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Inspection Summary


Overall summary & rating

Good

Updated 4 July 2019

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

  • Mandatory training compliance had improved since the last inspection. Safeguarding training and there were systems in place to protect patients from abuse. Vulnerable people were supported and their needs and preferences were addressed in a proactive way.
  • The services monitored patient safety incidents, learned from these incidents and fed back to staff. Information gathered from patient safety information was used to improve patient safety.
  • Multidisciplinary team working was evident across all the services we inspected. Staff worked with other agencies in a collaborative way.
  • There were strong processes around the assessment of patients’ mental capacity and good documentation that supported this.
  • Staff were caring and respected patients’ privacy and dignity.
  • There was a focus and action was being taken to improve access and flow for patients to reduce length of stay, to decrease readmission rates and to ensure that patients were treated in the right place at the right time.
  • There was a positive culture and staff liked working at the hospital. Senior managers were visible in the organisation and there were systems in place to reduce risk and to address performance. There was a systematic approach to continuous service development and improvement.

However:

  • There were limitations in the provision to meet the needs of children attending the paediatric emergency department. There were times when the children’s paediatric emergency department and some medical wards were not appropriately staffed.
  • There were some gaps in records within the emergency department and some medical wards.
Inspection areas

Safe

Good

Updated 4 July 2019

Effective

Good

Updated 4 July 2019

Caring

Good

Updated 4 July 2019

Responsive

Good

Updated 4 July 2019

Well-led

Good

Updated 4 July 2019

Checks on specific services

Services for children & young people

Good

Updated 7 February 2017

Children’s and Young Peoples were good at the Tameside General Hospital . This is because:

  • We saw evidence that incidents were being reported and that information following clinical incidents was fed back to staff.
  • Cleanliness and hygiene was of a good standard and staff followed good practice guidance in relation to the control and prevention of infection.
  • Staff were aware of their roles and responsibilities with regard to safeguarding and knew how to raise matters of concern appropriately.
  • The service used national guidelines to determine care and treatment and there were a number of evidence-based pathways in place.
  • Care was provided by committed, compassionate staff who were enthusiastic about their role. Parents felt confident about leaving their baby in the neonatal unit.
  • The Community Children’s Nursing team (CCNT) provided intervention to help avoid hospital admission, reduce the time children spent in hospital and prevent readmissions.
  • Quality and performance were monitored through paediatric and divisional dashboards.
  • The children’s unit had won the Nursing Times Student Placement of the Year award for 2016.
  • Safety testing for equipment was in place however we observed two ventilators that had not been serviced since 2013 and six breast pumps that had been due for servicing in 2014 on the neonatal unit. We reviewed this equipment on our unannounced visit and noted that servicing had taken place.
  • Of the nine band 6 and 7 paediatric nurses on the children’s unit, all had completed Advanced Paediatric Life Support (APLS) with the exception of two new staff, however only three were up to date at the time of our inspection. Plans were in place for three staff to attend a course in September 2016 and three in January 2017. Risk was mitigated by the on-site presence of a paediatric registrar at all times. advanced paediatric nurse practitioners, working in the paediatric emergency department had also completed APLS.

Critical care

Good

Updated 7 February 2017

We have rated critical care services as “good” overall. This is because;

  • There were sufficient numbers of suitably skilled nursing and medical staff to care for the patients.
  • We found a culture where incident reporting and learning was embedded and used by staff.
  • Care was delivered in line with evidence- based, best practice guidance.
  • There was strong clinical and managerial leadership at unit and divisional level.
  • There was an effective governance structure in place.
  • Patients and their relatives were cared for in a supportive and sympathetic manner and were treated with dignity and respect.

However,

  • The data showed there was an issue with comparatively high numbers of out of hours discharges when compared with similar units.

End of life care

Good

Updated 7 February 2017

We rated end of life care services as ‘good’ overall, because:

  • Care and treatment was provided safely to patients at the end of life. Infection control and prevention was embedded in the service. The environment from the wards to the bereavement centre and the mortuary was appropriate for the services provided. Staff were trained appropriately and used suitable tools and observations to identify and respond to patients who were deteriorating. Anticipatory medication for end of life was prescribed in line with the trust’s policies. There had been no serious incidents relating to end of life care.

