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Manor Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 25 July 2019

Our rating of safe requires improvement overall. In medicine and surgery staffing levels were not always maintained in sufficient ensure patients received safe care and treatment. Patient records were not always up to date or sufficiently completed.

Our rating of effective required improvement overall. The processes for ensuring patients capacity was assessed in line with the Mental Capacity Act 2005 were not robust. Some patients were deprived of their liberty without

Our rating of caring overall. Patients mostly received care which protected their dignity and privacy. Staff were kind and respectful and tried to get to know patients as individuals.

Our rating of responsive required improvement overall. Waiting times for triage and treatment in the urgent and emergency department did not meet national targets.

Our rating of well led required improvement overall. Not all required checks were in place to ensure directors were ‘fit and proper persons’. The management of risks and governance did not always ensure a flow of information which demonstrated robust oversight and decision making.

Inspection areas

Safe

Requires improvement

Updated 25 July 2019

Effective

Requires improvement

Updated 25 July 2019

Caring

Outstanding

Updated 25 July 2019

Responsive

Requires improvement

Updated 25 July 2019

Well-led

Requires improvement

Updated 25 July 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 25 July 2019

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

  • We rated medicine at the trust as requiring improvement overall, we have judged the service as requires improvement for safe, and good for caring, requires improvement for effective, good for responsive and well-led care and noted some innovative practices.
  • However, improvements in safety were needed to ensure that services were responsive to people’s needs. Although some elements of safety require improvement, the overall standard of service provided outweighs those concerns.
  • Staff followed good hygiene procedures to reduce risks to patients.
  • Incident reporting had improved since our last inspection and staff now knew what incidents to report and how to do so.
  • The service now met national targets for referral to treatment times and had created a new winter pressure discharge ward discharge to free up beds when patients were ready to go home.
  • The service treated concerns and complaints seriously. Managers investigated them and shared lessons learned with staff.
  • Nurse staffing levels were determined using an acuity tool and were regularly reviewed and the trust was actively recruiting nursing staff
  • However:
  • The service did not have enough nursing staff and there were high levels of sickness. The service was heavily reliant on bank and agency staff.
  • Safe storage of medicines was compromised by unlocked intravenous fluid storage cupboards.
  • Assessments of mental capacity were not always fully undertaken.

Services for children & young people

Good

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.

    However:

  • 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 25 July 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Mandatory training compliance levels for medical staff were below the trust’s target for seven of the 10 mandatory training modules.
  • The cover provided by the critical care outreach team was insufficient to sufficiently
  • mitigate risk.
  • The service did not always monitor infection risk well.
  • The service did not always provide care and treatment based on national guidance and evidence of its effectiveness. Follow up clinics were not conducted to support patients after discharge from the unit. We had raised this as a concern at our previous inspection.
  • Staff did not always deliver patient care and treatment seven days a week in accordance with national guidance.
  • All staff had access to trust policies and procedures but they were not always up-to-date. Several guidelines had not been updated to reflect the patient pathway since relocating to the new unit.
  • People could not always access the service when they needed it. Patients were not always admitted, treated and discharged patients in line with good practice and guidance.
  • Discharges from the critical care unit did not always take place at appropriate times or place.
  • The critical care service did not always use a systematic approach to continually improve the quality of the service and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The trust did not always collect, analyse, manage and use information well to drive improvement in the service.

However;

  • The service had suitable premises and equipment and looked after them well. The purpose-built unit met Health Building Note guidance for critical care units.
  • The service provided mandatory training in key skills to all nursing staff. The compliance rates were above the trust target for seven of the training modules and just below the trust target for the remaining three modules.
  • The service had enough nursing staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • Physiotherapy staffing was sufficient to provide respiratory management and rehabilitation components of care.
  • 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. Nursing staff met the trust’s target for all safeguarding and PREVENT training modules.
  • 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 had enough 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 exceeded the recommended levels of staff that had achieved their post registration qualification in critical care.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Nursing and medical staff compliance with Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training was above the trust target.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The trust planned and provided services in a way that met the needs of local people. The purpose-built facilities and premises were appropriate for the critical care services delivered.
  • Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The service had a clinical lead for critical care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff morale had improved since relocating to the new critical care unit.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The trust was committed to improving services by learning from when things went well and when they went wrong. The service promoted specialist critical care training, research and innovation.

End of life care

Good

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”.

However:

  • 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.

Outpatients and diagnostic imaging

Good

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.

