The Care Quality Commission
  • Organisation
  • SERVICE PROVIDER

Tameside and Glossop Integrated Care NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

12 Mar to 11 Apr 2019

During a routine inspection

Our rating of the trust stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well-led as good. We rated eleven of the trust’s 12 services as good and one as outstanding. In rating the trust, we took into account the current ratings of the six services not inspected this time.
  • We rated well-led for the trust overall as good.
  • Since our last inspection, there had been improvement in the completion of mandatory training across the trust and the concerns raised within maternity services had been addressed.
  • There were enough staff with the right qualifications, competence, skill and experience, in most areas, to deliver care and treatment to meet patient’s needs.
  • Effective systems were in place to protect patients from abuse, manage patient risk and safety incidents and provide evidence-based care.
  • The trust controlled infection risk well. Equipment and premises were kept clean in most areas and there were systems and processes in place to prevent the spread of infection.
  • Staff cared for patients with compassion. Feedback from patients and most carers confirmed that staff treated them well and with kindness.
  • There had been significant work undertaken to prevent admission to hospital, support people in their homes and improve access and flow across the trust. There were demonstrable reductions in length of stay, a reduction in patient cancellations, reduction in long stay beds and evidence of admission avoidance.
  • Leaders were experienced and had the capability to make sure that a quality service was delivered and risks to performance were addressed. The executive and service level teams were delivering good operational performance as well as being focused on the development of the local integrated care system. There was evidence of compassionate, inclusive and effective leadership across the organisation.

However:

  • There were not enough children’s nurses and emergency paediatric consultants to deliver a consistent 24-hour paediatric emergency care service in line with national guidance (DH Facing the Future).
  • Within the Stamford Unit delivering community inpatient services, the therapy service was limited to five days a week; therapy staff did not feel they were able to offer rehabilitation as much as they wanted to.

12 Mar to 11 Apr 2019

During an inspection of Community health services for adults

This service has not previously been inspected. We rated it as outstanding because:

  • There were innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs. This enabled patients’ needs to be met in the community setting, and wherever possible avoided the need for admission to hospital.
  • The service planned and provided services in a way that met the needs of local people. Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them. Outcomes for people who use services were routinely monitored, were positive and some exceeded expectations.
  • People could access community health services when they needed them. We saw that waiting times to access services were significantly better than all national targets and most locally set targets.
  • Staff were consistent in supporting people to live healthier lives, including identifying those who need extra support, through a targeted and proactive approach to health promotion and prevention of ill-health, and they used every contact with people to do so.
  • There was compassionate, inclusive and effective leadership at all levels. Leaders at all levels demonstrate the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. All managers had a deep understanding of issues, challenges and priorities in their service.
  • There was strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences.
  • The trust used a systematic approach to continually improving the quality of its services, safeguarding high standards of care and worked with other organisations to improve care outcomes.
  • Services were developed with the full participation of those who use them, staff and external partners as equal partners. Innovative approaches were used to gather feedback from people who use services and the public.
  • The service made sure staff were competent for their roles, had received mandatory training and received their appraisal.
  • The service had effective systems and processes in place to protect patients from abuse, assess, control infection risk and respond to patient risk.
  • The service had received a low number of complaints. Staff knew how to deal with complaints and concerns and complaints were acknowledged, investigated and responded to in an appropriate and timely way.

However:

  • The risk register did not always provide documentary evidence risks had been reviewed.
  • Staff did not have access to pictorial aids to assist when caring for a patient with additional needs.
  • Not all staff had the recommended equipment to use when assessing a patient for sepsis.

12 Mar to 11 Apr 2019

During an inspection of Community end of life care

We rated it as good because:

  • The approach to end of life care was multidisciplinary with both internal and external parties and all worked together to support patients at the end of their lives.
  • Care was evidence based and the service benchmarked itself to other external providers to ensure best practice was always maintained.
  • End of life care services were planned, organised and delivered well.
  • Services were safe and well managed.
  • There was 24-hour cover for end of life services and processes in place to support more vulnerable patients and their families.
  • Care given was holistic and feedback from patients and their families described excellent care and treatment.
  • Patients and their families were truly respected and the nurse’s communication with the patients and their families was excellent. Staff were compassionate and caring and involved patients and their families in decisions about their care and treatment.
  • Consideration of privacy and dignity was consistently embedded in everything that the staff did and this was evident in the conversations we had with staff and observations taken on home visits.