  • The palliative clinical nurse specialist team and complex discharge team provided a seven-day service. The HSPC team were available Monday to Friday. The mortuary team were on-call to attend out of hours. The end of life care provided was in line with evidence based professional guidelines, and work was ongoing to improve the services provided following the end of life care audit. The HSPC team, the end of life facilitator and the mortuary manager were integral in developing and delivering additional training to nursing and medical staff throughout the trust in end of life care and care after death. There was effective and collaborative multidisciplinary working.

  • All staff involved in end of life care were passionate about, and delivered, compassionate care and supported patients and their relatives emotional, and spiritual, needs. Patients and relatives spoke positively about the care and information that had been provided to them. The same level of caring, sensitivity and respect was evident in the care after death provided by the bereavement and mortuary teams.
  • Arrangements were in place for the rapid or fast discharge of end of life patients to their preferred place of care, which included transfer to hospice within two hours. The trust was able to carry out post mortem scans where requested, and authorised by the coroner, which responded to the funerary needs of faiths other than the Christian belief.
  • End of life care services were represented on the trust’s board by a non-executive director. The end of life strategy fed into the division’s wider strategy, including national and regional healthcare developments. There was a clear reporting structure in place; the leaders were visible, approachable and supported staff. The service engaged the local public in the Dying Matters campaign and were working closely with local students to develop the memory tree and garden for the bereavement centre.

However,

  • The service had more work to do to further encourage and increase the use of individual plans of care that take into account end of life care patients’ individual needs and those of their families, and to meet its internal key performance indicator on this. There was inconsistency in the quality and completion of do not attempt resuscitation (DNACPR) forms in some parts of the hospital, and some information within the wards’ end of life link nurse files were out of date. Although there had been a small increase in the proportion of people dying in their preferred place of care, this remained lower (worse) than the regional or national average. The proportion of patients, for whom rapid or fast discharge had been requested, that were discharged within the defined timescales was low.

Outpatients and diagnostic imaging

Good

Updated 7 February 2017

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We rated outpatients and diagnostic imaging services as good overall. This was because:

  • Staff were confident about raising incidents and there were systems in place for feedback and learning from incidents and complaints. The trust had strong arrangements in place to ensure that Duty of Candour was applied accordingly, in accordance with the Health and Social Care Act 2008 and that patients received an apology, full explanation and were supported going forward.
  • Staffing levels were appropriate to meet patient needs although increased demand on radiology services meant that some reporting on diagnostic imaging was outsourced overnight. There was ongoing forward planning on future staffing requirements.
  • There were appropriate protocols for safeguarding adults and children and staff followed safety procedures to keep patients safe.
  • Equipment was maintained and the environment was clean with steps being taken to minimise infection risks.
  • The trust reacted to new guidance and procedures accordingly and were proactive in looking at successful evidence-based care and treatment in other trusts to drive improvements. Audit outcomes were discussed with staff to seek solutions and improve.
  • Services were delivered by caring, committed and compassionate staff who treated people with dignity and respect.
  • The trust had made huge improvements in Referral to Treatment (RTT) times and was actively seeking improvements all the time to ensure that all clinical pathways met England standards.
  • There was a clear vision and strategy in place for improving the outpatients and diagnostic imaging services with identified problems, proposed solutions, clear targets, future performance measurements and achievements to date.
  • We saw a number of innovative practices to improve services and patient experiences and the trust sought potential solutions by researching with an outward vision and with a mind for minimum disruption to patients.

However,

  • The trust had staffing shortfalls in radiologists and were having difficulty in recruiting new staff due to a national shortfall. They were reliant on locum coverage to meet safe staffing levels.

Surgery

Good

Updated 7 February 2017

We gave the surgical services at the Tameside General Hospital an overall rating of ‘good’. This was because:

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in visibly clean and appropriately maintained premises.

  • The surgical services reported one ‘never event’ between June 2015 and May 2016. Remedial actions such as staff training and policy updates were taken to learn from the incident. The theatre teams followed the ‘five steps to safer surgery’ procedures and staff adherence to was monitored through routine audits.

  • The services provided effective care and treatment that followed national clinical guidelines and staff used care pathways effectively. The services performed in line with the England average for most safety and clinical performance measures.

  • Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. The majority of staff had completed their annual appraisals and achieved with the hospital’s internal targets.

  • The surgical services achieved the 18 week referral to treatment standards across most specialties. Actions were taken to improve compliance in the surgical specialties where these standards had not been achieved, such as for trauma and orthopaedics.

