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Manor Hospital Requires improvement

Reports


Inspection carried out on 2017 Unannounced 31 May 2017 and 20 to 22 June 2017

During an inspection to make sure that the improvements required had been made

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.

Surgery

  • 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

Safeguards.

  • 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.

Surgery

  • 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 carried out on 8 – 10 September 2015

During a routine inspection

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.

Surgery

  • 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

Safeguards.

  • 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.

Surgery

  • 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 carried out on 12 March 2014

During a routine inspection

We inspected Manor Hospital, Walsall on an unannounced, scheduled visit to review previously identified non- compliance in Outcome 21 (records). We also reviewed concerns received by CQC from a whistle blower regarding paediatric staffing levels.

Three compliance inspectors, a paediatric specialist advisor and the CCG lead nurse inspected Manor Hospital. We visited five wards and the accident and emergency department (A&E). We spoke with 31 staff including doctors and nurses, eight patients and five relatives.

At the previous inspection it was identified that improved record keeping was required to provide assurance that people would receive the care they needed. During this inspection we saw that many new, improved records were in place. We found that all areas we visited were adequately staffed, both in terms of nursing, care staff and medical personnel.

We reviewed the staffing levels at all grades for paediatric care in the hospital. We found that medical and nursing staff levels were appropriate for the delivery of care at the current time and these were continually under review. The staff we spoke with were all keen to demonstrate innovation and were enthusiastic about working for the trust.

One relative we spoke with told us: “I am very impressed with the care my mother has received”.

Whilst in A&E we identified that the consideration of safeguarding was not always documented. We brought this concern to the attention of the matron

Inspection carried out on 5 December 2012

During an inspection to make sure that the improvements required had been made

This inspection reviewed the trust's action in response to a compliance action in relation to records.

We visited wards 4, 10, 11, 16, 17 and the accident and emergency department. We looked at care records for 26 people, spoke with 24 people about the care they or their relative received and spoke with 15 staff about the needs of people whose care records we looked at.

We visited each person whose care records we checked. People we spoke with were positive about the care provided at Manor Hospital. People told us, "The care has been excellent", and "The care is great, the nurses have all been so good". We were able to see that dependent people on the wards were comfortably positioned, clean and cared for.

On the day of our visit the accident and emergency department was very busy causing challenges for staff. Before our visit we were contacted anonymously and told that the department was reliant on agency staff which put people at risk. We found that there were appropriate arrangements in place to cover staff absence. However improved records were needed to provide assurance that people would receive the care they needed whilst in the department.

We found that improvements had been made to the completion and availability of care records since our last inspection in July 2012. The trust told us that they would ensure that improvement continued. We shall assess the completion and availability of records again during our next inspection of the hospital.

Inspection carried out on 11 July 2012

During a routine inspection

We visited Walsall Manor Hospital as part of our planned programme of inspections and to review the improvements made since our previous visit. The visit was unannounced and neither the provider nor staff knew that we would be visiting.

A team of four inspectors visited Walsall Manor Hospital on the 10 and 11 July 2012. We visited wards: 1, 4, 10, 11, 14, 15, 16, 17, 20 and the Accident and Emergency Department. The inspection included the observation of care experienced by people in the hospital, talking to people who were in receipt of care, talking with staff on duty including ward managers and specialist nurse advisors, looking in detail at all aspects of care for 18 people, some of whom had complex needs and discussing their care with staff. This process is known as pathway tracking. During the two days of our inspection we spoke with 46 patients and relatives and 33 staff.

People were positive about the care they received. All but one person we spoke to told us that they were informed about the treatment options including possible risks of the treatment. One person told us, “I couldn’t fault the place, everyone is wonderful, they treat me with respect and always keep me private when they are doing any personal care". They were satisfied with the level of care and support they received.

We spoke with a visitor they told us they felt the staff were kind and supported their relative well.

People told us that they were informed about the treatment they needed and they were asked for their consent to treatment.

People we spoke with made positive comments about staff. Comments we received about staff included, "I could not fault them, they do a marvellous job". People told us that staff were respectful and maintained their dignity. One person told us, "They are very good, they cannot do enough for you", and "They are very respectful and have excellent manners". We observed that staff assisted people when needed and were polite and respectful.

The hospital had appropriate systems in place to protect people from harm and undertake required action to protect people from abuse and the risk of abuse or harm.

We have been told that the hospital has considerably reduced its incidence of reportable infections. People told us, "The hospital is always very clean", and "Staff are always washing their hands and I also see them using the handgels".

Staff all told us that they felt supported and were kept informed by senior staff and board members. We were told, "We have really good training opportunities".

We found that the trust which manages the hospital had responded positively to concerns and had appropriate systems in place to respond and learn from these concerns. There were appropriate systems in place to protect people from harm.

Inspection carried out on 25 May 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 8 November 2011

During a routine inspection

People were very positive about their experience and care they had received at the Manor hospital. We saw that staff promoted people's privacy and dignity. People told us that their treatment had been discussed with them and they felt well informed about their care and treatment. There were many complimentary comments about the staff including," Can't fault the staff,they are all kind, polite and patient and they have listened to me, nothing is too much trouble".

Generally staff felt supported but there was a lack of ongoing formal supervision in place. The frequency of staff meetings varied from ward to ward resulting in some staff not feeling fully informed.

There was a good system of quality monitoring in place. The hospital actively gains feedback from people who use their service to continually improve the quality of service it delivers. The hospital is actively trying to reduce the rates of clostridium difficile, however, systems need to impove further to reduce rates of infection.

Inspection carried out on 13 April 2011

During a themed inspection looking at Dignity and Nutrition

Patients and their relatives we spoke to said they were treated with respect and their care and treatment needs were met. They said they had been involved in discussing and agreeing their care and were given clear information about treatment. Patients we spoke to on the whole said they enjoyed the food and felt their nutritional needs were being met. Everyone said someone came round with a menu to help them to choose what they wanted to eat. They said staff always checked to make sure they have had enough to eat and that they have never missed a meal. Comments have included:

“I have never been in hospital before and found it reassuring when staff have explained what is happening next”.

“The staff were wonderful to mother and I feel less anxious about her mother now she was on this ward.”

“The food is very good on the whole. I left my meal today as I was not very hungry and staff asked if I was alright or if I wanted something else.”