The Care Quality Commission
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  • NHS hospital

Wythenshawe Hospital

Overall: Requires improvement read more about inspection ratings

Southmoor Road, Manchester, Lancashire, M23 9LT (0161) 998 7070

Provided and run by:
Manchester University NHS Foundation Trust

Important: This service was previously managed by a different provider - see old profile

All Inspections

8 March 2023

During an inspection looking at part of the service

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Wythenshawe Hospital.

We inspected the maternity service at Wythenshawe Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The inspection was carried out using a pre-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.  

Following the site visit, we conducted interviews with senior leaders, specialist staff and stakeholders. We held focus groups for staff of all grades and roles and reviewed feedback from women and families about the trust. We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We analysed the results to identify themes and trends.  

Wythenshawe Hospital is 1 of 3 sites for maternity services for the trust. It comprises of a delivery suite with 12 birthing rooms, with 1 room with a birthing pool and adjacent maternity theatres. There are 3 high dependency rooms within the delivery suite. There are post and antenatal wards, an antenatal assessment unit and early pregnancy assessment unit. The service has a maternity triage unit. The service also has a fetal medicine unit which provides services to women and birthing people from across Greater Manchester and the Northwest region. There is an alongside midwifery led unit called Manchester Birth Centre with 5 birthing rooms. Ante and postnatal clinics are also provided at this location.

The local maternity population come from higher levels than deprivation than the national average with 30% in the most deprived decile compared to 14% nationally. A higher proportion of mothers were Asian or Asian British compared to the national averages. 

Our rating of this hospital ​went down​. We rated it as ​requires improvement​ because:

  • Our ratings of the maternity service changed the ratings for the hospital overall. We rated maternity services as ​inadequate​ in safe and requires improvement in well-led ​ and the hospital as ​requires improvement​.

We also inspected 2 other maternity services run by Manchester University NHS Foundation Trust. Our reports are here:

Saint Mary’s Hospital – https://www.cqc.org.uk/location/R0A05

North Manchester General Hospital – https://www.cqc.org.uk/location/R0A66

Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

2nd October - 8th November 2018

During a routine inspection

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

  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Staff kept themselves, equipment and the premises clean.
  • We saw evidence that staff prescribed, administered, recorded and stored medicines appropriately.
  • There were some outstanding example of staff caring for patients and their families, particularly in the critical care units and for patients receiving end of life care.
  • The services took account of most patients’ individual needs. For example, there were systems in place to support vulnerable patients within surgical services, including a ‘theatre buddy’ system, cognitive impairment trollies, communication aids and activity boxes.
  • The service planned and provided services in a way that met the needs of local people. People could mostly access the service when they needed it.
  • Managers across the services had the right skills and abilities to run a service providing high-quality sustainable care.
  • There was a positive culture across the hospital and most staff were positive about the leadership changes.

However:

  • Planned staffing levels were not consistently achieved particularly in the emergency department.
  • The hospital consistently failed to meet the standards for waiting times from referral to treatment and arrangements to admit, treat and discharge patients within four hours and the trust’s monthly median total time in the department for all patients was consistently longer than the England average.
  • The service did not always have sufficiently robust procedures in place to meet the needs of patients with additional support needs. We saw examples of where staff were not responsive to ensuring the patients’ needs were documented and followed.
  • Although, the service treated concerns and complaints seriously as well as investigating them, the response time to complaints was not timely and did not meet the trust’s policy.
  • Capacity assessments and Deprivation of Liberty Safeguard applications were not always fully completed particularly in medical wards and the emergency department.