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Manor Hospital Requires improvement


Other CQC inspections of services

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

Inspection carried out on 19 Mar 2019

During a routine inspection

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 carried out on Unannounced: 5, 6 and 12 June 2018

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. Acute hospital services are provided from one site, Walsall Manor Hospital. Walsall Manor Hospital has 550 acute beds. There is a separate midwifery-led birthing unit (this is currently not operating), and the trust’s palliative care centre in Goscote is their base for a wide range of palliative care and end of life services.

The trust was placed in special measures by the Secretary of State for Health in February 2016 following our announced comprehensive inspection in September 2015.

After a further inspection in June 2017 the Care Quality Commission served the trust with a Section 29a Warning Notice of the Health and Social Care Act 2008. This outlined the quality of healthcare provided by Walsall Healthcare NHS Trust for the following regulated activities required significant improvement:

  • Diagnostic and screening procedures

  • Maternity and midwifery services

  • Surgical procedures

  • Treatment of disease, disorder or injury

The warning notice set out the points of concern and timescales to address this and was wholly related to maternity services. The trust responded to this with a detailed plan for remedial action.

This inspection was an unannounced focussed follow-up inspection of maternity services on 5, 6 and 12 June 2018. The purpose of our inspection was to determine if the maternity service at Walsall Healthcare NHS Trust had made the improvements we highlighted were required following our 2017 inspection and establish if work had progressed to meet the requirements of the warning notice.

During this inspection, we visited all areas of the maternity service at Manor Hospital. We did not inspect community midwifery services or the standalone midwifery led unit.

We spoke with nine patients and relatives, and 32 staff members at all levels, including consultants, midwives, student midwives, maternity support workers and administration staff.

We reviewed 20 prescription charts and 17 patient medical records.

A range of data was requested from the trust as part of this inspection.

We also held maternity staff focus groups for all staff levels and community staff following the inspection to give staff the opportunity to feedback about the service. In total, there were 46 attendees.

We rated this service 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 service did not always ensure vaccination provision was sufficient to protect women and their babies.
  • 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.
  • 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.
  • Leaders recognised further leadership improvements were required however, 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. However, we saw a phased plan to re-open the MLU to accept patients to birth there.
  • 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.

The service had made improvements against all of the concerns we raised in the 2017 warning notice:

  • Monitoring, recording and escalation of concerns for Cardiotocography (CTG)

  • Insufficient numbers of midwives with HDU training to ensure that women in HDU

    are cared for by staff with the appropriate skills.

  • Safeguarding training was insufficient to protect women and babies on the unit who

    may be at risk.

  • There were insufficient numbers of suitably qualified staff in the delivery suite and on the maternity wards

At this inspection, we saw the following improvements for maternity services:

  • 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.
  • The service had reduced the average combined elective and emergency caesarean section rate since the last inspection.
  • Maternity staff fully completed early warnings scores consistently well and could identify a patient’s deterioration.
  • 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 bi-monthly.
  • The maternity service had been nominated for an award in transitional care.

We saw several areas of outstanding practice including:

  • Funding had been secured for 170 midwives to conduct PHI learning. This learning is endorsed and supported by the Royal College of Midwives.

  • The transitional care service was an innovative and dedicated approach to postnatal care.

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

Importantly, the trust must:

  • Ensure information in different languages, picture formats, and cue cards are available to patients.

In addition, the trust should:

  • Ensure all staff complete mandatory training as required for their role.

  • Ensure actions on action plans to address non-compliance for infection prevention and control are followed through.

  • Ensure regular infant abduction exercises are conducted in the department to check for any gaps in the process and assess staff awareness of their role.

  • Ensure gases were stored with the required signage on the doors

  • Ensure processes are in place to store breast milk safely.

Professor Ted Baker

Chief Inspector of Hospitals

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.


  • 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 carried out on 8 September 2015

During Reference: R6 not found

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 and the trust serves a population of around 260,000. Acute hospital services are provided from one site, Walsall Manor Hospital which has 606 inpatient beds made up of 536 acute and general beds, 57 maternity beds and 13 critical care adult beds. There is a separate midwifery-led birthing unit and a specialist palliative care centre in the community.

We carried out this announced comprehensive inspection on 8 to 10 September 2015. We held two public listening events in the week preceding the inspection visit and met with individuals and groups of local people and analysed data we already held about the trust to inform our inspection planning. Teams, which included CQC inspectors and clinical experts, visited Walsall Manor Hospital and inspected eight core services: 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. We also inspected three out of four community services: adult services, children, young people and families and end of life care services. We did not inspect community inpatient services as this service was registered with the local authority. We also carried out three unannounced inspection visits after the announced visit on 13, 20 and 24 September 2015.

