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Inspection Summary


Overall summary & rating

Good

Updated 12 August 2016

The Pennine Acute Hospitals NHS Trust provides general and specialist hospital services to around 820,000 residents across the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham, Rochdale and parts of East Lancashire.

Rochdale Infirmary is part of The Pennine Acute Trust and the trust has three other acute hospital sites, which are: North Manchester General Hospital, Oldham General Hospital and Fairfield Hospital (Bury), and also provides a large community service.

We were told that 13,100 patients had attended the day surgery unit from July 2014 to June 2015.

During our inspection, we visited five theatres, two recovery wards and the ophthalmic ward

The Care Quality Commission (CQC) carried out a comprehensive planned inspection at Rochdale Infirmary between 23 February and 3 March 2016; we inspected urgent care, medical, surgical and outpatient and diagnostic services. There are 21 inpatient beds at the hospital.

The urgent care centre provides non-emergency services to around 240,000 residents that live in the communities of Heywood, Middleton and Rochdale. The department is open 24 hours a day, seven days a week.

Medical services at Rochdale Infirmary are provided from two wards and an endoscopy department. The clinical assessment unit (CAU) accepts patients via GP referral, or patients may be admitted via transfer from other trust sites or the urgent care centre. Rochdale Infirmary also hosts the oasis unit, which is a five bedded specialist dementia ward, offering medical treatment to patients with a diagnosis of dementia or delirium.

The surgical services at Rochdale Infirmary carry out a range of surgical procedures such as ophthalmology, colorectal surgery and general surgery (such as gastro-intestinal surgery. 13,100 patients attended the day surgery unit from July 2014 to June 2015.

The outpatient department (OPD) provides a number of clinics, including orthopaedic, urology, rheumatology, pain, respiratory and infectious diseases. The radiology department provides digital radiography services, computed tomography (CT) and magnetic resonance (MR) imaging.

The overall rating for this hospital was good for medical care, surgery and outpatients and diagnostic services, however, urgent care services required improvement.

Our key findings were as follows:

Incident Reporting

  • Staff were encouraged to report incidents, which included near misses. Feedback was optional but staff reported that feedback was given when asked for.
  • We saw evidence of incidents being reviewed by the clinical lead in the department and actions being taken so that lessons were learnt. If a serious incident occurred, the trust policy was for it to be escalated to the risk management team who would then assign it to an appropriate member of staff for investigation.

  • Patients were given information about how to make a complaint. There had been four complaints about medical services at the hospital between 1 December 2014 and 31 December 2015. Complaints were discussed at clinical governance meetings and a quarterly learning from experience was sent to the trust board.

  • However, complaints and concerns were not responded to in a timely manner to help improve services within the urgent care department.

Cleanliness and infection control

  • Medical services were clean and tidy. Infection prevention audits were completed and showed that the areas we visited were compliant with trust policies. We saw staff using personal protective equipment, such as aprons and gloves and observed them washing their hands appropriately.
  • In surgical services we observed good infection prevention practices by staff and noted good compliance in this area.

Caring

  • Staff were kind, caring and compassionate. They maintained the privacy and dignity of patients in their care.
  • Patients were cared for in an individualised way of the oasis unit and their carers and families were encouraged to be involved in their care.
  • Friends and family test results showed that 97.5% of patients would recommend medical services at Rochdale Infirmary. Open visiting was in place and there was access to specialist mental health services.

Leadership, vision and clinical governance

  • Overall the hospital leadership was strong and cohesive, with a clear vision and strategy.
  • Care and treatment was delivered in line with evidence based practice and national guidance, such as those from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (CEM).
  • Local audits were completed and the endoscopy unit was accredited by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG).
  • Staff described the culture as friendly and supportive and they were proud of the services they provided; staff were positive about working in the service and described a culture of flexibility and commitment.
  • Staff had been involved in the development of the trust vision and values and the “healthy, happy, here” programme of work.
  • However, Patient risk was not always monitored and documented appropriately through the use of the early warning scores (EWS) and the Manchester early warning score (MANCHEWS) for children in the urgent care department.
  • The effectiveness of treatment was not measured on a regular basis so that there was the opportunity to improve services within the urgent care department.
  • Patient records were not consistently recorded in line with GMC guidelines within the medical department and not always kept securely in the surgical department.

Staffing

  • Medical and nursing staffing levels and skill mix in surgical services was recognised as being appropriate to meet patient need and reflected current guidance. Operating theatres were established against the ‘Association for Perioperative Practice (AfPP) staffing recommendations.
  • In medical services, nursing staffing had been calculated using a recognised acuity tool and shift fill rates were very high. Medical cover was provided 24 hours a day and senior advice was available from Fairfield General Hospital.
  • However, there were not always sufficient numbers of staff with the appropriate skills available in the urgent care department at all times.

