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Manor Hospital Requires improvement

The rating for ‘Maternity and gynaecology’ shown on this page does not reflect our latest judgement of services at Manor Hospital. We now inspect maternity and gynaecology services separately.

At our latest inspection, in June 2018, we rated the maternity services as requires improvement. We did not inspect the gynaecology services.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 20 December 2017

Walsall Healthcare NHS Trust provides acute hospital and community health services for people living in Walsall and the surrounding areas. The trust serves a population of around 270,000 people. Acute hospital services are provided from one site, Manor Hospital, which has 550 acute beds. There is a separate midwifery led birthing unit and a specialist palliative care centre in the community.

The trust is currently in special measures, as we wanted to ensure services found to be providing inadequate care at the trust did not continue to do so. The trust went into special measures in February 2016 following our announced comprehensive inspection on 8 to 10 September 2015. We also carried out three unannounced inspection visits after the announced visit on 13, 20 and 24 September 2015.

Following the 2015 inspection, we rated this trust as ‘inadequate’. We made judgements about 11 services across the trust as well as making judgements about the five key questions we ask. We rated the key questions for safety, effective and well led as ‘inadequate’. We rated the key questions, for caring and responsive as 'requires improvement’.

After the inspection period ended, the Care Quality Commission served the trust with a Section 29a Warning Notice, Health and Social Care Act 2008 which wholly related to concerns within maternity services.

The Section 29a Warning Notice set out the points of concern and timescales to address this. The trust responded to this with a detailed plan for remedial action. We have received weekly maternity information from the trust which has showed significant improvements relating to all concerns outlined in the Section 29a Warning Notice.

We undertook an unannounced inspection on 31 May 2017 where we inspected community services for adults, children and young people, and end of life care. On the day of the unannounced inspection, we announced to the trust we would be returning for a short notice announced inspection on 20 to 22 June 2017. We conducted unannounced visits to eight hospital services to include; emergency department, medical services, surgery services, critical care services, maternity services, children and young people services, end of life services and outpatients and diagnostic services. The inspection team included CQC inspectors and clinical experts.

We held focus groups with a range of staff in the hospital and community before and during the inspection. These included consultants, junior doctors, midwives, nurses, student nurses, healthcare assistants, administrative and clerical staff, and community staff. We also analysed data we already held about the trust to inform our inspection planning.

We have rated this hospital as requires improvement. We made judgements about eight services across the hospital as well as making judgements about the five key questions we ask. We rated the key questions for safety, effective, responsive, and well led as requires improvement. We rated the key question for caring as good.

At this inspection, we saw some significant improvements in ratings for all acute services at Manor Hospital with the exception of maternity and gynaecology services.

In our previous inspection, we rated urgent and emergency services as inadequate however, we saw improvements had been made throughout this service and this was rated as requires improvement.

In our previous inspection, we rated medical care, surgery, critical care, services for children, young people end of life care, outpatients and diagnostic imaging as requires improvement.

In this inspection, we saw all of these services apart from critical care, had significantly improved and we rated them all as good. Critical care remains as requires improvement.

We rated Walsall Manor Hospital as requires improvement overall.

Our key findings as follows:

  • The trust did not meet its target compliance rate of 90% for mandatory training.
  • Compliance rates within adult and children’s safeguarding training was low.
  • Areas we identified during our last inspection (2015) such as staffing levels and training continued to remain a concern. However, we saw that the trust was being proactive in trying to address these.
  • Staff inconsistently completed trust documentation in patient records. We observed inconsistencies throughout the records with staff initials, signatures, and job roles. Not all entries were legible.
  • Staff were not always managing deteriorating patients appropriately.
  • Many guidelines remained out-of-date following our last inspection.
  • Serious incident action plans were not always monitored or completed.
  • The senior leadership team in maternity was in its infancy and there had been little oversight of governance and incidents at a senior level.
  • The ED dementia lead nurse had contributed to significant staff awareness and understanding of the needs of patients living with dementia.
  • Staff were knowledgeable about consent and mental capacity. Consent for treatment was obtained appropriately and in line with legislation and guidance.
  • Multi-Disciplinary Team (MDT) working was effective.

We saw several areas of outstanding practice including:

Urgent and Emergency Services

  • Staff and patients’ relatives all told us the ED dementia lead nurse was making significant improvements for patients living with dementia.
  • Staff told us about a seriously ill patient who had arrived into the department by ambulance a few days before their son’s wedding. Because there was a danger the patient may not have lived long enough to attend the wedding, staff made arrangements for a small wedding ceremony to take place in the department’s relatives’ room, to allow the patient to see their son married.

End of Life Care

  • The service provided access to care and treatment in both the acute and the community settings 24-hours a day, seven days a week.

Outpatients and diagnostic imaging

  • Outpatients and diagnostic imaging staff had made significant progress since the previous inspection in November 2015. The culture in the outpatients department had changed considerably for the better, with local staff taking responsibility and ownership for their own areas and specialities.
  • Development opportunities amongst junior nursing and care staff were very good across outpatients. Senior nurses had recognised the limited opportunities for promotion, therefore had put measures in place to develop staff within their current roles. For example, the staff nurses now undertook auditing in each other’s areas and formulated action plans together. These were the responsibility of the staff nurses to ensure improvements and take ownership of problems and solutions.