We have rated this trust as ‘inadequate’. We made judgements about eleven 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’.

Our key findings were as follows:

  • Maternity services had multiple issues with staffing, delivery of care and treatment and people were at high risk of avoidable harm. The service had limited capacity and staffing resources which impacted negatively on patient experience and compromised patient safety.

  • The latest MBRRACE report presented results for still births, neonatal mortality and extended perinatal mortality rates for 2013. Standardised results for Walsall were slightly higher than their comparator group. MBRRACE recommended that Walsall should consider a local review to better understand factors that may contribute to these results. In response to this the trust with its partners in the CCG and Public Health had participated in a detailed local study and agreed an action plan both of which have been shared with the Trust Board in public following our inspection.

  • The Emergency Department (ED) triage process was ineffective, there was a shortage of qualified paediatric nurses and no paediatric consultant based in ED. There were regular delays with patient handover from ambulance to ED. The trust had been consistently performing worse (5 to 9 minutes) than the England average (median 3 to 6 minutes) for the time to initial assessment of patients between January 2013 and April 2015.

  • The percentage of patients seen within the national four hour target to see, treat and admit or discharge 95%, was worse than the standard or national average for almost all of the period between April 2014 and May 2015. We saw the percentage of emergency hospital admissions waiting four to twelve hours from the decision to admit until being admitted (18 to 50%) was consistently above the England average of 5 to 15% between April 2014 and April 2015.

  • Incident reporting, particularly feedback to staff was variable across the trust. There was a mixed approach to incident reporting which differed between services. The trust promoted incident feedback to staff through various methods. However, this was dependent upon individual service managers to disseminate lessons learned and staff’s capacity to engage.

  • Previous concerns relating to the trust’s management of duty of candour had improved. We looked at several serious incident records which demonstrated the trust had adopted a more open and rigorous approach to the duty of candour regulation and its process.

  • Staff were caring and compassionate towards patients and their relatives. We did however see that in both ED and Maternity the excessive workload led to the standards of caring falling below that we would expect. Patient’s dignity and privacy was largely ensured and we saw many examples of good care across the trust from staff at all levels.

  • Community services for Adults, Children, Young people and Families and End of Life Care, were rated as good overall. Governance structure and risk management were well embedded and general leadership of community teams was supportive and nurturing.

  • The trust took part in all the national clinical audits they were eligible for, and had a formal clinical audit programme, where national guidance was audited and local priorities for audit were identified.

  • The Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die. It was recognised that the SHMI for Walsall Manor Hospital had increased over an extended period of time, March 2015 was 107.41, April 2015 was 110.54 and May was 102.64. This represented a risk to patient safety.

  • The trust was still seeing the effects of implementation of the new electronic patient administration system nearly 18 months previous. Improvements had been made however, the trust was still struggling with simple tasks, (e.g. making patient appointments) as well as experiencing difficulties in gathering accurate information for decision making and performance management.

  • The culture of the trust was described by many staff as poor. Morale was low across many wards and departments and we heard examples of senior managers and in some cases executive members taking a heavy handed approach to problem solving. Despite ‘low morale’ staff demonstrated a positive approach to patient care and a genuine compassion to deliver the best care possible.

  • Divisional and corporate risk registers did not accurately reflect identified risks trust wide.

  • The trust had failed to implement the new checks and tests necessary to fulfil the requirement for all directors to be ‘fit and proper’ persons. This statutory requirement came into effect in November 2014. We saw no checks had been carried out for any directors within the trust and there was no Fit and Proper Person Policy in place. Following the announced inspection, the trust had taken remedial action to satisfy statutory requirements which demonstrated compliance with the Fit and Proper Person Regulation before the inspection period ended.

  • The Trust Board was aware that the organisation faced significant quality and performance challenges and had launched an Improvement Plan in June 2015 to seek to address these.

  • The Trust described to us a “perfect storm” in 2014 as a result of significant increases in emergency and obstetric activity and problems following the replacement of the patient administration system. The Trust Board recognised that the organisation faced significant quality and performance challenges in 2015 and had launched an Improvement Plan (“Improving for Patients; Improving for Colleagues; Improving for the Long-Term”). The plan included a programme of work to develop the two to five year strategy for the Trust and its services. The plan had been launched in June and as in its early stages at the time of our inspection in September 2015.

Importantly, the trust must:

  • Improve the governance of incident reporting systems to ensure that processes are embedded across the trust.
  • Improve duty of candour training to ensure staff have a clear understanding of the process.

