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Macclesfield District General Hospital Requires improvement

We are carrying out checks at Macclesfield District General Hospital. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 April 2018

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We rated safe, effective and well led as requires improvement. We rated effective, responsive and caring as good. We took into account the current ratings of services not inspected this time.
  • We found medicines were not consistently dispensed, recorded, stored correctly and safely within the medical wards. Storage of medicines on medical wards did not always follow best practice medicine guidelines.
  • We found equipment stored in front of fire escapes on some medical wards.
  • On the children’s ward, there was a shortage of band 6 nurses who had the advanced paediatric life support training.

However:

  • The ratings for medical care, surgery, maternity and children and young people had improved.
Inspection areas

Safe

Requires improvement

Updated 12 April 2018

Effective

Good

Updated 12 April 2018

Caring

Good

Updated 12 April 2018

Responsive

Good

Updated 12 April 2018

Well-led

Requires improvement

Updated 12 April 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 15 May 2015

Incidents were not always reported in line with trust policy, which meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in outpatients and diagnostic imaging services. Records in the outpatients department and the occupational therapy, physiotherapy and orthotics department were not stored securely, which meant that there was a risk of people’s records and personal details being seen or removed by people in the department. Records were not always available in time for clinics; on occasion this led to the cancellation of clinics.

The organisation of the outpatients departments was not always responsive to patients’ needs. The trust recognised that the layout and size of the department was insufficient to provide a safe environment for the number of people using the unit. However, there were no action plans or procedures that had been put in place to mitigate risk or to change the environment. Equipment had not been maintained in line with manufacturers’ recommendations. Nearly a third of clinics were cancelled and patients experienced delays when waiting for their appointments. The vision and strategy for outpatients and diagnostic imaging services were not clear. Risk management and quality measurement systems were reactive and not proactive. Outpatients and diagnostic imaging services had not identified all risks to service users, and those identified were not being managed effectively.

 

Cancer waiting times were consistently better than the England average for 31-day and 62-day targets. Since September 2013, RTT for patients with incomplete pathways were better than the England average. RTT for non-admitted patients had been inconsistent between April 2013 and May 2014 but were better than the England average from June 2014. Diagnostic waiting times had been better than the England average since November 2013.

 

There was evidence of good multidisciplinary working in the outpatients and diagnostic imaging departments. Doctors, nurses and allied health professionals worked well together. We found that staff were approachable, welcoming and friendly. Staff were discreet and kind when they saw that a person was upset, and we saw them take extra time to communicate with people if they deemed it necessary.

Maternity

Good

Updated 12 April 2018

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

  • Staff had completed mandatory training and specific skills and drills for this service.
  • Most staff had received safeguarding training updates and understood how to keep patients safe.
  • Most areas we visited were visibly clean and there were processes for checking and maintaining equipment.
  • There were sufficient numbers of midwifery and medical staff to meet the needs of the service.
  • Midwives worked in both the hospital and community, in teams, to provide continuity.
  • Patient records were generally completed appropriately by all staff both paper and electronic.
  • Staff provided medication, including pain relief, promptly and appropriately to patients.
  • Staff understood how to report incidents and received feedback.
  • Staff followed national guidance and monitored the service.
  • Staff were appraised and supported by senior staff.
  • There was effective multidisciplinary working over seven days.
  • Patients were kept comfortable and supported by staff with individualised care.
  • There was an open and transparent culture with clear supportive leadership.

However:

  • Sluice rooms were unlocked; these stored cleaning fluids. In the community clinic there was no area to handle patient samples.
  • Fridge temperature checks did not include recording the range.
  • Partners of women requiring a caesarean section could not stay with the women in the recovery area of theatre.
  • Complaints were not always resolved quickly.
  • There was no vision and strategy for the maternity service. The service followed the wider network strategy.