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

Importantly, the trust must:

Maternity and Gynaecology

  • Ensure all staff have completed the required level of safeguarding training.
  • Ensure the governance of the service is improved.
  • Ensure risks are explained when consenting women for procedures.
  • Ensure the service uses an acuity tool to evidence safe staffing.
  • Ensure the service promotes a no blame culture.
  • Ensure that action plans are monitored and managed for serious incidents.
  • Ensure that lessons are disseminated effectively to enable staffing learning from serious incidents, and incidents.
  • Ensure staff follow best practice national guidance.

Urgent and Emergency Services

  • The trust must take action to improve ED staff’s compliance with mandatory training.

Critical care

  • The trust must ensure that plans are in place for staff within the critical care unit to complete mandatory training. This includes appropriate levels of safeguarding training.
  • The trust must ensure any staff working within the outreach team are competent to do so.

Medical care

  • The provider must ensure mandatory training is up-to-date including safeguarding training at the required level.
  • The provider must ensure there are sufficient numbers of suitably qualified, competent, skilled, and experienced staff to keep patients safe.


  • The service must ensure that all professional staff working with children have safeguarding level 3 training.
  • The service must ensure that all staff are up to date with safeguarding adults.
  • The service must ensure that patient records are completed, that entries are legible and each entry is signed, dated with staff names and job role printed.
  • The service must ensure that all shifts have the correct skill for wards to run safely.
  • The service must ensure that all staff are up-to-date with mandatory training.

Children and young people

  • All local guidelines are updated and regularly reviewed for staff to follow.

End of life care

  • Ensure attendance for mandatory training is improved.
  • To undertake required safeguarding training as required for their individual role.
  • All staff are trained and competent when administering medications via syringe driver.
  • All staff must complete end of life documentation where appropriate.

Outpatients & diagnostic imaging

  • Staff undertake required mandatory and safeguarding training as required for their role.
  • Staff within outpatients have the required competencies to effectively care for patients, and evidence of competence is documented.
  • All staff received an appraisal in line with local policy.
  • Staff keep patients’ medical records secure at all times.
  • All outpatient clinics are suitable for their purpose.

In addition the trust should:

Maternity and Gynaecology

  • Staff are compliant with the Mental Capacity Act (2005) and Deprivation of Liberty


  • There is a consultant obstetrician as the designated guideline development lead.
  • Staff read and sign newly launched guidelines in a timely manner.
  • Staff opinion is sought when developing the service.
  • Complaint information is displayed appropriately.
  • There are chaperone signs in outpatient areas.
  • There are available appointments for women to access the clinic for vaginal birth after caesarean.
  • Women do not have long waits to be discharged from the fetal assessment unit.
  • Women are informed and involved in the planning of their care.
  • Women are supported during their stay.
  • Pain relief is given as prescribed or when requested.
  • Documentation is completed and audited.
  • Handovers follow a Situation Background Assessment Review (SBAR).
  • The service had an alternative plan in place based on the NHS England March 2017 national guidance advocating for education and quality improvement (A-EQUIP).
  • Student midwives are not practising unsupervised.
  • There is a robust data collection system.
  • The stillbirth rate is reviewed and an action plan developed.
  • The dashboard data is reviewed and action plans are monitored and reviewed.
  • Breast milk fridge is locked.
  • Women are offered breast feeding support.
  • Scans are uploaded to the electronic database.
  • All cardiotocography machines have the correct time.
  • Staff know their role in a major incident.
  • Staff complete major incident training in line with the trust target.
  • VTE risk assessments are completed.
  • Prescription charts are fully completed.
  • Women’s antenatal handheld records are fully completed.
  • All the areas of the electronic computer system are completed.
  • Medical records are stored safely.
  • Invasive treatments to babies are performed in a private environment respecting privacy and dignity of the baby.
  • Environmental audit results are monitored and actions to improve.
  • All areas are visibly clean.
  • Audits of surgical infections are performed.
  • An audit programme is developed and presented to the service.
  • Low harm incidents are reviewed in a timely manner.
  • Gynaecology staff complete the adult resuscitation training.

Urgent and Emergency Services

  • Ensure its nominated ED triage nurse is clearly identifiable to ambulance staff.
  • Risk assess and re-evaluate its use of a cubicle as an ED review room.
  • Reassess its policy for the use of review rooms in ED, ensure all staff are aware of, and adhere to the process.
  • Take action to ensure no confidential conversations between doctors, patients or their representatives take place in the ED review rooms, if there is a chance they could be overheard by other patients or visitors.

  • Raise awareness of its chaplaincy service amongst its ED staff and ensure patients and relatives who may benefit from it are made aware of it.
  • Ensure ED is able to offer written information to patients in languages other than English.
  • Review its decision-making process around using RAT cubicles in ED to accommodate patients in time of increased demand, rather than ring fencing the cubicles to allow the RAT team to contribute to ED patient flow.
  • Continue to improve its staff appraisal completion rates.