  • There were 243 elective operations cancelled on the day of surgery between July 2015 and June 2016. The most frequent reason for these cancellations was bed unavailability. There had been no non-elective (emergency) surgery operations during this period. The services also performed better than the England average for the number of patients whose operations were cancelled and were treated within the 28 days.

  • The theatre service improvement project included actions to improve efficiency and minimise patient delays. Measures such as the ‘golden patient’ had led to improvements in the number of theatre lists starting on time. The hospital had also launched ‘Home First’ initiative, which aimed to reduce bed occupancy by supporting suitable patients to receive care in their own place of residence.

  • There were systems in place to support vulnerable patients. Staff applied ‘reasonable adjustment’ principles for patients with learning disabilities and care plans were in place to instruct staff on how to care for patients with learning disabilities.

  • Patients and their relatives spoke positively about the care and treatment they received. They told us they were kept fully involved in their care and the staff supported them with their emotional and spiritual needs. Patient feedback from the NHS Friends and Family Test showed that most patients were positive about recommending the surgical wards to friends and family.

  • The hospital’s values and objectives had been cascaded across the surgical services. Key risks to the services, audit findings and performance was monitored though routine departmental and divisional governance and quality and safety meetings.

  • The staffing levels and skills mix was sufficient to meet patients’ needs. Most staff had completed their annual appraisals and mandatory training. However, the mandatory training completion rate was below the hospital’s internal target.

  • There was effective teamwork and visible leadership across the services. Staff were positive about the culture within the surgical services and the level of support they received from their managers. Complaints were resolved in a timely manner and shared with staff to aid learning.

Urgent and emergency services

Good

Updated 4 July 2019

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

  • The trust had improved their mandatory training levels since our last inspection.
  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. For example, systems to escalate concerns were in place ensure vulnerable adults and children were safe from abuse. The service encouraged an open and transparent culture about safety, staff were confident in reporting incidents and felt supported to do so. We saw that senior managers investigated incidents appropriately when something went wrong.
  • Staff managed and stored medicines correctly in most areas. All medication records we reviewed, accurately reflected the medication stocked in cupboards.
  • Staff were supported to deliver effective care and treatment, including through meaningful appraisals that supported their learning and development objectives.
  • Staff from different teams and services worked together to assess, plan and deliver patient care. We saw examples of collaborative working amongst different services to meet the needs of patients.
  • Staff in the adult emergency department proactively signposted patients to services within the hospital and external organisations if they wanted support and advice on how to improve their health and wellbeing.
  • Most staff responded compassionately when people needed help and they supported them to meet their basic personal needs. All staff involved patients and carers in making decisions about their care and most patients felt well informed.
  • Since the last inspection, the flow throughout the department had improved. Although the trust did not meet the Department of Health’s target of 95% of patients admitted, transferred or discharged within four hours of arrival at the department between December 2017 to November 2018, they had put a range of streaming systems in place to admit, transfer and discharge patients within four hours of arrival.
  • Leaders had the experience and capacity, capability and integrity to ensure that the emergency department strategy could be delivered.
  • Leaders were visible in the department, there were processes in place to support succession planning amongst the team.
  • The governance structure ensured there were lines of accountability. Processes supported joint working arrangements and quality and performance. For example, senior managers attended meetings with the ambulance service to discuss category 3 and 4 cars pilot scheme.
  • We saw that there were effective and comprehensive processes in place to identify, understand, monitor and anticipate current and future risks. There were clear routes of escalation to ensure risks were regularly reviewed. For example, the department coordinator used a predictive dashboard that used data from the following year to anticipate the number of attendees to the department during that day.

However,

  • There were times when the children’s paediatric emergency department was not adequately staffed. The service did not always have a minimum of two paediatric staff on duty to meet national recommendations. A business case for additional paediatric nurses, in line with the national standards was being submitted in May 2019. Additional funding had been authorised.
  • At the time of inspection, the children’s paediatric emergency department was not staffed with a paediatric emergency medicine consultant with dedicated session time allocated to paediatrics.
  • The service did not conduct hourly intentional rounding in line with national guidelines so that aspects of care such as pain, personal needs and positioning could be regularly checked. Instead the coordinator carried out two hour and 30 minutes comfort rounds that were documented within the national early warning score documentation.
  • We could not be assured that the content in pathways, policies and processes were in line with up to date evidence-based guidance and standards set by organisations like the National Institute of Health and Care Excellence and the Royal College of Emergency Medicine. We found examples of flowcharts, assessment tools and guidance that had not been referenced or were overdue review.
  • Some records were not fully completed. For example, capacity assessments and referrals to the Raid Assessment Interface and Discharge team were not always completed.
  • We found staff in the children’s emergency department were inconsistent with their support to parents.
  • The trust did not meet their national performance targets for patients admitted, transferred or discharged within four hours of arrival at the department.
  • The trust did not meet national performance targets that state that the time patients should wait from time of arrival to receiving treatment should be no more than one hour.