12 Mar to 11 Apr 2019

During an inspection of Community health services for children, young people and families

We had not previously rated this service. We rated it as good because:

  • Community services for children, young people and families directorate provided staff with training in safety systems, processes and practices and staff had a high level of compliance in training. Training was monitored by local managers and by the trust and was conducted on induction and on a regular basis.
  • The trust had an in-date safeguarding policy and training modules which were available to all teams in the directorate. Staff had a high level of compliance with training and staff we talked to in the directorate knew the policy existed and knew how to apply it to protect children and families.
  • The trust had an infection prevention and control policy and training module, which was available to all teams in the directorate. Training rates were high and audits with good outcomes were undertaken by staff to ensure compliance.
  • The directorate reported no incidents classified as never events and no serious incidents in the period to December 2018. Incidents were reviewed and monitored.
  • The directorate used evidence based policies and national guidelines across its services, these included guidance from the Department of Health and the National Institute for Health and Care Excellence.
  • Staff in the directorate understood the relevant consent and decision-making requirements of legislation and how this related to young people such as guidance for Mental Capacity Act 2005, Children’s Acts 1989 and 2004, Gillick competence 1985.
  • Staff of all professions in the directorate acted with compassion and respect towards the patients and families. We observed staff talking to patients and carers continually about what was happening and providing re assurance.
  • Staff teams understood and met the needs of local people and had introduced systems so that staff deployment met the need of high and low population areas.
  • The staff in the directorate were aware of the diversity of populations and the challenges faced by some of its communities. Staff had access to multi-lingual sources such as translation services to support patient care.
  • The directorates leaders had the skills, knowledge and experience to guide and lead staff. management were respected, seen as supportive and effective in their roles.
  • Leaders in the trust and in the directorate had a vison for children and families’ services which focused on promoting well-being and nurturing. The service planned to move to a more holistic model of care which was connective with other services to promote well-being.

12 Mar to 11 Apr 2019

During an inspection of Community health inpatient services

We had not rated this service before. We rated it as good because:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service controlled infection risk well. Staff kept equipment and the premises clean. They used control measures to prevent the spread of infection.
  • The service had suitable premises and equipment and looked after them well.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff kept detailed records of patient’s care and treatment and the records were completed and managed appropriately.
  • The service has systems in place that ensured that medicines were administered and stored safely. Patients received the medicines they were prescribed in a safe manner.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service monitored safety using information from a range of sources. The information was monitored over a period, to feed into service improvement.
  • Patients care and treatment was planned, delivered and monitored in line with current evidence-based guidance, standards, best practice, legislation and technologies.
  • Staff ensured that they gave patients enough food and drink to meet their needs and improve their health.
  • Staff gave pain relief to patients when required. There was an effective process to ensure patients’ pain relief needs were met and pain was well managed by the service.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them.
  • Staff members were supported to deliver effective care and treatment through recruitment, training and development. There was a clear approach for supporting staff and managers appraised staff member’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Patients were supported to make decisions and, where appropriate, their mental capacity was assessed, recorded and acted on in line with relevant legislation.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • Staff tried to ensure that patients and those close to them were partners in decisions about their care and treatment.
  • The service planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • Patients could access the right care at the right time. Waiting times were minimal and managed in a manner that met patients’ needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose, based on shared values.
  • The trust used a systematic approach to continually improve the quality of its services.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them and coping with both the expected and unexpected.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The trust engaged well with staff to plan and manage appropriate services and collaborated with partner organisations effectively.
  • There was a positive focus on continuous learning and improvement for all staff. Staff members said they were supported to develop their professional skills and encouraged to shared good practice and identify innovation.

However:

  • The therapy service was not provided at the weekend at the time of inspection.
  • Therapy staff did not feel they were able to offer rehabilitation as much as they wanted to meet individual patient need.

8 – 11 August 2016

During a routine inspection

Tameside and Glossop Integrated Care NHS Foundation Trust is a major provider of hospital services in Tameside and Glossop, providing care to a population of approximately 250,000. Care was provided from a single acute hospital site situated in Ashton-under-Lyne.

In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce Keogh (the Medical Director for NHS England) as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures because there were concerns about the care of emergency patients and those whose condition might deteriorate. There were also concerns about staffing levels (particularly of senior medical staff at night and weekends), patients’ experiences of care and, more generally, that the trust board was too reliant on reassurance rather than explicit assurance about levels of care and safety.