  • Implement systematic training for complaints investigation, improve the RCA process and dissemination of lessons learned to front line staff and their managers.

  • Ensure there are adequate numbers of qualified staff across all services, particularly in: maternity services, emergency department and medical services to meet the needs of patients to protect them from abuse and avoidable harm.

  • The trust must ensure there is an adequate supply of equipment in good working order and fit for purpose across all services. Any mitigation to replace equipment must have clear reasons, regular review and an up –to-date action plan clearly demonstrating alternative options and timescales to support actions.

  • The trust must ensure equipment is stored appropriately; all fire exits must be kept free without compromising patient and staff safety and staff can access equipment when required.

  • Mental Capacity Assessments (MCA), Deprivation of Liberty Safeguards (DoLS) and Do Not Attempt CPR (DNACPR) assessments to be carried out in a timely manner and supported by appropriate documentation.

  • Review the patient administration system to minimise problems associated with missed patient appointments. Ensure data is accurate and the system is a reliable resource for staff to use which meets the need of patients using the service.

  • Ensure health records are completed appropriately and patient data is confidentially managed. Patient confidentiality is maintained at all times across all service.

After the inspection period ended, the Care Quality Commission issued the trust with a Section 29a warning notice outlining there was significant improvement required. This set out the points of concern and timescales to address this. The trust has responded to this with a detailed plan for remedial action.

Importantly, the trust must:

  • ensure there are adequately qualified staff across all services to meet the needs of patients and protect them from abuse and avoidable harm.

  • improve the embedding of governance of incident reporting systems trust wide.

  • ensure medication is stored, administered and recorded appropriately across all services.

  • ensure patient confidentiality is maintained at all times across all services.

  • ensure all fire exits are kept clear.

  • ensure the birthing pool in maternity services is always accessible and available for use and the birthing pool room is free from clutter and non- essential equipment.

  • ensure there is an adequate supply of equipment in good working order and fit for purpose across all services. Any decision not to replace equipment must have clear reasons, regular review and an up to date action plan clearly demonstrating alternative options and timescales to support actions.

  • ensure equipment is stored appropriately without compromising patient and staff safety and that staff can access equipment when required.

In addition the trust should:

The Emergency department SHOULD:

  • consider redesigning the seating arrangement in the ED general waiting area to provide some personal space between the seats.
  • improve staff annual appraisal rates within the ED.
  • ensure all staff can be easily identified by patients and visitors at all times when on duty.
  • better inform patients and their relatives/carers about the streaming systems in operation in the ED and how patients are going to be seen.
  • review the purpose and use of the ED log sheets.
  • consider setting out its overarching vision for the ED.

Medical services SHOULD:

  • provide a protected, suitable environment for physiotherapy.
  • review its stock of equipment including, but not limited to syringe pumps and weighing scales.
  • ensure that feedback is given on all reported incidents.
  • ensure that the patient safety dashboards on display in medical wards are maintained with up-to-date and accurate information.
  • inspect its physiotherapy equipment to ensure that it complies with infection prevention and control guidelines.
  • arrange for a patient group directive to be written for the administration of saline flushes.
  • ensure that fluid balance front sheets are consistently completed for any patient having their fluid intake and output monitored.
  • review the contents and layout of its nursing assessment documentation booklet.
  • reinstate a programme of acute illness management training for nurses working on medical wards.
  • review its major incident training and the method of its delivery to improve understanding among staff.
  • take action to improve staff understanding of the meaning of the butterfly symbol to indicate patients living with dementia and the purpose of butterfly bays on wards.
  • ensure that it consistently reports on its performance against the NHS 18-week referral-to-treatment target.
  • ensure that robust translation services are used to communicate with patients who do not understand English.

Surgery services SHOULD:

  • review the low uptake of medical devices training across the trust.

  • review the environment in recovery for children post-surgery to promote a child safety area.

  • ensure operating theatres are deep cleaned on a regular basis and should review how equipment is stored in the theatre environment

  • ensure equipment used specifically for children in the operating theatres is up to date

  • ensure intravenous fluids are stored in secure environments

  • ensure easier access to translation services.
  • review the provision of physiotherapy services to ensure initiatives such as the ‘joint school’ can be re-established.

Critical care Services SHOULD:

  • review its morbidity and mortality review process to ensure all deaths are reviewed.

  • review its checking system for fridge temperatures so that if temperatures are out of range, they are rechecked to ensure medicines are stored at the correct temperature.

  • review infection control procedures to ensure staff wash their hands after removing gloves and aprons rather than just using sanitising gel.

