Macclesfield District General Hospital

Updated 4 October 2019

Macclesfield District Hospital has approximately 344 general and acute beds and six critical care beds. The emergency department is a type one department that treats approximately 50,000 new patients per annum.

Macclesfield District Hospital provides urgent and emergency care, medicine, surgery, critical care, maternity, children and young people’s services, end of life care and outpatients services.

At this inspection, we inspected urgent and emergency care services, critical care services, end of life care services and outpatient services.

Updated 4 October 2019

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

• We previously inspected and rated safe in medical care, surgery and services for children and young people as requires improvement.
• At this inspection, we rated responsive in urgent and emergency care and outpatients as requires improvement.
• We found patients could not always access services when needed and receive treatment within national expectations or NHS consitutional standards, particularly within the emergency department and outpatients.

However:

• We previously inspected and rated medical care, surgery, maternity and services for children and young people as good overall. At this inspection we inspected and rated urgent and emergency care, critical care, end of life care and outpatients as good.
• The services had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Incidents were managed well and learning was disseminated to all staff. Infection control processes were in place and staff could identify deteriorating patients and escalate them appropriately.
• Staff provided treatment based on national guidance and best practice. The effectiveness of care and treatment was monitored and findings were monitored to make improvements. Staff were competent for their roles and all staff worked together as a team for the benefit of patients. Most services were available seven days a week to support patient care. Consent processes were followed and patients were supported who lacked capacity.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The services planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. The service took account of patients individual needs and made reasonable adjustments.
• Leaders were visible and approachable and the services used systems to manage services effectively. Governance processes were in place and staff were clear about their roles. Staff felt respected and valued and there was a good open culture and engagement of staff and patients. There was continuous learning and improvement in the hospital.

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.

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.

Updated 4 October 2019

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

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Updated 4 October 2019

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

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, attended to nutrition and hydration needs appropriately, and gave them anticipatory pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Compliance with mandatory training was low for the specialist palliative care team.
• Specialist end of life services were only available during weekdays in the hospital.
• There was no dedicated bereavement officer or office at the trust.
• The risk register did not record all identified risks for the service.

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.

Updated 4 October 2019

We rated this service as good because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. However, staff did not always keep up to date records.
• Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People requiring urgent care were seen promptly.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• People requiring routine treatment could not always access the service when they needed it and there were long waits for some specialities.

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.

Updated 4 October 2019

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

• The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Incidents were managed well and learning was disseminated to all staff. Infection control processes were in place and staff could identify deteriorating patients and escalate them appropriately.
• Staff provided treatment based on national guidance and best practice. The effectiveness of care and treatment was monitored and findings were monitored to make improvements. Staff were competent for their roles and all staff worked together as a team for the benefit of patients. Services were available seven days a week to support patient care. Consent processes were followed and patients were supported who lacked capacity.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. The service took account of patients individual needs and made reasonable adjustments.
• Leaders were visible and approachable and the service used systems to manage services effectively. Governance processes were in place and staff were clear about their roles. Staff felt respected and valued and there was a good open culture and engagement of staff and patients. There was continuous learning and improvement in the department.

However

• Staff did not always assess and monitor patients regularly to see if they were in pain and give pain relief in a timely way.
• Patients could not always access services when needed and receive treatment within agreed timeframes in accordance with NHS constitutional standards.
• Equipment was not always checked according to trust policy.
• Documentation was not always fully completed.