We carried out a comprehensive inspection of the trust in 2014 and followed up our inspection findings in a focused inspection April 2015. As part of this inspection a number of improvements were recognised particularly in critical care.

However, in April 2015 we remained concerned in respect of the safety, effectiveness and responsiveness of  some services particularly in medical care (including frail elderly).

This inspection was a fully comprehensive inspection to ensure improvements had been continued and sustained.

We inspected Tameside and Glossop Integrated Care NHS Foundation Trust on 8-11 August 2016.

We inspected

  • Urgent and Emergency Care Services
  • Medical Care (including Frail Elderly)
  • Surgical Services
  • Critical Care Services
  • Maternity and Gynaecology
  • Children and Young Peoples Services
  • End of Life Care
  • Outpatient and Diagnostic Imaging Services.

Our key findings were as follows:

We were pleased to note that the trust had continued to make improvements in a number of key areas particularly in urgent and emergency care.

Good progress had been made that resulted in the ‘requires improvement’ rating for urgent and emergency care services being increased to ‘good’.

Vision and Leadership of the trust

  • The trust was led and managed by a stable, visible and accessible executive team. The senior team led the trust with a good focus on service quality and positive patient experience. Staff confirmed that it was commonplace to see the senior team and Chief Executive in the wards and departments.
  • The trust's aim was ‘to deliver, with our partners, safe, effective and personal care, which you can trust’. This was underpinned by a set of values and behaviours that were based on safety, care, respect, communication and learning.
  • The trust's aims, values and behaviours were well understood and adopted by all staff groups.

Culture within the trust

  • There was, in the main a very positive culture throughout the trust.
  • Staff of all grades were committed to the continuous improvement regarding the quality of care and treatment delivered to patients.
  • Staff felt comfortable and confident in respect of raising matters of concern. In addition staff felt that they could share ideas for improvement and innovation with managerial support.
  • There was a range of reward and recognition schemes that were valued by staff. Staff were supported to be proud of their service and celebrate achievements.

Governance and risk management

  • The trust's governance arrangements were centred on the divisional structure of services. Each division was managed by a triumvirate of manager, nurse and doctor. The triumvirates reported to the board through a committee structure.
  • Mechanisms were in place to ensure that committees were managed and reported appropriately so that performance was challenged and understood. There was challenge and scrutiny by non-executive directors in respect of quality and risk.
  • The Board Assurance Framework (BAF) was suitably aligned to strategic objectives and was linked appropriately to divisional risk registers.
  • There were divisional governance meetings where performance, risks and learning was discussed and shared. Staff had access to management information to support good performance which included trends and correlation of data to promote identification of poor performance and support timely action planning.

Mortality rates

  • Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by robust and well understood review and escalation procedures. All deaths were reviewed. Key learning points were cascaded to staff appropriately.
  • Lessons learned were disseminated through the divisional governance structure to enable appropriate actions to be embedded and learning from mortality reviews to be shared by divisional teams. The review of every death provided an assurance of quality care delivery and provided valuable information and learning regarding avoidable deaths.
  • The mortality review proforma incorporated recommendations and guidance from NHS England, PRISM2 study and the Mazars report (2015).
  • Monitoring arrangements were in place at board level to ensure that opportunities for learning and improvement were implemented.
  • The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The December 2014 to December 2015 SHMI of 115 was above the ‘expected’ level (100). The trust’s HSMR for the latest 12 month period (to February 2016) is 92.6. The trust investigated the reasons for the divergence in these indicators performance the action put in place were
  • A mortality review process of the care provided for all inpatient deaths.
  • A Trust Mortality Steering Group, where improvement is tracked through monthly performance monitoring and national benchmarking tools, are used to flag areas of concern.

Safeguarding

  • The trust had safeguarding policies and procedures in place which were readily available on the trust’s intranet site. Policies were supported by staff training. The trust had improved its performance with regards to adult safeguarding staff training, 98% of staff having received training in 2015-16 raising awareness.
  • The majority of staff were aware of how to refer a safeguarding issue to protect adults and children from suspected abuse.
  • Overall, safeguarding training was above the trust's target of 95% and across the trust averaged 98% for safeguarding adults and 99% for safeguarding children. However, there were departments within the trust where safeguarding children's training compliance levels were below the trust's target. These areas included medical and nurse staffing within A&E, the medical division and women's services.   
  • The trust had an internal safeguarding team who could provide guidance and support to staff in all areas. This team were easily accessible by telephone and email. During out of hours periods staff had access to senior nursing staff within the hospital management team to seek advice and guidance on safeguarding issues.
  • The team worked with staff, patients and families to develop plans of care in order to fully meet the patient's individual needs. This included support for people living with dementia, a learning disability, and autism spectrum conditions, patients with physical disabilities and patients with mental illness.

