the replacement of the allied health professional senior manager for the trust.

  • Reduce their did not attend rates in the OPD and in radiology.

  • Ensure that in paediatric outpatients staff are up to date with their appraisals.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Inadequate

Updated 12 August 2016

Effective

Requires improvement

Updated 12 August 2016

Caring

Good

Updated 12 August 2016

Responsive

Requires improvement

Updated 12 August 2016

Well-led

Inadequate

Updated 12 August 2016

Checks on specific services

Maternity and gynaecology

Inadequate

Updated 12 August 2016

We judged the service as Inadequate because. .

·     

There was an unacceptable level of serious incidents with delays in investigations including those resulting in severe harm.

·

There was a failure to effectively investigate and learn from incidents with a lack of openness about outcomes. T

here was a lack of learning from complaints and a lack of learning and sharing of knowledge from discussions about mortality and morbidity. 

There was a shortage of midwifery staff which led to some delays in transfers during labour and inductions of labour. M

idwives and medical staff were not up to date with training and competence for some of the tasks they performed.

There was no emergency gynaecology provision out of hours and no inpatient gynaecology provision at this site. 

There was a lack of clear systems and processes for managing risks and performance of the service. There were few mechanisms for staff engagement and plans to improve this had not taken place.

However

Some improvements had been made as a result of the maternity improvement plan including the purchase of necessary equipment. Midwifery and medical staff worked well as a team and provided compassionate care  There was an enthusiasm amongst the staff to improve the services.  

There were changes in the leadership of the service following our inspection. Between the announced and unannounced inspection some practical changes had been made and staff told us there was already an improvement in communication

Medical care (including older people’s care)

Inadequate

Updated 12 August 2016

We judged medical care services was inadequate  because:

Incidents were not always investigated in a timely way and staff did not always receive feedback from incidents.

Learning was not shared through established systems and channels.

 Problems with the environment on many of the wards and areas we visited meant that infection control best practice could not always be followed. 

The Manchester treatment centre was not a suitable environment for patients to stay overnight as there were no facilities for them to wash or to store belongings. I

ntentional rounding was not completed in a timely and effective way. The trust protocol for the use of early warning scores was not always used. Deteriorating patients were not always referred for a medical review deterioration. Staff on the medical emergency unit (MEU) had not received training to use the continuous cardiac monitoring in place on four beds and there was no monitoring system in place at the nurses station.

Thickening agent was stored at patient’s bed areas without appropriate risk assessments despite a patient safety alert that was issued in 2015.

  

 

P

atients waited for longer than necessary for beds and more than half of patients were moved once of more during their admission.

Patients were moved overnight when necessary although trust policy was that patients should not be moved between 8pm and 8am. Specialist beds on the infectious diseases ward could not be used for their intended purpose because they were filled with medical outliers.

Complaints were not investigated and completed in a timely way.

M

any leaders at ward level were new in post and their leadership was therefore in its infancy, although staff spoke positively of the changes.

S

taff told us there was a culture of bullying at some levels and historically, there had been.

        

 

However

Nursing staffing levels on medical wards had been assessed using a recognised acuity tool. Fill rates were good for qualified and unqualified nursing staff during the day and at night;. Verbal nursing handovers were comprehensive 

Care and treatment was provided in line with national guidance from NICE and Royal College of Physicians, the Royal College of nursing and locally produced guidelines 

 

Patients were cared for by staff who were kind, caring and compassionate. Staff respected and upheld patient’s privacy and dignity. Friends and family test response rates were high and results were generally positive. Some wards frequently received 100% positive feedback. The trust scored in the top 20% for 25 out of 34 areas on the inpatient cancer experience survey in 2013/14. The trust was performing better than the England average for all four parts of the patient-led assessments of the care environment.

Communication was sensitive when providing patients with distressing information. Families and loved ones were involved in decisions about care and treatment. 

There was a good awareness and understanding of patients individual needs. A new system was in place to identify patients with specific needs such as dementia or at risk of falling. There was a dementia nurse consultant and a trust wide dementia strategy and some wards had begun to make changes to the environment to make them more dementia friendly.

Staff spoke positively about the chief nurse. She visited the ward regularly and staff felt she was approachable. The divisional manager was visible on the wards and seen daily. There were good relationships with the medical team. There was public and staff engagement in quality monitoring and development of the service.

Urgent and emergency services (A&E)

Inadequate

Updated 12 August 2016

We judged emergency and urgent care services to be ‘inadequate’ because;

The department had continuously failed to meet the department of health target to see, treat, discharge or admit 95% of patients within 4 hours.

Records indicated that there had been a high number of patients waiting for over 12 hours in the department.

B

etween August 2015 and the time of inspection the department continuously failed to meet national targets to triage patients within 15 minutes. . Some staff told us that they did not always report incidents as they felt nothing would be done about them

We found that medical staffing was poor, relying heavily on locum staff and there was limited assurance that the performance of the locum doctors was being reviewed . The establishment of nurses had calculated with some recognition of an appropriate acuity tool. However, a peer review indicated that the number of nurses was lower than required.

However

We saw examples of patients being treated in a compassionate way, having their privacy respected and dignity maintained while being examined. Patients and relatives spoke in a positive way about the staff in the department.

There were safeguarding systems in place to keep people safe. Staff were aware of what types of things to raise as a concern and the procedure for doing this.

Surgery

Requires improvement

Updated 12 August 2016

We judged  surgical services  as requires improvement. because

Sepsis management and associated processes were implemented in June 2014. However, since June 2014 there was limited staff uptake in sepsis management training. To-date, 4% of nursing staff had attended this training.