Maternity and gynaecology

Requires improvement

Updated 15 May 2015

There had been an emphasis on completing the necessary audits and training to obtain and maintain level three in the Clinical Negligence Scheme for Trusts (CNST). This recognises a high standard of training and care. However, the standard of some of the more basic day-to-day practices and procedures, which were not included in this work, had not been maintained. Staff did not always follow procedures correctly for the management of controlled drugs or for the completion of some records. There was no formal system for deciding the serious nature, or potential outcomes, of an incident or for how it should be investigated. This meant that not all incidents with potential risks of harm were formally investigated or recorded or lessons shared. Some of the facilities, such as those for parents of babies in the neonatal unit and to facilitate infant feeding, were not fit for purpose.

 

There were no inpatient beds used specifically for patients undergoing a gynaecology operation or termination of pregnancy. Such patients could be accommodated in a mixed ward but this did not protect their dignity or the potentially sensitive nature of the support they would need. A high number of gynaecology operations were cancelled at short notice. There was no clear vision or strategy to improve or develop gynaecology services within the hospital. The trust provided information regarding the strategy for gynaecology services but staff within the service were unaware of both the strategy and any of the development plans in place. There was a lack of monitoring of day-to-day procedures and this had led to poor practice not being identified or rectified. Not all areas of risk had appropriate assessments in place or actions to reduce those risks. The trust had identified the need to plan to sustain maternity services and had identified several actions. However, senior midwifery staff did not identify these plans when we spoke with them.

 

The maternity services used local and national data and good practice guidance to develop policies and procedures. The working procedures and outcomes were audited to monitor the effectiveness of the service. Action plans were in place to improve outcomes in the areas identified as being below either national standards or the trust’s own targets, including for the number of normal deliveries and third and fourth degree tears. There was a multidisciplinary approach to the care and support of patients, with the inclusion of specialists from other medical areas such as diabetes management and mental health services. However, there was a lack of joint working with theatre staff. The competence of staff was monitored and midwives received the necessary supervision and support. Staff were caring and treated people with respect and dignity. People spoke highly of the care they had received and the attitude of staff. There were opportunities for staff to develop personally and professionally, with clear lines of leadership and accountability in the service.

Medical care (including older people’s care)

Good

Updated 12 April 2018

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

  • Staff kept appropriate records of patients’ care and treatment. Records were clear, legible date available to all staff providing care. This had improved since the previous inspection.
  • There were processes in place to ensure care and treatment was provided in a safe way to patients. We observed that a range of risk assessments were completed by nursing staff.
  • Staffing levels and skill mix were planned, implemented and reviewed to keep people safe, although there was a high reliance on the use of bank and agency staff to provide care and treatment. This was due to high vacancy rates across the service.
  • Staff knew what incidents to report and how to report them. When things went wrong patients received an apology.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
  • The expected outcomes were identified and care and treatment was reviewed and updated as needed.
  • Patients were supported to make decisions and, where appropriate, their mental capacity was assessed, recorded and acted on in line with relevant legislation.
  • Staff, including volunteers were appropriately recruited, qualified and had the skills they need to carry out their roles. Their performance was monitored to make sure that they were able to deliver appropriate care and treatment to patients.
  • Staff worked well together in order to meet the range and complexity of patients’ needs
  • Feedback from patients was positive about the way staff treat people. Overall, patients and their relatives told us they were treated with dignity, respect and kindness.
  • Performance indicators, including the average length of stay for medical elective patients and referral to treatment times (admitted performance) had been consistently above the national average.
  • Leaders were visible and approachable. The leadership was knowledgeable about issues and priorities for the quality and sustainability of services.

However,

  • We found medicines were not consistently dispensed, recorded, stored correctly and safely. Storage of medicines on medical wards did not always follow best practice medicine guidelines.
  • We found equipment stored in front of fire escapes on some wards.
  • We found records trolleys were not stored securely to prevent unauthorised access and not all computer terminals were locked down after use and displayed confidential information.
  • Although strategies had been implemented to increase patient flow there were delays in transfers of care, and bed occupancy rates and outlier numbers remained high.
  • There was no consultant review at weekends for patients on the coronary care unit and no consultant ward round at weekends on the medical wards.
  • Staff reported the results from national audits was not cascaded back to them and were not aware of the actions taken to improve.
  • Appraisal rates across the workforce did not meet the expected trust targets. This was particularly evident for the medical staff.
  • As part of the escalation procedures, extra bed spaces had been created on wards to provide care and treatment to patients. Although risk assessed, these areas were not designed to provide a bed space for patients.