  • review junior medical cover to ensure doctors are available to attend consultant ward rounds in critical care and document contemporaneous patient plans in notes.

  • review multidisciplinary team working in critical care to enable multidisciplinary team ward rounds and effective multidisciplinary team working.

  • review systems to improve flow throughout the hospital to reduce the number of delayed discharges in critical care.

  • ensure patients have access to patient information leaflets in languages other than English.

Maternity and gynaecology services SHOULD:

  • ensure fridges used for the storage of medicines are kept locked and secure from unauthorised access.

  • ensure that medicines that look similar are not stored next to each other.

  • consider how it enables staff to attend required training and supports staff to gain additional qualifications to support the service.

  • consider how it can improve care records to ensure that risk assessment and safeguarding issues are easy to locate.

  • consider the use of specialist midwives to improve the experience of families including :bereavement, teenage pregnancy and diabetes,

  • consider ways to support and improve active birth.

  • consider ways to reduce the induction of labour and caesarean section rates.

  • consider ways of improving the sharing of information and improving engagement with midwifery staff, so they are aware of and involved in future developments.

  • consider ways to improve breastfeeding support to new mothers.

  • consider involving patients fully in care decisions by developing a ward round on delivery suite to incorporate every woman present.

  • consider ways to improve relationships between maternity and gynaecology to allow the joint use of the gynaecology theatre.

  • evaluate the management of outliers on the gynaecology ward.

  • consider NICE and best practise recommendations and ensure guidelines reflect up-to-date guidance.

  • consider individual feedback to staff reporting incidents.

  • consider the ways to inform patients of the role of Supervisors of Midwives.

  • consider the use of an assessment tool for the prevention of pressure ulcers for all maternity patients.

  • consider the use of the maternity safety thermometer tool.

  • consider a way to identify when a piece of equipment is clean and ready for use.

  • improve the cleanliness of the delivery suite and delivery suite theatres.

  • consider the use of disposable straps for the CTG machines.

  • consider the use of wireless CTG monitoring.

  • consider trialling the child abduction policy.

  • consider increasing audits to improve practice such as the audit of one to one care in labour.

  • consider the use of a debrief for patients following a caesarean section to discuss suitable mode of birth if they choose to have more children

  • consider the need for a policy for transferring women to a tertiary unit.

  • consider the need for a transition care ward for babies needing extra care.

  • consider a pool evacuation policy and suitable equipment to evacuate patients in all areas where pools are used.

  • improve the consistency of checking resuscitation equipment on the delivery suite.

  • consider a strategy for capping bookings for the service as the number of births increases.

Children and young people services SHOULD:

  • take steps to further improve the safety of, and reduce risks to CAMHS (patients receiving care on the children’s ward.

  • ensure the neonatal unit is suitable for the service provided and is large enough to accommodate the number of babies using the service at any one time.

  • review the scope of root cause analysis investigations and the process used to review mortality and morbidity to ensure all possible contributory factors are considered.

  • take action to maintain the standards of hygiene and cleanliness within the Starfish suite along with equipment within the suite, and ensure it is appropriate for the purpose for which it is used.

  • ensure patient records and referral documents are available in a timely way for children’s outpatient attendances.

  • ensure action plans are in place to improve practice in relation to national quality audits and monitor progress against these.

End of Life Care services SHOULD:

  • take action to ensure that there are sufficient mortuary fridges in working order.

  • ensure that all patients approaching end of life have their spiritual and religious needs assessed and are offered support.

  • ensure both amber care bundles and advance care planning are being used consistently.

  • consider how the trust provides dedicated bereavement care.

  • consistently identify a patient’s preferred place of death and support them to achieve this.

  • ensure there are appropriate areas for patients in the last days and hours of life that provide privacy and dignity for them and their relatives.

Outpatient and diagnostic imaging services SHOULD:

  • have a clear plan to replace ageing equipment in the radiology unit.

  • consider improving the post-operative procedure facilities for patients attending the day surgery unit and the endoscopy unit.

  • ensure all staff have access to trust policies and procedures.

  • ensure receptionists are available to meet and book in patients when they are attending for appointments and procedures.

  • ensure staff handling food for patients have attended basic food hygiene training.

  • ensure resuscitation trolleys are checked daily as recommended by the Royal College of Anaesthetists.

In response to these concerns, the Care Quality Commission issues Walsall Healthcare NHS Trust with a section 29a warning notice on 26 October 2015 setting out concerns and significant improvement required.

Since issuing the section 29a warning notice we have seen the trust take significant action to address these issues.

Professor Sir Mike Richards

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.”