Nurse Staffing

  • Nurse staffing levels, although improved remained a challenge in a number of areas particularly in the medical directorate. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff.
  • Where possible, regular agency and bank staff were used which meant they were familiar with policies and procedures. Any new agency staff received an induction prior to working in the hospital.
  • We reviewed a report produced on the 27 April 2016. The report indicated that a number of wards in the medical directorate were below 80% staff fill rates for qualified day staff. The report highlighted issues in ward 41, 44 and 46 where qualified nurse fill rates were between 79% to 74%. This was escalated to board level and in the the safer staffing report of July 2016 it was noted that getting the correct numbers of nurses, midwives and healthcare assistants in place was essential for the delivery of safe and effective patient care and the chief nurse was providing scrutiny, leadership and oversight of this essential area of quality and safety.
  • The trust was actively recruiting nationally to address the nursing vacancy rates currently at 89% for day staff and 98% for night staff (June 2016) .
  • The trust was working with other agencies to fill rota gaps to maximise nurse staffing capacity. Never the less, there were times when wards were not fully staffed.

Midwifery Staffing

  • A review of midwifery staffing numbers had been undertaken in January 2016 using birth-rate plus criteria and calculation tool, in line with the NICE guidance for Safe Midwifery Staffing for Maternity Settings (NICE, 2015). This identified a growing number of births with impact on the required number of midwives which was to be monitored via the maternity dashboard.
  • We saw when midwife numbers were below those planned for a shift additional staff were sourced and put in place. The labour ward coordinator was responsible for monitoring any shortage of staff and capacity issues.
  • Recruitment of midwives was not difficult for the trust. 13 midwives which represented 9.7 whole time equivalent midwives had been recruited to start work between August and October 2016. This would meet the vacancy rate of 9.8 full time posts.
  • The midwife to birth ratio had been 1:30 in June but had improved to 1:28 with new midwives starting employment.
  • We were told one to one care in labour was achieved.
  • Two midwives were on call to assist at any home births out of hours.
  • A new manager for the community midwives had been appointed in June 2016. The current systems of working were under review and a new model was being considered.
  • Community midwives and the community midwife manager were unable to tell us how many patients they had on their caseload. Therefore there was no management of the equity or suitability of the size of community caseload. During the inspection one midwife had accepted seven visits which they could not complete. Managers were aware of this and a scoping exercise to address it had begun.
  • There was a midwife from the enhanced team based in the hospital Monday to Friday 9am to 5pm and one on call in the community. Out of these hours safeguarding support was provided by the on call supervisor or the children’s safeguarding team.

Medical Staffing

  • The proportion of middle career doctors and junior doctors within the trust was greater than the England average. The proportion of consultants was below the England average (37% compared with the England average of 42%). The proportion of registrars was also below the England average (27% compared with the England average of 36%).
  • These figures were an improvement from last year and the urgent and emergency care department had slightly above the England average number of consultants. The trust continued to work with other trusts to look at innovative ways to recruit and retain staff, including overseas recruitment and talent management. At the time of our inspection in surgical services there were appropriate numbers of medical staff to meet the needs of patients.

Cleanliness and infection control

  • Clinical areas at the point of care were visibly clean, the trust had infection prevention, and control policies in place that were accessible to staff and staff were knowledgeable about their role in controlling and preventing infection.
  • Staff followed good practice guidance in relation to the control and prevention of infection in accordance with established trust policies and procedures.

Competent Staff

  • Newly appointed staff had an induction for up to four weeks and their competency was assessed before working unsupervised. Agency and locum staff also had inductions before starting work.
  • Practice educators that oversaw training processes and carried out competency assessments based on national competency guidelines.
  • Staff told us they routinely received supervision and annual appraisals. Records up to June 2016 showed the appraisal rate was 95.6%. This showed the majority of staff had completed their annual appraisals and the hospital’s internal target of 90% appraisal completion was achieved across all
  • The nursing and medical staff we spoke with were positive about on-the-job learning and development opportunities and told us they were supported well by their line management.