Critical care

  • Review systems to improve flow throughout the hospital to reduce the number of delayed discharges in critical care.
  • Provide follow up clinics to patients after discharge from the critical care unit in line with Core Standards for Intensive Care.
  • Consider how to effectively identify and manage all infectious patients in the critical care wards given the lack of appropriate isolation facilities.
  • Essential equipment is procured and used with relevant patients; and staff are fully trained and competent to use this equipment, for example, capnographs.
  • All risks to the service are included on the risk register.
  • Deprivation of Liberty Safeguards are applied in all cases where these are required; for example restricting patients movements by use of bed rails.

Medical care

  • Medication trolleys are adequate for medications stored.
  • Computers are password protected to protect against unauthorised access and that these are not left unlocked.
  • Patients have access to call bells at all times and that all call bells can be heard by staff and used to signify an emergency.
  • Review the nursing documentation to ensure it is fit for purpose and that risks, such as falls are regularly reassessed and recorded.
  • Staff on wards have sufficient knowledge to care safely for neutropenic patients, including knowledge of neutropenic sepsis.
  • Ensure that patient’s nutritional needs are assessed and reviewed in accordance with current guidance.
  • All staff are up-to-date with their appraisals.
  • Sufficient staff trained in administering medication via a peripherally inserted central catheter line.
  • Medical records are kept secure and that information contained within is kept safe.
  • Fire exit on ward 29 is alarmed to alert staff if a patient leaves the ward.


  • Cleaning rota responsibilities are completed and documented on all wards.
  • Razors and COSHH items are stored appropriately, securely and in places where people who use services are not able to access.
  • That it is easy to see what contents should be available in the paediatric difficult intubation trolley in the surgical recovery area.
  • Intravenous fluids and other fluid items, such as nutritional drinks, are stored in a locked place and are not accessible to the public on ward 10.
  • Fridge and room temperature checks’ monthly audits are carried out and recorded consistently across all wards.
  • Controlled drug checks’ monthly audits are carried out and recorded consistently across all wards.
  • Streamlining their processes for patient records. There are a number of different formats and systems for one patient record, which can cause confusion and has a potential risk of staff not having all relevant information when treating patients.
  • Continue with improvements in performance of patient outcomes.
  • Continue with improvements in performance of referral to treatment times and patient flow through the hospital.
  • Continue with improvements in managing deteriorating patients.
  • Continue with improvement plans for IT software to ensure full compliance with the Accessible Information Standards.
  • Continue to do all it can to resolve the issues with recruitment to improve staff morale.
  • Consider reviewing the developmental opportunities available for junior physiotherapists.

Children and Young People’s Services

  • Review the system for recording safeguarding training and assure themselves that clinical staff in children’s services complete safeguarding children training to level 3.
  • The trust should review and update local clinical guidelines for children’s services and ensure they are based on national guidance and best practice.
  • Introduce a systematic approach to assessing and monitoring children’s nutritional and hydration risks.
  • Review the environment within the fracture clinic and make improvements to meet the needs of children using the service.
  • Implement systems and processes to identify those with a learning disability and ensure adjustments are made to cater for their special needs.
  • Improve the timeliness of provision of medicines for children to take home.

End of life care

  • Look for ways to improve privacy on the wards/department when breaking bad news or consoling bereaved families.
  • Ensure staff including porters are clear on who is responsible for cleaning trolleys when

transferring patients from one department to another.

  • Look for ways to support the porters with equipment such as trolleys that are not always suitable to use but have no other option but to use.

Outpatient and diagnostic imaging

  • There is a robust system in place for monitoring clinic running times to ensure they are running to time on a consistent basis, and take action where this is not the case

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 20 December 2017


Requires improvement

Updated 20 December 2017



Updated 20 December 2017


Requires improvement

Updated 20 December 2017


Requires improvement

Updated 20 December 2017

Checks on specific services

Medical care (including older people’s care)


Updated 20 December 2017

We rated this service as good because:

  • Senior managers were being proactive in solving difficulties with nursing recruitment.

  • Staff had undertaken projects to look at areas for improvement and to determine what actions were needed to drive improvement forward.

  • Staff were aware of how to report incidents and were encouraged to do so. Senior staff shared learning in unit and divisional meetings.

  • We saw some good infection control techniques such as hand washing and personal protective equipment (PPE). Staff put measures into place to manage an infection outbreak on some wards.

  • The hospital participated in clinical audits and monitored its compliance against the National Institute for Health and Care Excellence (NICE) guidelines.

  • The trust participated in the nurse preceptorship programme; this gave newly qualified nurses the opportunity to be supported by a mentor whilst developing their nursing skills.

  • We saw evidence of good multidisciplinary team working where staff worked together to safely discharge patients or to plan patients’ care.

  • We saw that staff adhered to the Mental Capacity Act, 2005 and that they applied Deprivation of Liberty Safeguards (DoLS) when a patient met the criteria.

  • Most patients were happy with the care they received; they felt staff were kind and helpful and that staff treated them with dignity and respect.