Outliers were located throughout the surgical service. This relates to patients who were situated away from the speciality they should have been admitted to. Concerns were also identified that patients placed on general surgical wards or outliers were not reviewed daily.

Not all staff understood the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards, however in the majority of cases consent was taken appropriately.

There were no formal surgical service strategies were not in place.

Newly implemented governance, risk and quality measurement processes were in place, which meant that learning and monitoring processes from governance and quality measurement processes might not be as robust as they should have been.

Some of the staff we spoke with identified that their knowledge of the trust core values and what they involved was limited.

However

Care was provided in line with NICE CG50. Patient’s risks were assessed to determine their fitness for surgery. The service had protocols and guidelines in place to assess and monitor patient risk in real time.

Systems were in place to ensure that risks to elective and emergency patient groups were identified pre-operatively.

We observed visibly good infection prevention practices by staff and noted good compliance in this area.

Clinical equipment had been serviced. Daily checks of resuscitation equipment had taken place.

Consent processes were generally robust and documentation associated with these processes adapted to the individual patient’s needs and understanding. The records we reviewed showed that consent was taken correctly.

There was good access and flow to services, which met patient’s needs. Service developments had improved patient access to treatment.

Patients received evidenced based care, treatment and patient outcomes were good. Good multi-disciplinary working existed between the trust, surgical day service, local clinical commissioning groups and community services.

Staff were caring, compassionate and respectful.

 

.

Intensive/critical care

Good

Updated 12 August 2016

We have judged  the critical care services provided were good because.

  • There were systems in place for reporting and learning from incidents.There were sufficient numbers of suitably skilled nursing and medical staff to care for the patient Care and treatment was planned and delivered in accordance with evidence based guidance.Critical care services were delivered by caring, compassionate and committed staff.We saw patients, their relatives and friends being treated with dignity and respect.There was a positive culture with staff and the public being engaged in the development of the service.

However

  • It was rare for there to be a supernumerary clinical co-ordinator on duty as set out in the national service specification for intensive care (D16).There was a problem with delayed and out of hours discharges.Governance processes were present but yet to be embedded.

Services for children & young people

Inadequate

Updated 12 August 2016

We judged that children’s services were inadequate because 

 

Patient safety was a significant concern. Risks were not escalated appropriately . There were unacceptable delays in the investigation of incidents including those resulting in severe harm. There was a failure to effectively investigate and learn from incidents. There was a lack of learning from complaints and a lack of learning and sharing of knowledge from discussions about mortality and morbidity.  

 We found that care and treatment did not always reflect current evidence-based guidance, standards and best practice. Standardised care plans were not in place. Several policies and procedures were not up to date. 

Patients received care from staff that did not have the skills or experience that is needed to deliver effective care. We found that the needs of the local population were not fully understood when planning this service particularly when considering the number of under two’s that would access the children’s wards. On the paediatric ward the number of nurses that were planned for each shift did not meet recommended ratios in 95% of the shifts we reviewed. Some people are not able to access services for treatment when they need to. Over one month 21 patients were transferred to other hospitals to receive their care

There was significant concern regarding how well led the service was. The delivery of high quality care was not assured by the leadership, governance or culture in place.

 However

On the neonatal unit staff interactions were positive and babies were treated with kindness and compassion.  In paediatrics we saw staff engaging with children and their parents kindly. Parents and carers were, in the main, positive about the care and treatment provided.

 

End of life care

Good

Updated 12 August 2016

Overall we judged the service as Good because.

 

Incident reporting systems were in place and learning from incidents was discussed 

 We saw assessment information from occupational therapy and physiotherapy and good comprehensive nursing assessments in the records. Appropriate risk assessments were in place. Th

e service had developed an individual plan of care and support for the dying person (IPOC) to guide care and support documentation in the last days of life in line with current evidence-based guidance and best practice. 

    

There was an audit plan in place and the reports we saw included appropriate recommendations and action plans to address the delivery of care where standards were not met. 

The service held a weekly multi-disciplinary team (MDT) meeting where cases and new referrals were discussed. 

  

End of life care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill

However

·T

he rapid transfer process was in its infancy and the service was taking steps to put improvements in place. T

here were numerous new systems in place or in planning to improve the provision of EOLC including the new steering group, the new reporting operational policy and the proposals for a new bereavement service, seven day working and an electronic palliative care co-ordination system (EPaCCs).  

·        

Some patients were not prescribed all of the recommended anticipatory end of life medications. 

There was no seven day service in place and although the potential risks of the impact on patients had been identified, assurance around the management of these risks was not clear. 

 

 

Outpatients

Good

Updated 12 August 2016

We judged  the service as Good because

   

·        

Mandatory training levels were good and the environment was visibly clean and tidy. Equipment was checked regularly and there was evidence to support this. Staff knew how to report incidents and the learning from these incidents was followed up through regular staff meetings.

·         

 

·        

Staff were using national guidelines which were being reviewed for compliance by the trust. There were good opportunities for staff development and evidence of effective multi-disciplinary team working. Leadership was good at an operational level  in both OPD and radiology and information was shared at all levels in the division; however some allied health professionals were unhappy with the lack of leadership for their professions in the trust.

 

·        

Pathology services were efficient with patient blood test results being available during clinics. The service  was provided a 24 hour, seven day per week service.

 

However

·

The did not attend for appointment (DNA) rates in OPD were higher than the England average and the trust did not have anything in place to address this. DNA rates were also high in the radiology department.

·

There were issues around the storage of medicines in OPD clinics but the trust were working to change this with pharmacy colleagues.

Other CQC inspections of services

Community & mental health inspection reports for North Manchester General Hospital can be found at The Pennine Acute Hospitals NHS Trust.