We saw several areas of outstanding practice including:

  • The main Hartshead building was designed with input from a disabled patient user group. Access to the building was good with clear signposting. There was a team of volunteers that provided mobility scooters by request and supervised their use throughout the hospital so patients with mobility difficulties could move through the site easily.
  • The radiology department offered a “Virtopsy Service”. This virtual post-mortem service was used when a CT scan could determine the cause of death. This speeded up the process of determining cause of death and respected the religious and cultural needs of some of the local population. Scans were carried out at night and reporters were experts in reporting on virtual post-mortems. Deceased persons were transported to the unit via a private corridor. The trust was one of the first in the North West to offer this service.

However, there were also areas of practice where the trust must make improvements.

Importantly, the trust MUST:

Urgent care

  • Ensure that patients can access emergency care in a timely way.
  • Ensure all staff receive mandatory training at the required level and within the appropriate time frame.
  • Ensure that fridges used to store medications are kept at the required temperatures and checks are completed on these fridges as per the trust's own policy.

Medical Services Including Older People

  • Ensure there are appropriate numbers of nursing staff deployed to meet the needs of patients

Children and Young People

  • Ensure all equipment used to provide care or treatment to a service user is properly maintained.
  • Ensure that there is one nurse on duty on the children’s ward trained and up to date in Advanced Paediatric Life Support on each shift.

In addition the trust SHOULD:

Urgent and emergency care

  • Ensure that staff receive their annual appraisal.

Medical services including Older people

  • Ensure children’s safeguarding training across all professions within the medical directorate is up to date.
  • Look to reduce the number of medical patients being cared for on surgical wards.
  • Continue to monitor staffing arrangements on wards.

Surgical Services

  • Take appropriate actions to improve mandatory training compliance rates.
  • Take appropriate actions to reduce the number of cancelled elective operations.

Maternity and gynaecology

  • Ensure the improvements in the infection prevention and control measures and the environment on ward 27 should continue.
  • Emergency medicines should be safely stored in the obstetric theatre in line with trust’s policy for the safe use of emergency medicines.
  • Records should be securely stored in the ward areas.
  • Appropriate actions should be taken to improve the mandatory training compliance rates for infection control and children's safeguarding.
  • Ensure that a deteriorating patient’s care was managed in line with the trust’s policy.
  • Continue to make improvements in the completion of the safer surgery checklists.
  • Develop a system to ensure patients received required home visits by the community midwives.

Children and Young People

  • Ensure recording of fridge checks include the maximum and minimum temperatures in accordance with national guidance.
  • Ensure dates of cleaning and safety checks are legible on equipment.
  • Review documentation for infants when intervention is reduced to high dependency or special care.
  • Ensure the security and confidentiality of medical records in the paediatric outpatients department.
  • Ensure PEWS documentation is completed and audited to improve compliance.
  • Ensure the neonatal unit consistently collect patient feedback using the NHS Friends and Family Test.
  • Ensure inpatient discharge summaries and outpatient clinic letters are sent in a timely way.
  • Ensure regular staff meetings take place on the neonatal unit.

End of life care

  • Consider how it can increase uptake of the use of the individual care plan for end of life care patients.
  • Consider how it can encourage improvement in the accuracy and completeness of DNACPR forms, including the undertaking and recording of mental capacity act assessments, the recording of best interests decisions, and discussions with patients and their relatives.
  • Consider reviewing information held within the palliative rapid discharge link nurse files held in wards and units across the trust to ensure the information held is accurate, up to date, and in line with prescribing and dosage guidelines for anticipatory medicines.
  • Consider what actions it could take to further increase the proportion of end of life care patients dying in their preferred place of care.
  • Consider what actions it can take, within its control and where requested, to increase the percentage of end of life care patients discharged within the timescales of the rapid and fast discharge process.

Outpatients and Diagnostics

  • Continue the active recruitment of radiologists to meet actual WTE requirements and maintain safe staffing levels.
  • Resolve the issue of allied health professionals being unable to accurately record mandatory training levels.
  • Carry out an infection control risk review of positioning aids foam pads in radiology, to ensure that the risk of infection is minimised.
  • Ensure that all entries on patient notes are signed and dated.
  • Continue to increase the numbers of staff who have undertaken children's safeguarding training to meet trust targets.
  • Review version controls on Local Rules for Radiation Protection and ensure that all staff have signed them to indicate that they have read and understood them.
  • Continue to seek a solution to the lack of an electronic system that interfaces with local GP surgeries.
  • Continue to seek viable solutions to reduce “Did Not Attend” (DNA) rates.
  • Continue to seek solutions to improve “Referral to Treatment” (RTT) times so that all clinical pathways met national standards.
  • Review the consultation room in clinic nine where the door opens outwards to improve privacy and dignity for patients.
  • Review the children’s play area in outpatients' clinics six to nine to see whether this could be better located or children observed and kept safer.
  • Improve patient knowledge of how to access PALS should they need to do so.