  • Staff respected patient confidentiality by closing curtains and knocking on doors.

  • The trust had recently increased its ambulatory care service opening hours so that it was open from 8am to 8pm from Monday to Sunday. This meant that the hospital was able to close an overflow ward.

  • There was a frail elderly service operating between 8am and 8pm Monday to Friday and from 8 am to 4pm at weekends. The service completed holistic assessments, treatment, support, referrals, and signposted patients to other services. This service helped to prevent unnecessary hospital admissions, with many patients being discharged the same day.

  • We saw that the trust responded to complaints and kept patients or their relatives updated when timescales for responding were not met. Complaints were discussed at both ward and divisional meetings.

  • The average length of stay for medical elective patients was better than the England average.

  • Between October 2016 and March 2017, the trust performed better than the England average for referral to treatment times.

  • Most staff felt their managers were visible, approachable, and supportive.


  • The trust did not meet its target compliance rate of 90% for mandatory training. Compliance rates within adult and children’s safeguarding training was low.

  • The trust was unable to meet NICE guidelines on staffing levels for stroke patients. The trust used clinical support workers to compensate for registered nursing gaps. We saw that many wards were regularly short staffed, staff told us this affected the time they spent with patients, completion of documentation and put pressure on existing staff.

  • Medication trolleys were not always adequate for medicines stored, which meant there was a potential risk of medication errors.

  • Staff did not always complete daily cleaning documentation to show they had completed daily cleaning tasks.

  • We found that nursing documentation did not contain a section for staff to review a patient’s risk of falls.

  • Neutropenic patients did not have access to a dedicated area or ward for initial management. This meant that out-of-hours’ nurses who may not have oncology knowledge were caring for neutropenic patients.

  • Nurses did not always assess patients’ nutritional risks effectively. We saw that staff were not always completing malnutrition universal screening tools (MUST).

  • Only 80% of staff had received an appraisal; this did not meet the trusts target compliance rate of 90%.

  • We saw that there was not always someone trained on the acute medical unit to administer intravenous antibiotics through a peripherally inserted central catheter line.

  • Some patients told us that medical professionals did not always keep them up to date in relation to their care and treatment.

  • The length of stay for non-elective geriatric medicine was higher than the England average.

  • Staff in the chemotherapy department told us that there was not always enough chairs for patients and that this impacted on the time patients needed to wait.

  • Areas we identified during our last inspection (2015) such as staffing levels and training continued to remain a concern. However, we saw that the trust was being proactive in trying to address these.

Services for children & young people


Updated 20 December 2017

We rated this service as good because:

  • Systems were in place to ensure there were adequate numbers of suitably trained and qualified staff to provide safe and effective care.

  • There was good clinical leadership and staff felt well supported by their managers and the senior leadership team.

  • Processes were in place to identify when a patient’s condition deteriorated and escalation to medical staff resulted in a prompt response.

  • There was a positive approach to incident reporting and the review of incidents to identify learning, was improving.

  • The trust participated in national audits and assessed their adherence to national guidance and best practice through a range of clinical audits. We saw an improving picture of performance in relation to these.

  • Collaboration with other agencies and providers of care had improved the safety, responsiveness and effectiveness of care for specific groups of patients; in particular those with mental health needs.

  • Staff were kind and caring in their approach and there was good emotional support for children and their parents.

  • Governance processes had been strengthened and improved. Staff demonstrated a commitment to providing quality care and an enthusiasm for further improvement.


  • The environment within the fracture clinic was unsuitable for children and the trust did not provide any separate waiting area for children in this department.

  • Although the individual needs of some specific groups of patients were recognised and addressed, systems and processes were not in place to identify those with a learning disability and ensure adjustments were made to cater for their special needs.

  • Delays to discharge sometimes occurred due to a delay in the provision of medicines to take home.

  • A significant number of local clinical guidelines required review.

Critical care

Requires improvement

Updated 20 December 2017

We rated this service as requires improvement because:

  • The CCU environment was not fit for purpose; the high dependency unit (HDU) and intensive care unit (ICU) were located on separate wards, which were a few minutes’ walking distance from each other. There were ICU overspill beds in an adjoining unused surgical recovery room. This area was an empty room into which patient beds and equipment were wheeled. If the door was shut, this area would not be visible to the main ICU.

  • We saw there was only one isolation room for the whole of CCU; this was located on ICU. This was not sufficient to manage infection prevention and control when more than one patient presented with an infectious illness or a patient had compromised immunity.

  • Limited space between beds on HDU meant staff had a limited area to treat a patient in an emergency situation.

  • We saw there were not enough capnography machines (to measure ventilated patients’ carbon dioxide levels). This had consistently been raised as a riskduring clinical governance meetings for almost a year, however was not actioned until after our inspection.

  • Mandatory training levels were below trust target for the majority of modules including safeguarding.

  • The outreach staff did not maintain competencies and skills relating to critical care, and were isolated from the main CCU team.

  • There were no follow up clinics for patients discharged from CCU as required under the Core Standards for Intensive Care Units.