Providing responsive services

  • The hospital was generally responsive to people’s needs and the oasis unit within the medicine department is was an example of outstanding innovation and service planning and met meets both the needs of the local population and individual needs; the oasis unit was designed to be dementia friendly. The unit reflected the needs of patients living with dementia and staff delivered patient-centred care. There was a trust wide dementia strategy and a nurse consultant in dementia care.
  • Ambulatory care was available seven days a week, reducing the need for patients to be admitted to hospital.
  • Patients with a learning disability were identified and there was a learning disability specialist nurse.
  • Pain was assessed and patients received timely pain relief. Patients had their nutritional needs assessed.
  • Feedback from staff and patients had resulted in changes to aspects within the service.

Access and flow

  • The urgent care & emergency services department had performed consistently well in achieving the Department of Health target for 95% of patients to be seen, treated, discharged or admitted within 4 hours.
  • Referral to treatment times (RTT) and cancer waiting times were better than the England average, clinicians engaged with appointment booking staff to meet targets around RTT.
  • There were clear admission and discharge processes in place and a transfer of care team was available to support with more complex discharges.
  • In medical services, the average length of stay was lower (better) than the England average and the overall risk of readmission was also lower.
  • In surgical services, service developments had improved patient access to treatment through the introduction of new elective lists.
  • However, the did not attend (DNA) for appointment rates in the outpatient department (OPD) were higher than the England average and DNA rates were also high in the radiology department.

We saw several areas of outstanding practice including:

  • The oasis unit was an example of outstanding innovation and service planning to meet both the needs of the local population and individual needs. The unit opened in 2014 and was thought to be the first of its kind in a hospital in England at this time. This unit offered specialist care for patients with delirium or living with dementia during periods of acute illness. The unit was designed to be dementia friendly and offered patient-centred care. The positive impact of the unit had been recognised and was doubling in size as a result of this.
  • The Outpatient and Diagnostics department had a patient tracking list that was clinically led.
  • The radiology department had no backlog in reporting in any modalities; this had been recognised nationally as extremely good practice.

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

Action the hospital MUST take to improve:

Urgent care

  • The department must ensure that there are sufficient numbers of staff with the appropriate skills available at all times. This includes ensuring that there are sufficient numbers of staff available to resuscitate adults and children.
  • The department must ensure that staff have Advanced Life Support training.
  • The department must ensure that patient risk is monitored and documented appropriately through the use of the early warning scores (EWS) and the Manchester early warning score (MANCHEWS) for children.
  • The department must ensure that the effectiveness of treatment is measured on a regular basis so that there is the opportunity to improve services when required.

Action the hospital SHOULD take to improve

Urgent Care

  • The department should improve performance in relation to triage times.
  • The department should ensure that they provide appropriate documentation and training to support staff when providing care to patients whose circumstances make them vulnerable, such as those living with dementia or a learning disability.
  • The department should ensure that all equipment is checked on a regular basis and that it is safe for use.
  • The department should ensure that fridge thermometers are working in a way that ensures that medication is kept in an appropriate environment and these should be recorded daily.
  • The department should continuously monitor the service that they provide through local audits and audits that are recommended by the royal college of emergency medicine (RCEM). This should include developing action plans to facilitate improvement.
  • The department should facilitate all planned training days so that staff can maintain and develop their skills.
  • The department should ensure that complaints and concerns are responded to in a timely manner.

Medicine

  • The department should ensure that records are completed and maintained in line with General Medical Council (GMC) guidance on keeping records and CG2 - record keeping guidelines.
  • The department should carry out a risk assessment of the environment manometry room with specific consideration of infection control, accessibility, storage of equipment and supplies and privacy and dignity.
  • The department should ensure that there is a system in place to deploy sufficient numbers of suitably qualified, competent and skilled staff on the oasis unit to maintain the safety of all patients, regardless of the presence of staff employed by other trusts.
  • The department should ensure that staff receive a regular and effective appraisal to enable staff to carry out the duties they are employed to perform.
  • The department should consider undertaking local patient surveys to gain feedback from the public about services provided.

Surgery

  • The department should consider the provision of additional training for staff in relation to the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards.
  • The department should develop surgical strategies as part of the ‘Healthier Together’ strategy.
  • The department should ensure that access to clinical waste is restricted to designated staff groups.
  • The department should ensure that patient records are secure at all times.

Outpatients and diagnostics

  • The department should continue to reduce the waiting times for the diagnostic procedures of colonoscopy, gastroscopy and sigmoidoscopy.
  • The department should consider the replacement of the allied health professional senior manager for the trust.
  • The department should reduce their did not attend rates in the outpatient department (OPD) and in radiology.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 12 August 2016

Effective

Good

Updated 12 August 2016

Caring

Good

Updated 12 August 2016

Responsive

Good

Updated 12 August 2016

Well-led

Good

Updated 12 August 2016

Checks on specific services

Medical care (including older people’s care)

Good

Updated 12 August 2016

We judged the service  as good because:

  • Incidents were reported and learning was shared via a monthly newsletter. Harm free care was monitored and measured monthly and the wards we visited had a good track record on safety.
  • Medical services were clean and tidy.  We saw staff using personal protective equipment, such as aprons and gloves and observed them washing their hands appropriately.
  •  Staff were aware of their responsibilities in relation to safeguarding. Safeguarding children and adults level two had been completed by 93% of staff.
  • There were systems in place to ensure that patients were assessed and risks were monitored and minimised.
  • Nursing staffing had been calculated using a recognised acuity tool and shift fill rates were very high. Medical cover was provided 24 hours a day and senior advice was available from Fairfield General Hospital..
  • Care and treatment was delivered in line with national guidance and best practice.
  • Pain was assessed and patients received timely pain relief. Patients had their nutritional needs assessed.
  • Staff were supported to develop their skills.
  • Staff were kind, caring and compassionate. They maintained the privacy and dignity of patients in their care.
  • Patients were cared for in an individualised way of the oasis unit and their carers and families were encouraged to be involved in their care.
  • Friends and family test results showed that 97.5% of patients would recommend medical services at Rochdale Infirmary.
  • Services had been planned to meet the needs of local people,  Ambulatory care was available seven days a week, reducing the need for patients to be admitted to hospital.
  • Referral to treatment times for the trust for admitted (adjusted) patients were above (better than) the England indicator and England average.
  • The specialist oasis unit was thought to be the first of its kind in a hospital in England. This type of unit is an example of outstanding practice.
  • There were clear admission and discharge processes in place and a transfer of care team was available to support with more complex discharges.
  • Patients were given information about how to make a complaint.
  • Staff were aware of the trust vision and values. Staff had been involved in the development of the trust vision and values and the “healthy, happy, here” programme of work. There was a service improvement plan in place for the division of integrated community services.
  •  The risk register was up to date and detailed actions taken to reduce identified risks.
  • Leaders were visible and staff felt supported by them.
  • Staff described the culture as friendly and supportive and they were proud of the services they provided.
  • Leaders were supported to be innovative in the way they worked and were able to give examples of changes they made to improve services for patients such as an onsite blood laboratory and an onsite doppler service.

However,

  • Infection control training rates fell below the trust target, particularly for staff with patient contact roles.
  • The manometry room was not fit for purpose and required improvements to be made.
  • . The approach to documentation in records was not consistent between staff.
  • Nursing staffing numbers on the oasis unit did not take account of when mental health nurses were not available.
  • Performance on the national heart failure audit was poor in comparison the England average
  • There was access to diagnostic testing, but if this was required out of hours or at weekends, then patients were transported to other sites within the trust.
  • Bed occupancy rates were high at around 93% and there was sometimes a waiting list to access the oasis unit.
  • Although there were open and honest care boards detailing actions taken from patient feedback, there had been no local patient surveys carried out recently.

Urgent and emergency services (A&E)

Requires improvement

Updated 12 August 2016

  • Overall we judged  the department as ‘requires improvement’, because:
  • The department was not always able to achieve the correct number or the right skill mix of staff to meet patient need.
  • The department was not always able to ensure that staff with up to date training in resuscitation were provided.
  • Performance against the Royal College of Emergency Medicine (CEM) standard of patients being triaged within 15 minutes of arrival was poor.
  • There was limited measurement of the effectiveness of the treatment provided.

However, :

  • The department had a clear vision and strategy which was part of the divisional five year forward plan.
  • The department had performed consistently well in achieving the Department of Health target for 95% of patients to be seen, treated, discharged or admitted within 4 hours.
  • Care and treatment was delivered in line with evidence based practice and national guidance, such as those from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (CEM).

Surgery

Good

Updated 12 August 2016

Surgical services were judged as good because.

  • Systems were in place to ensure incidents were reported, investigated and lessons learnt.

  •  Patient’s risks were assessed to determine their fitness for surgery. Only lower risk patients were identified to proceed with surgical treatment at this hospital site.

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

  • We observed high levels of staff attendance at training sessions, 100% of day surgery nursing staff had completed mandatory training.

  • Consent processes were generally robust and documentation associated with these processes was adapted to the individual patient’s needs and understanding.

  • Medical and nursing staffing levels and skill mix was recognised as being safe and reflected current guidance.

  • There was good access and flow within the service and people’s needs were being met.

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

  • Staff were caring, compassionate and respectful. Staff were positive about working in the service and described a culture of flexibility and commitment.

  • The service was well led and a clear leadership structure was in place. Individual management of the different areas were well led.

However

  • Patient records on the day surgery unit were observed to be in an open top records trolley, which did not ensure their security.

  • Discussions with some staff showed that they did not understand the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards, which could affect the support they provided to patient groups.

Outpatients

Good

Updated 12 August 2016

We judged the outpatient and radiology services as good .

  • 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 this 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 there was evidence of good relationships between doctors and nurses and effective multi-disciplinary team working.
  • Referral to treatment times (RTT) and cancer waiting times were better than the England average, clinicians engaged with appointment booking staff to meet targets around RTT.
  • Leadership was effective in the OPD but not as good in the radiology department where there had been some recent changes in the management arrangements.

However

  • The did not attend (DNA) for appointment 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 , the trust was working to change this with pharmacy colleagues.
Other CQC inspections of services

Community & mental health inspection reports for Rochdale Infirmary can be found at The Pennine Acute Hospitals NHS Trust.