Professor Sir Mike Richards

Chief Inspector of Hospitals

8 – 11 August 2016

During an inspection of Community health inpatient services

The Stamford Unit at Darnton House had only recently opened for patient use and therefore we were unable to gain sufficient information to provide a rating for this service. In summary we found that:

  • The ward area was fit for purpose, clean and spacious.

  • Incidents were reported through effective systems and lessons learnt or improvements made following investigations were shared.

  • Staff followed good hygiene practices and there were good systems for handling and disposing of waste.

  • There was evidence of multidisciplinary team working with regular meetings held to review patients' ongoing needs.

  • Staff had access to information they required, for example diagnostic tests and risk assessments.

  • Best practice guidance in relation to care and treatment was followed.

  • The service was planning to participate in local audits in the near future.

  • The care provided by the service was patient centred and patients were involved in their care and planning individual goals.

  • Patients were observed receiving compassionate care and their privacy and dignity were maintained.

However:

  • Staffing levels were not always sufficient and there was a high reliance on bank and agency staff members. Recruitment was ongoing to fill current vacancies.

  • Patients' records were not completed contemporaneously in all cases.

  • There were not sufficient processes and systems in place to manage patients who had a do not attempt cardio pulmonary resuscitation order in place.

  • Patients' choices in relation to their resuscitation status were not taken into account and were not always respected.

  • Staff were not aware of their role and responsibilities around the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards.

28 - 29 April 2015

During an inspection looking at part of the service

Tameside Hospital NHS Foundation Trust is a major provider of hospital services in Tameside and Glossop, providing care to a population of approximately 250,000. Care was provided from a single acute hospital site situated in Ashton–under-Lyne.

In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce Keogh (the Medical Director for NHS England) as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures because there were concerns about the care of emergency patients and those whose condition might deteriorate. There were also concerns about staffing levels (particularly of senior medical staff at night and weekends), patients’ experiences of care and, more generally, that the trust board was too reliant on reassurance rather than explicit assurance about levels of care and safety.

The trust was inspected by CQC under its comprehensive methodology in April 2014. Significant concerns remained over the trust’s ability to assure safe services and to respond to people’s needs. CQC was specifically concerned about the critical care services, but also about medical care, surgical and outpatient services. In publishing our report in July 2014; we recommended the trust remain in special measures and be reviewed within 12 months.

This inspection was designed to review that position.

We inspected Tameside NHS FT on 28-29 April 2015.

We inspected

  • Urgent and Emergency Care Services
  • Medical Care (including Frail Elderly)
  • Surgical Services
  • Critical Care Services.
  • Outpatient and Diagnostic Imaging Services.

During our 2014 inspection we rated critical care as ‘Inadequate’, medical care and outpatient services as ‘Requires Improvement’ with inadequate ratings within them, and surgery as ‘Requires Improvement’ for four of the five domains.

In our 2014 inspection we rated urgent and emergency care services as good; but since that visit the CQC A&E survey showed the services as having the worst response in the country. We visited this service during this inspection to understand the reason for this change and to provide an assurance on the current position.

At our previous inspection, maternity and children’s services achieved a ‘Good’ rating and were not reviewed this time. We saw no evidence during our inspection to challenge our decision on this.

Our key findings were as follows:

  • We found that Tameside NHS FT has made significant progress in all the areas we identified in our 2014 inspection visit.
  • We were particularly impressed with the level of progress in critical care services which have now moved from an Inadequate rating to a Good rating.
  • Overall the trust has made excellent progress in dealing with governance and complaints. The evidence we reviewed suggested that the trust was improving their response to these issues in a better and more sustainable way.
  • We saw a strong culture of patients and safety first.
  • There were a number of issues we identified in the safe domain (medication checks and safeguarding); in the effective domain (improved outcomes against national benchmarks) and the responsive domain (improved compliance on access targets) where additional progress was required; however it is our view this is entirely in the trust’s grasp and additional progress is already being made. We can see the systems the trust has in place will support this progress.
  • Overall, the concerns we had in our 2014 visit were being resolved and the organisation was in a stronger position.