Surgery

Requires improvement

Updated 25 July 2019

Our rating of this service stayed the same. We rated it as requires improvement because:

  • The service did not have 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.
  • Patient risk was not always assessed and responded too appropriately.
  • Staff did not keep appropriate records of patients’ care and treatment. The surgical division considered patient records a risk.
  • Although staff had patient handovers before starting their shift, it was clear that temporary staff covering wards were not given appropriate handovers.
  • Staff mandatory training was not always complete. Low compliance rates were seen across nursing and medical staff.
  • The surgical division did not always control infection risk well. Shared facilities were not always clean and hygienic. For example, during our inspection we observed a piece of faeces soiled clothing in a shared area.
  • Allied health professional staffing was not sufficient to deliver the services proposed by the division.
  • People could not always access the service when they needed it. For example, there had been an increase in cancelled surgeries.
  • Quality and sustainability challenges were understood by leaders but they could not always identify the actions needed to address them.
  • The service had a system for identifying risks, planning to eliminate or reduce them but the risk register was not complete. There was a lack of assurance all risks associated with the surgical division had been recorded and mitigated.
  • The service did not always collect, analyse, manage and use information well to support all its activities, using secure electronic systems with security safeguards.
  • Service performance measures were not always collected, monitored or reviewed and it was unclear whether they were being effectively used to improve practice.
  • There were some occasions where patients did not receive care which protected their privacy and dignity.
  • Staff did not always respect confidentiality when conversations about patient care took place.

However:

  • Medical staffing arrangements on surgical wards were safe.
  • 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.
  • In general, the service had suitable premises and equipment and looked after them well.
  • Mandatory training was provided and compliance was monitored. The service made sure staff were competent for their roles.
  • Nutrition and hydration met the needs of patients.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Most staff always cared for patients with compassion, privacy and dignity and supported patients to minimise their distress.
  • Most staff always involved patients and those close to them in decisions about their care and treatment and respected confidentiality when conversations about patient care took place.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
  • The trust was committed to improving services by learning from when things go well and when they go wrong, promoting training, research and innovation.

Urgent and emergency services

Good

Updated 25 July 2019

Our rating of this service improved. We rated it as good because:

  • There had been improvements in all areas from the previous inspection in 2017.
  • Although there were still issues around safe, there had been improvements in both mandatory training compliance and triage and treatment targets. These areas, however, still required further improvement in order to reach targets.
  • Staffing levels had increased since the last inspection.
  • Risk management and incident reporting were improved since the last inspection and clear processes and learning were embedded.
  • Infection prevention and control processes had developed since the previous inspection and recent audits were encouraging.
  • Medicines management was safe and in line with guidance.
  • New grades of staff had been introduced to the department and there was an upskilling of staff within the ED.
  • There was a comprehensive audit programme, with performance data used to drive change.
  • There was good multidisciplinary working and patient pathways.
  • Feedback was positive regarding patient care.
  • There were improving services for mental health and elderly patients.
  • Leadership was responsive.
  • Investment was signed off for the department to move into a purpose-built facility.
  • There were good governance systems and embedded and improving clinical practice.

Maternity

Good

Updated 25 July 2019

Our rating of this service improved. 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 mostly had suitable premises and equipment and mostly looked after them well, although there were some shortages.
  • Staff completed and updated risk assessments for each patient. They kept clear records and asked for support when necessary.
  • The service had enough nursing and medical staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment.
  • 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 used safety monitoring results well. Staff collected safety information and shared it with staff, patients and visitors. Managers used this to improve the service.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • Staff mostly gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other preferences.
  • Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • 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.
  • The service made sure staff were competent for their roles. Managers appraised staff’s work performance and could, if need be, offer supervision meetings with them to provide support and monitor the effectiveness of the service.
  • Staff of different kinds worked together as a team to benefit patients. Consultants, midwives and other healthcare professionals supported each other to provide good care.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the service policy and procedures when a patient could not give consent. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • 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.
  • Understanding and involvement of patients and those close to them.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • The service took account of patients’ individual needs.
  • People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.
  • The service mostly treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. However, complaints were not investigated and closed in line with their complaints policy.
  • Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care.
  • The service 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 across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
  • The service mostly 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 service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.

However,

  • The service did not always control infection risk well. Staff did not always keep themselves, equipment and the premises clean. They used control measures to prevent the spread of infection
  • The service did not always follow best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
  • Staff did not always keep detailed records of patients’ care and treatment. Records were not always clear, up-to-date and easily available to all staff providing care.
  • Managers did not close all complaints in the time frame set out in the service’s complaint policy.
  • The risk register did not accurately reflect the current risks to the department.

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.
Other CQC inspections of services

Community & mental health inspection reports for Manor Hospital can be found at Walsall Healthcare NHS Trust.