  • We saw that the CCU had mixed sex breaches due to delayed discharges. Bed occupancy was consistently high.

  • Deprivation of Liberty Safeguards (DoLS) were not applied for when using bed rails to prevent patients leaving or falling out of their bed.

  • There was a lack of suitable facilities to accommodate visiting relatives, friends and carers.

  • Not all risks were recorded and managed under the CCU risk register, despite being discussed at clinical governance meetings.


  • Staff were aware of how to report incidents, had a good understanding of the duty of candour, and provided evidence of learning from incidents.

  • No never events had been recorded for the reporting period April 2016 to March 2017.

  • Mortality and Morbidity meetings were multidisciplinary and conducted monthly; the chair emailed presentations to any required person who had not attended.

  • In the main we observed infection prevention and control to be effective . Staff adhered to hand hygiene guidance during the inspection; this was supported by audit results.

  • Records were well maintained; legible, securely held and accessible to all relevant staff. Appropriate risk assessments were included within a single patient documentation booklet.

  • Staff had a clear understanding of safeguarding adults and children; and how to raise a concern. This was despite staff training being below the trust target.

  • Data shared with the Intensive Care National Audit and Research Centre (ICNARC) demonstrated the critical care unit were performing either within expected levels, or better than expected levels as compared to similar sized units.

  • We saw the unit was run in a multidisciplinary way; including input from pharmacists, physiotherapists, pain management nurses and specialist nurses for organ donation.

  • All staff during the inspection were caring and compassionate towards patients in their care. We saw staff worked hard to provide a respectful environment for patients.

  • The unit did not transfer any patients to a different hospital for non-clinical reasons.

  • The unit had provision for patients with additional needs, for example patients with learning disabilities and bariatric patients.

  • Staff reported local leadership were supportive and worked well to ensure substantive staff could carry out their duties.

  • The critical care unit had a risk register assigned to it which addressed a range of risks; which were regularly reviewed.

  • Substantive staff reported a rise in morale and a positive culture since the start of the new build critical care unit. Staff told us that they had some input into the planning of the unit.

End of life care


Updated 20 December 2017

We rated this service as good because:

  • Between April 2016 and March 2017, the trust reported no incidents that were classified as never events for end of life care.

  • The trust reported no serious incidents (SIs) for end of life care that met the reporting criteria set by NHS England between April 2016 and March 2017.

  • There had been no end of life care incident, which required duty of candour (DoC) investigation in the palliative, and end of life care service.

  • The service monitored patient outcomes through national and local audits; these were fed back to the board and end of life dashboard along with the trust’s quality report.

  • Multi-Disciplinary Team (MDT) working was effective within the end of life care service. The team worked as a one integrated team across the acute and community sites.

  • DNACPR forms were filed out correctly in front of patient records so that staff could locate them quickly. Since the last inspection 2015, the trust has improved significantly around the DNACPR documentation.

  • Staff cared for patients in a compassionate, dignified, and respectful manner.

  • We saw in one of the viewing rooms at the mortuary that there were facilities for washing the body for religious and cultural reasons. We saw this as an understanding and respect for patients’ cultural and religious needs.

  • The chaplain service offered spiritual support to patients 24-hours a day, seven days a week.

  • Patient discharge, including moving patients between acute and community care settings, followed patient-centred care best practice.

  • The SPCT worked closely with commissioners and other providers to ensure patients’ needs were met.

  • The ensured patients who required end of life and palliative care were seen promptly and were identified in a timely way, that deceased bodies were cared for, and that religious and spiritual beliefs were respected and dignified.

  • The professional lead chaired a multi-professional group. Membership included the acute and community , palliative care team, and representation from the clinical commissioning group (CCG) as well as the director of nursing.

  • The service leaders had a clear direction of the service. Their aim was for an effective integrated service to ensure patients were provided with quality end of life care.

  • Staff of all levels felt supported from the end of life and palliative care team.

  • We saw the trust’s five-year strategy plan for 2017-2022 called, “Becoming your partners for first-class integrated care”.


  • We spoke with the hospital porters around incidents and learning from incidents, they told us they did not have access to a computer or IT access. The porters told us they received no feedback or actions in relation to incidents.

  • Ward staff knowledge and awareness of when to use individualised care plans when caring for end of life patients varied from ward to ward.

  • Porters we spoke with during our unannounced visit on 6 July 2017 informed us that they were never informed if a patient had an infection, especially when transporting patients from one department to another.

  • The trust set out a target of 90% for completion of safeguarding training; as at 31 March 2017 nursing staff for end of life care services failed to meet training targets.

  • There was a low completion rate for major incident training at Walsall Hospital. As at 31 March 2017, only 56 out of 188 eligible staff (30%) had completed this training.

  • The trust had the amber care bundle on some wards as part of a phased roll out programme from the . This was being introduced in the last inspection in 2015 but this had still not been fully embedded throughout the wards.

  • We saw nutritional assessments were being carried out, but was not always documented as part of the individualised care plan.

  • Documented evidence of completed advance care plans (ACP) was only noted in 63 patients and these were predominantly within the community setting, only five patients in the acute setting had an ACP in place.