We saw several areas of outstanding practice including:

  • The trust has made significant progress in duty of candour. It shares external reviews of incidents with patients; it encourages (and trains) its staff in difficult conversations. The trust demonstrates both the fundamental principles but also the underlying values of duty of candour.
  • There had been a strong leadership response from the trust executive and senior management team to the issues we identified last year and saw significant progress.
  • There was an enhanced culture of “this is how we do things round here now” and “the Tameside journey”; both of these engaged staff and have contributed to sustainable improvement.
  • There was clear staff ownership of their future in the trust and engagement in the trust values and vision.
  • There were good responses to patients’ needs such as moving ward rounds to slightly later in the day to allow nursing staff to complete patients’ personal care needs before clinical care rounds began.

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

Importantly, the trust must:

  • Ensure that medical staffing is sufficient and appropriate to meet the needs of patients at all times including out of hours.
  • Improve patient flow throughout the hospital to reduce the number of patients transferred at night and ensure timely access to the service best suited to meet the patient’s needs, particularly in A&E and medical care services.
  • Improve the completion levels of mandatory training and appraisals for nursing and medical staff.
  • Ensure that medicines, particularly controlled drugs are stored, checked and disposed of in line with best practice in all areas but particularly in A&E and Outpatients.

For a list of the actions the trust SHOULD take please see the location report for Tameside General Hospital.

Professor Sir Mike Richards

Chief Inspector of Hospitals

7, 8, 13, 16 and 17 May 2014

During a routine inspection

In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce Keogh (the Medical Director for NHS England) as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures because there were concerns about the care of emergency patients and those whose condition might deteriorate. There were also concerns about staffing levels (particularly of senior medical staff at night and weekends), patients’ experiences of care and, more generally, that the Trust Board was too reliant on reassurance rather than explicit assurance about levels of care and safety.

We inspected Tameside NHS Foundation Trust in May 2014 and visited the trust on five separate days both announced and unannounced visits.

The announced visits were 7 and 8 May and the unannounced visits were 13, 16 and 17 May 2014.

This was a full comprehensive inspection.

The inspection team inspected the following core services :

  • Accident and Emergency (A&E)
  • Medical care (including older people’s care)
  • Surgery
  • Intensive / Critical care
  • Maternity and Family Planning
  • Children and young people’s care
  • End of life care
  • Outpatients

This inspection was a comprehensive inspection, which took note of the previous inspection in January 2014, to monitor the trust’s improvements in meeting the regulations.

We saw Tameside trust at an early point on their journey of improvement. The Trust is showing its ability to respond to and manage the improvement challenges it faces. The ratings and this report reflect the early stages in this journey. The trust service managers and executive teams are working strongly together to address the issues already raised in this report.

We saw good leadership from the new executive team. We saw that the executive team were beginning to exert strong processes with the organisation and manage systems.

We saw that the executive team were beginning to create a strong culture within the trust. We heard from staff in the focus groups of their ability to see change within the trust leadership and of their recognition of a stronger future for the trust.

We also saw some areas of good leadership in some clinical services, with the formation of a good culture.

However whilst we saw that there was a growing opportunity for change and improvement, overall we found that the services provided by the trust were inadequate.

Our key findings were as follows:

  • We found a service improved from the assessment made at the time of the Keogh Review
  • We found that caring was good across all areas of the organisation.
  • We found staff to be committed to making improvements.
  • We found a strong and visible Executive Team providing leadership to the organisation and driving delivery of the improvement plan.
  • We found that A&E, maternity services and childrens/young people’s services were good.
  • We found that critical care services were inadequate including: lack of availability of national audit (ICNARC) data, incident reporting and feedback, record keeping, equipment and patient monitoring.
  • We found that parts of medical care services required improvement were including: aspects of medication processes, record keeping and medical staffing.
  • We found some elements of surgical care requires improvement including monitoring and management of preoperative patients.
  • Despite many improvements already made we found that elements of outpatient care required improvement including clinic organisation and efficiency of booking processes. The implementation of the new Lorenzo record system was of most concern.