Urgent and emergency services (A&E)

Good

Updated 15 May 2015

Systems were in place for reporting and managing incidents. Patients received care in safe, clean and suitably maintained environments with the appropriate equipment. Medicines were not managed consistently in line with requirements. This was because the controlled drugs registers had not always been signed by two staff members when controlled drugs were dispensed and controlled drugs that were wasted (unused) during a treatment had not been recorded since February 2014. Systems to dispose of controlled drugs were not being followed.

 

Patients were assessed for pain relief; however, the pain score had not always been recorded and, when a score was indicated, appropriate and regular pain relief was not always recorded as being given. Staffing levels were sufficient to meet patients’ needs and processes were in place to ensure that resource and capacity risks were managed. The ratio of junior doctors was worse than the England average and the trust was having difficulty recruiting to four additional registrar posts. Shortfalls were covered by locum, bank and agency staff. Security arrangements were in place at the emergency department at Macclesfield but there was no on-site security at the MIU.

 

Overall, the trust had met the national Department of Health target to admit or discharge 95% of patients within four hours of arrival at accident and emergency (A&E) between 5 January 2014 and 28 September 2014. However, we found discrepancies in the recording of waiting times at the MIU. Waiting times were recorded only from when the nurse actually saw and treated the patient to when the patient was discharged. This meant that data did not provide an accurate picture of the waiting times for this service. Overall however, this had limited impact on the trust’s waiting time targets.

 

Care and treatment provided were evidence-based and adhered to national guidance. We saw effective collaboration and communication among all members of the multidisciplinary team and services were geared to run seven days a week. Staff treated patients with dignity, compassion and respect, even while working under pressure.

 

The trust’s vision and strategy had been cascaded to all staff, and staff were proud of the work they did. Key risks and performance data were monitored. There was clearly defined and visible leadership and staff felt able to challenge any staff members who were seen to be unsupportive or inappropriate in carrying out their duties. The emergency department faced challenges such as patient flow and local changing needs, including an increased elderly population, but it had initiatives in place to tackle these.

Surgery

Good

Updated 12 April 2018

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

  • The service provided mandatory training in key skills to all staff.
  • There were arrangements in place to help safeguard adults and children from abuse and neglect.
  • The service controlled infection risks well and used control measures to prevent the spread of infection
  • The service had suitable premises and equipment and staff looked after the majority of them well.
  • Risks to people using services were assessed, monitored and managed on a day to day basis.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up to date and available.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose.
  • The service managed patient safety issues well. Staff recognised incidents and reported them appropriately.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service gave patients enough food and drink to meet their needs and improve their health.
  • Staff assessed pain levels and provided pain relieving medicines when required.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff worked together as a team to benefit patients and supported each other to provide care.
  • Patients were comprehensively assessed so that their clinical needs and general health status could be considered
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.

However:

  • The risk of unauthorised access in theatre areas was not always managed effectively.
  • The safe storage of medicines was not always consistent. For example the recording of maximum and minimum fridge temperatures was not always monitored in line with guidance.
  • Risk assessments were completed when necessary but assessments did not include all of the potential risks. I

  • Staff were competent in their role however the service did not always ensure that this was recorded and monitored using the trust individual staff self-assessment scoring system.
  • Patients were not always able to access the service when they needed it. Waiting times for treatment and arrangements to admit, treat and discharge patients were not always in line with good practice.
  • Information systems used to share information electronically with staff was not wholly effective. Staff struggled to locate information.

Intensive/critical care

Good

Updated 15 May 2015

The introduction of the National Early Warning Score (NEWS), a system used to determine whether or not a patient’s condition was deteriorating, had been effective and audits had shown a marked improvement in the recording and use of observations. However, the outreach service that provided support for the management of deteriorating patients on the wards was limited to weekdays only with no out-of-hours or weekend support provided. Consultant cover was limited due to only six of the nine consultants being trained in intensive care. Also, there was a reliance on locum cover for junior doctors’ vacancies. Only 80% of patients were assessed by a consultant within 12 hours of admission to the CCU and the provision of two daily ward rounds was not achieved at weekends.