  • Combined results across both sites (community and acute) demonstrated that the use of the individualised end of life care plan was 20% (45 patients in acute setting).

  • Registered nurses on the wards had received training to enable them to safely administer medications through the T34s McKinley infusion pumps; however this was not consistent, some staff were not trained or did not know which syringe drivers were being used.

  • Porters we spoke with said they had not received any specific end of life training; they told us that newly appointed staff learnt from and shadowed porters that were more senior.

  • Ward staff told us that it was difficult at times to support relatives during an emotional time, as there were no specific rooms to speak with relatives in private.

  • The trust did not have any dedicated beds for end of life care patients, they were cared for on general wards throughout the hospital.

  • The route that people had to walk to the mortuary for the general office was long and poorly signposted.

Maternity and gynaecology


Updated 20 December 2017

We rated maternity and gynaecology services as ‘Inadequate’. The majority of concerns related to maternity services, because:

  • Serious incident action plans were not always monitored or completed.

  • There was poor evidence of learning from maternity incidents.

  • Low harm incidents in maternity were not always categorised correctly or reviewed in a timely manner.

  • Most staff we spoke with across maternity services could not explain duty of candour and were unable to tell us in detail about the process involved.

  • Prescription charts were not fully completed.

  • Medical and maternity records were not kept securely in all areas and were not easy to navigate through.

  • Staff had not completed safeguarding training in accordance with the trust’s target.

  • Midwifery staffing was not at the agreed level and with high rates of vacancy and sickness staff were under constant pressure.

  • Maternity staff did not always complete the venous thromboembolism risk assessment.

  • Maternity staff we spoke with knew a major incident plan existed but nobody could be specific and explain their role within the major incident plan.

  • Staff did not always plan care and treatment that was in line with current evidence-based guidance, standards and best practice.
  • Audits and plans to improve maternity services were limited.
  • Most women we spoke with following birth felt that their pain control had not been well managed.
  • There was out-of-date information displayed or in folders for staff to refer to.
  • There were many guidelines that remained out-of-date following our last inspection.
  • Medical staff within maternity did not always explain the risks to women before a procedure.
  • The milk fridges were not locked which meant breast milk could be tampered with.
  • Instrumental births and caesarean section rates continued to be higher than the national average.
  • Staff did not have the right qualifications, skills, knowledge and experience to do all aspects of the care they provided to women who used maternity services.
  • Handovers were not always focused and in an effective environment.
  • Women did not have access to the midwifery led unit due to staffing issues.

  • Staff morale across maternity was low due to high levels of stress and work overload. Staff did not feel respected and valued.
  • The maternity dashboard showed several risks that had continued to be evident without improvement.
  • Due to the challenges facing the maternity service the senior team was focused on managing the daily strains it faced with little innovation evident.
  • Women did not always receive compassionate care. Maternity service staff were trying to provide a caring and compassionate service in challenging circumstances.
  • The trust performed worse than other trusts for two out of 19 questions in the CQC Maternity survey 2015.
  • There was no consistency of how maternity meetings were held and minutes recorded.
  • The senior leadership team was in its infancy and there had been little strategic oversight of governance and incidents at a senior level.
  • Maternity staff did not feel involved with the decisions made about the service at a senior level.


  • Medicines were stored in locked cupboards, and disposed of safely.
  • Adult resuscitation equipment was checked daily in all areas.
  • Maternity and Gynaecology staff completed early warnings scores.
  • Gynaecology documentation was good.
  • Medical staffing on the delivery suite was in line with RCOG Safer Childbirth recommendations.

  • Multi-disciplinary team (MDT) working was in the maternity and gynaecology service.
  • Women on the gynaecology ward we spoke with told us that they had received pain relief when requested in a timely manner.

  • Areas we visited were mostly visibly clean.

  • Hand hygiene audits carried out in January 2017 and February 2017 showed 100% compliance with recommended practice in all areas of the service.

  • Fluid balance charts we observed were used and correctly calculated and up-to-date.

  • Community midwives had good engagement with each other in the primary care setting.

  • Gynaecology nurses had an understanding of the MCA, and could explain the process to us.

  • There was an active maternity services liaison committee (MSLC), which meant that service user views were considered.

  • Management was visible and approachable.

Outpatients and diagnostic imaging


Updated 20 December 2017

We rated this service as good because:

  • Staff reported incidents in a timely manner and we found evidence of learning from incidents. We found the radiology department met the requirements of Ionising Radiation (Medical Exposure) Regulations 2000. We found good infection control and waste management systems in place. Staff had a robust system in place to manage medication and the distribution of prescriptions.

  • We found evidence based policies and procedures across all departments. Staff worked in facilities that promoted the effective treatment of patients. We found good evidence of multidisciplinary working across outpatients and imaging service. All registered nurses and doctors asked understood the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards 2010. However, three unregistered staff did not understand the legislation.

  • All staff provided compassionate, supportive, and understanding care to patients. Staff encouraged patients to ask questions and be involved in the decision made about their care. Patient feedback about the service was positive. However, the latest Friends and Family Test results showed a lower than national average positive response.