We saw several areas of outstanding practice including:

  • The children’s unit development that included significant user and community involvement in its design.
  • The trust had an outside garden area for patients which was dementia-friendly.
  • The trust welcomed visits by patient groups, such as Healthwatch or Tameside Hospital Action Group, to see for themselves how the hospital was performing.
  • Patients were assessed regarding their rehabilitation needs and the physiotherapy team were available seven days a week to contribute to meeting the goals for each patient’s recovery. The physiotherapy team was led by a consultant in physiotherapy so that a senior person was available regarding complex issues.
  • One of the hospital’s community midwives had recently won the British Journal of Midwifery’s Community Midwife of the Year Award. This midwife had been recognised for recently supporting four women with cancer during their pregnancies and reportedly, “Continually goes that extra mile to support women and their families”, said the head of midwifery.
  • In 2012, the maternity unit launched a fundraising campaign called the Bright Start appeal. This highly successful campaign had funded the development of the birthing pool room and would fund the future development of the midwifery-led birth room.
  • The maternity service actively participated in national research and audit projects. This included: “The Healthy Eating and Lifestyle in Pregnancy Study” which was being undertaken with Cardiff University and Slimming World; “The Building Blocks: A trial of Home Visits for first time mothers” in partnership with University Hospital South Manchester and “The Bumpes Trial” which was being undertaken by the University College London.
  • The facilities for bereaved parents included a private room, garden and en suite bathroom. The room contained a television, lounge, kitchen and hot beverage facilities. A midwife, usually bereavement trained, was allocated to the family whilst in hospital. After being discharged from hospital, the nurse visited the family at home or contacted them by telephone. The trust held an annual forget-me-not remembrance service.
  • The maternity service had developed a teenage pregnancy reduction initiative in response to local need which had a positive impact in reducing the number of teenagers who were expecting their second child. The trust appointed a specialist teenage pregnancy midwife, created a more teen friendly environment, improved the continuity of care from staff.
  • The trust worked creatively with commissioners and other trusts to plan new ways of meeting the needs of children and young people. Together, they developed integrated pathways of care, particularly for children and young people with multiple or complex needs.
  • The trust had a dedicated children’s safeguarding team which evidenced proactive outreach programmes and service adaptations aimed at meeting the needs of people in vulnerable circumstances.
  • The trust developed an observation and assessment unit and community nursing team for children and young people, which significantly reduced hospital admissions and accident and emergency department attendance.
  • The trust raised the profile of end of life care by appointing an end of life care facilitator who worked with other staff and external agencies to implement best practice in the mortuary and chaplaincy service, improve care on the wards and facilitate rapid discharge.
  • The trust had adapted the equipment used for transporting deceased patients to resemble an empty bed. This was discreet and made for a dignified journey through the hospital to the mortuary.
  • The trust had three syringe drivers available for the sole purpose of facilitating a rapid discharge for any patient who required this equipment, which was normally supplied by community services.
  • The trust’s paediatric outpatient department provided a stimulating and interesting environment in the waiting, consultation and treatment areas. This environment had been designed as a result of consultation with a local primary school so that it appealed to children and young people. This included small details, such as a glass cabinet in the reception desk where a toy replica of a hospital was placed to reduce the boredom of children when they were waiting at the desk.
  • The trust had an electronic system for logging and identifying patient records, which resulted in improved access to records for outpatient clinics.

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

Importantly, the trust must:

  • ensure there are at all times, enough appropriately skilled staff in all areas or on call to meet people's needs.
  • take action to ensure that care and treatment reflects published research evidence and guidance issued by the appropriate professional and expert bodies.
  • take action to ensure staff are adequately trained and regularly appraised.
  • take action to ensure they adequately safeguard patient information.
  • take action to ensure that staff continue to report and learn from incidents.
  • take action to ensure that they learn from complaints and concerns.
  • take action to ensure that suitable infection prevention and control measures are in place, to reduce the number of surgical site infections.
  • take action to ensure that they appropriately prioritise patients waiting for surgery.
  • take action to ensure that they seek and have regard for appropriate professional and expert advice when planning their critical care services.

In addition the trust should:

  • ensure that they regularly update policies and procedures.
  • ensure there is a robust system for disseminating information, such as learning from complaints or incidents, amongst all staff.
  • ensure they share accurate information in a timely way with patients or people acting on their behalf.
  • ensure there are robust systems in place to safeguard staff who handle patient records against workplace injury.
  • ensure they adequately monitor the quality of their bed management.
  • consider how they work together with the local community to facilitate safe and prompt discharges.
  • consider how they promote patient engagement methods, such as the inpatient survey or the Friends and Family Test, in wards or units with low response rates, such as the day case or endoscopy unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.