 

Care was delivered in the CCU by a well-led team of competent nursing staff and in accordance with national and best practice guidance, for example National Institute for Health and Care Excellence (NICE) guidance. The service was effective at monitoring, managing and improving patient outcomes. Patients and relatives spoke positively about the care they had received and the kindness and efficiency of the staff. Staff were responsive to patient feedback and used information to improve the quality of the service.

 

There were reliable and effective systems in place, including for reporting and learning from incidents. Infection prevention and control measures, including hand washing and the use of personal protective equipment, were practised well and the unit was found to be clean and well maintained. There were reliable planned maintenance systems in place to ensure that equipment was available for use and fit for purpose.

Services for children & young people

Good

Updated 12 April 2018

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

  • Action had been taken and the service had improved since our previous inspection.
  • The service provided mandatory training in key skills to staff. Mandatory training had been improved since the previous CQC inspection through the development of a paediatric essentials course.
  • There were arrangements in place to help safeguard children and young people from abuse and neglect.
  • The service controlled infection risks well and used control measures to prevent the spread of infection. Cleanliness, infection control and hygiene had improved since our previous inspection and effective systems and processes were now in place.
  • The service had systems in place to assess and respond to risk. Children and young people were monitored for signs of deterioration using a paediatric early warning score system (PEWS). A sepsis tool was used to help staff escalate appropriately when signs of sepsis had been detected.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience, most of the time, to keep people safe from avoidable harm and to provide the right care and treatment.
  • Record keeping had been identified as requiring improvement at the last inspection and the staff had been working to improve this. Staff now kept appropriate records of patients’ care and treatment.
  • Medicines were managed and stored safely and securely.
  • The service provided care and treatment based on national guidance and used the findings to improve them.

However:

  • There was a shortage of band 6 nurses with APLS training on night shift. This was not compliant with national guidance.

End of life care

Requires improvement

Updated 15 May 2015

Consultant and specialist palliative care services were available but lacked clear lines of communication between them. There was a committed specialist palliative care team but end of life care services lacked organisational structure and leadership. The palliative care service was limited to weekdays only with only informal consultant cover provided during periods of absence. Staff had not received any training for end of life care in the past six months due to staff shortages. There were variations in the completeness of DNA CPR forms across the hospital. Forms were supposed to be reviewed daily but evidence suggested that this did not happen consistently. Action plans had been developed in response to the National Care of the Dying Audit of Hospitals (NCDAH) but their implementation was only partially completed at the time of the inspection. There was evidence of good multidisciplinary team working on the wards and that pain relief was managed effectively. In the main, medicines were managed safely and administered by competent staff. However, some ‘when required’ (PRN) medicine such as pain relief did not have a maximum dose prescribed that could be administered within a 24-hour period. This meant that patients could potentially receive more than the recommended dose.

 

Most staff were aware of how to report and respond to incidents and they received feedback to ensure that they learned from incidents. Safeguarding systems were well embedded in the service. In the NCDAH for 2012/13, the trust had performed in line with or better than the England average for 14 of the 17 key performance indicators. The end of life care plan introduced in July 2014 had been developed to replace the Liverpool Care Pathway. The plan included guidance for the care team about recognising and responding to deteriorating patients to ensure that their care was timely and managed effectively and that patients’ preferred priorities for care were met.

 

The fast-track system worked well and requests were usually fulfilled within a day. There was evidence to show that most people managed to die in their preferred place of care. Consultants commented on the timely response they received to requests for support from the palliative care consultant. Patients and relatives had confidence in the medical and nursing staff and felt that they had been involved in planning their end of life care. Staff were observed to listen and respond appropriately to patients’ requests in a kind and caring manner. Patients and relatives told us that they found the staff to be kind and understanding and they spoke highly of the care and support provided.

Other CQC inspections of services

Community & mental health inspection reports for Macclesfield District General Hospital can be found at East Cheshire NHS Trust.