  • The trust was not meeting the national standard for the 18-week referral pathway. The fracture clinic environment was not easily accessible for patients who required a wheel chair or crutches to mobilise. Staff within outpatients had not undertaken any dementia awareness training. However, outpatients and imaging had received a low number of complaints.

  • Staff had a positive attitude and we found an ethos of team working across the departments. Staff felt included within the team and that they could and did make a difference. We found good engagement with the public in the form of health promotion. However, we found meetings often lacked structure and detail, and did not routinely discuss feedback from complaints and incidents.


Requires improvement

Updated 20 December 2017

We rated this service as requires improvement because:

  • Staff were not always managing deteriorating patients appropriately. Significant improvements were needed to ensure deteriorating patients were identified, escalated and reviewed by a doctor in a timely manner.

  • There were significant issues with the hip fracture pathway, which was evident in poor audit results and data on patient outcomes.

  • Staffing was an issue and skill mix was not always correct. There was high vacancy, turnover, sickness absence and agency rates, and a low fill rate at night. The service filled these gaps with agency and clinical support workers.

  • Staff inconsistently completed trust documentation in patient records. We observed inconsistencies throughout the records with staff initials, signatures and job roles. Not all entries were legible.

  • Safeguarding adults and children staff training compliance rates were low. Not all staff were trained to level 3 in safeguarding children, which is a requirement of the Intercollegiate document (2014).

  • Mandatory training was not up to date, which saw none of the mandatory training modules achieving the trust’s completion target of 90%.

  • A lack of storage in theatres and on some wards meant items were not always stored appropriately. Intravenous fluids and nutritional drinks were not always protected from tampering and people who used services had access to razors and harmful chemicals.

  • The service was still not meeting referral to treatment times and patient outcomes. Improvements had been made but there was still more to be done.

  • The service was not fully compliant with the Accessible Information Standards.

  • Staff morale was low in areas due to staffing levels and limited developmental opportunities for junior physiotherapists.


  • There was a good incident reporting culture. Staff understood the need to raise concerns and report incidents, and were supported when they did.

  • Concerns and incidents were investigated appropriately, and lessons were learned, shared and acted upon. Improvements were made to the quality of care as a result of complaints and concerns.

  • The service routinely monitored and collected data to ensure safety and effectiveness. There was involvement in relevant local and national audits.

  • Quality and safety was monitored and used to identify where improvement was needed, and actions were taken as a result, working together with external stakeholders.

  • The application of the World Health Organisation (WHO) checklist and five steps to safer surgery was appropriate and effective.

  • Staff were active and engaged with local safeguarding procedures, and involved relevant organisations.

  • Medicines were stored securely and appropriately.

  • Staff were knowledgeable about consent and mental capacity. Consent and treatment was obtained appropriately and in line with legislation and guidance.

  • There were robust governance processes in place and risk registers reflected risks across the division.

  • The service took into account the needs of individual people. Processes were in place to remove barriers for those who found it hard to use or access services.

  • The service planned and delivered people’s care and treatment in line with current evidence-based guidance, standards and best practice.

  • There were good processes in place to ensure discharge arrangements were safe, which included relevant specialist teams and took account of people’s individual needs and circumstances.

  • Multi-disciplinary teams were coordinated and collaborative to ensure good assessment, planning and delivery of people’s care and treatment.

  • Staff were qualified and had the skills they needed to carry out their roles effectively.

  • Managers identified the learning needs of staffand supported them to deliver effective care and treatment through appraisals. Training was accessible to meet those learning needs.

  • Staff treated people with dignity, respect and kindness involving people in their care and with making decisions.

  • People’s confidentially, privacy and dignity was maintained and staff responded compassionately when people needed their help.

  • Feedback from people who used the service was positive.

  • The service had a clinically lead model with a clear vision and strategy that was focused on quality and patient safety.

  • The leadership was knowledgeable about quality issues and priorities, understood what the challenges were and took action to address them.

  • The service was transparent, collaborative and open with all relevant stakeholders about performance.

Urgent and emergency services

Requires improvement

Updated 20 December 2017

We rated this service as requires improvement because:

  • We found instances of unsatisfactory infection prevention and control practice.

  • Medicines management was not satisfactory in some areas of the department.

  • We saw some patients accommodated in a potentially unsafe environment.

  • ED was not achieving target times for assessment, treatment, or admitting, transferring or discharging patients.

  • ED was not achieving the trust’s targets for its staff to complete mandatory training, or to have appraisals.


  • Staff demonstrated a positive culture of incident reporting and audits, and of learning from incidents, audit results, complaints and concerns.

  • Many improvements had been made since our inspection in September 2015, including: increased staff numbers and skill mix; equipment storage and availability in the resuscitation area; dedicated, and separate paediatric waiting and treatment areas.

  • Staff considered patients’ basic care a priority. Scheduled rounds took place ensuring patients were comfortable and had food and drinks where appropriate.

  • Care and treatment was delivered in line with national guidelines and evidenced best practice.

  • Internal and external multidisciplinary working was embedded and effective, and was constantly reviewed and improved.

  • Feedback from people who use the service, their families, and carers was positive about the way staff treated people. People said staff cared about them.

  • The dementia lead nurse had contributed to significant staff awareness and understanding of the needs of patients living with dementia.

  • Staff spoke very positively about the department’s managers, and told us they were supportive, approachable and ‘a part of the ED family’. Staff and managers were proud of the progress they had made but aware the department needed to improve further, and were keen to help it do so.

Maternity (inpatient services)

Requires improvement

Updated 15 August 2018

We rated maternity services as requires improvement because:

  • The number of never events had increased in the service from no never events between June 2016 to June 2017 to two never events for the following year.
  • The service did not effectively address the findings from audits to demonstrate effective management of infection control risks.
  • Overall, the incident reporting process had improved however further improvement was still required as staff told us feedback from incident investigations was not always shared with staff and action plans were not always circulated to all appropriate staff.
  • Breastfeeding support provision for patients was insufficient.
  • Fridges to store breast milk were unsecured during our inspection. The service addressed this in a timely way however, there was not a process in place to ensure these fridges remained locked.
  • There had not been any recent infant abduction drills conducted.
  • The closure of the midwifery led unit in July 2017 had improved staffing levels in the acute setting however, women who may have chosen to birth in the MLU may not have access to the same facilities and equipment to support a normal birth on the main site.
  • There was limited availability of accessible information in different languages, picture formats, and cue cards. The use of the translation phone service was variable and did not always protect patient privacy.
  • The service did not currently have any internal services dedicated for counselling parents who had experienced the loss of a baby.
  • Leaders recognised further leadership improvements were required, we were not wholly assured the pace of change was sufficient to drive improvement in a timely way.
  • Some long-standing midwives felt excluded as they perceived they had fewer opportunities than recently recruited midwives.
  • Some cultural issues remained an issue with some pockets of staff and reports of staff undermining other staff. The coherence of some consultants required further improvement.
  • Some staff felt they were not sufficiently involved in discussions regarding the closure of the MLU. We did not see a plan in place to re-open the MLU to accept patients to birth there.
  • Senior staff needed to continue to accept and address the concerns identified in maternity services and maintain the pace of change.
  • The maternity improvement action plan did not sufficiently document specific individual actions identified by the 2017 CQC report or external reviews of culture in the maternity service.
  • Service leaders did not sufficiently prioritise or support the normality agenda.
  • Governance was more organised and process driven but there was still a long way to go to be fully functional by ensuring all staff were fully engaged with the governance process of the department.
  • Improvements in the sustainability of the service and improved staffing levels in the hospital setting had been partly achieved by having a birth cap in place and by closing the midwifery led unit. We had concerns that the service may not be sustainable if the unit was delivering to its capped level and the midwifery led unit re-opened.

However, we saw the maternity service had made some improvements since our last inspection.

  • Maternity staff safeguarding training compliance rates had significantly improved since our last inspection. As of 30 May 2018, midwives and support staff and medical staff safeguarding training compliance exceeded the trust target of 90% for all levels of adult and children’s safeguarding they were required to conduct.
  • Midwifery staffing levels had significantly increased since the last inspection.
  • Between May 2017 and April 2018, mandatory training rates had improved across the service.
  • Maternity staff fully completed early warnings scores consistently well and could identify a patient’s deterioration.
  • The service had reduced the average combined elective and emergency caesarean section rate since the last inspection.
  • Overall, patients reported positive care experiences.
  • We observed all staff interactions with patients were caring and supportive.
  • Patients received compassionate and supportive care for as long as they needed.
  • The bereavement midwife offered patients emotional support following pregnancy loss.
  • The transitional care service was an innovative and dedicated approach to postnatal care.
  • Since the last inspection, the service now had a leadership structure in place with clear lines of escalation. The corporate leadership team and frontline staff were more linked and confidence in leaders had improved.
  • Overall, consultants were now more engaged with the improvement process in maternity services.
  • Service leaders and members of the trust’s executive team demonstrated they had improved oversight of the challenges the maternity service was facing.
  • Staff felt their contributions to the maternity service were more valued by the senior leadership team.
  • Community staff told us they felt well supported by the community leaders who formed part of the changed leadership structure.
  • Junior doctors told us the maternity leadership team were approachable and they to felt comfortable to raised issues with the Clinical Director if necessary.
  • The maternity service leaders had developed a clearer vision and strategy for the service in place compared to our previous inspection. This included expanding the bereavement service provision.
  • Senior staff were most proud of the improvement in staff morale and staff engagement in the improvement journey of the service.
  • The local maternity risk register accurately documented the main risks to the service.
  • A new purpose built second theatre was being constructed which mitigated risks identified at our previous inspection relating to the
  • Following the inspection, we saw evidence the service had implemented procedures to manage staff who were openly not adhering to guidelines and procedures.
  • The maternity service supported a multidisciplinary forum ‘Walsall Maternity Voices Partnership’ which met quarterly.
  • The maternity service had been nominated for an award in transitional care.