Medical care (including older people’s care)

Good

Updated 4 July 2019

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

  • There was training and development in place for staff so that they were competent for their roles. This included safeguarding training and there were systems in place to protect patients from abuse.
  • The service monitored patient safety incidents, learned from these incidents and fed back to staff. Information gathered from patient safety information was used to improve patient safety.
  • Multidisciplinary team working was evident and was used to improve patient safety, patient outcomes and supported patient flow through the hospital. Staff also worked with other agencies in a collaborative way.
  • There were strong processes around the assessment of patients’ mental capacity and good documentation that supported this.
  • Staff were caring and respected patients’ privacy and dignity. Staff involved carers and relatives in decisions about patients’ care. Work was ongoing to improve interactions between staff, patients and carers to improve patient care, this had a positive impact on patient safety.
  • The service was striving to improve access and flow for patients to reduce length of stay, to decrease readmission rates and to ensure that patients were treated in the right place at the right time. Vulnerable people were well supported and their needs and preferences were addressed in a proactive way.
  • There was a positive culture and staff liked working at the hospital. Senior managers were visible in the organisation and there were systems in place to reduce risk and to address performance. There was a systematic approach to continuous service development and improvement.

However

  • On some wards we were not always assured that nurse staffing levels were appropriate for the acuity of the patients.
  • Records were not always fully completed on all wards.
  • Attendance at the service’s quality, operational governance group was sometimes poor with many members failing to attend.

Maternity

Good

Updated 4 July 2019

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

  • The service had improved the concerns around safety we had identified at the previous inspection in relation to the storage of records, compliance with mandatory training, and risk assessments to assess and escalate risks of deterioration.
  • There were systems and processes for safeguarding women and babies, including training to level three in safeguarding children, and regular supervision sessions by the safeguarding lead midwife
  • There were processes to prevent infection risk and maintain cleanliness and hygiene.
  • Staffing numbers and skill mix for medical and midwifery staff were sufficient to meet patient needs at the time of our inspection and the service used national guidance to assess and plan safe staffing.
  • The service managed patient safety incidents well and there was evidence of learning and actions following incidents.

  • The service provided care and treatment based on national guidance and monitored performance. They were performing well in relation to the ‘Saving Babies Lives’ care bundle, they were one of the top ten maternity services in the country for detection of foetal growth restriction.
  • Staff had the competencies and skills to carry out their role and were supported to maintain and develop competencies. Staff of different kinds worked together as a team to benefit patients and there were examples of good multidisciplinary working, such as involvement in a regional maternity working group and multidisciplinary team learning days.
  • The service had initiatives to promote the health of women and babies and involve women in their own health.
  • Staff were caring and compassionate in their interactions with women and families and all staff displayed a clear patient focus.
  • The trust planned and provided services in a way that met the needs of local people and took account of women’s individual needs. There was an enhanced care team of midwives who supported women with complex needs.
  • There were initiatives to meet and promote individual needs. The service had received approval to develop an aromatherapy workshop service; and the service provided ‘baby bundles’ and cribs to mothers who were not able to purchase or access these resources themselves.
  • Access and flow was well managed and there was evidence of learning from complaints and feedback.
  • There was a positive team-based culture and staff were engaged with and proud of their work. Senior managers were visible in the organisation and there were systems in place to reduce risk and to address performance. There was a systematic approach to continuous service development and improvement.

However:

  • We identified concerns in relation to the storage and tracking of medicines to take out in the maternity ward, this was immediately addressed when we raised it.
  • At the end of 2018 there had been a theme of missed postnatal visits in the community, this was acted on promptly and there was evidence of improvement by the time of our inspection.
  • The service’s last deanery review in May 2018 had highlighted some concerns for junior doctors in the service, there had been actions taken and we saw evidence of improvement at the time of our inspection.
Other CQC inspections of services

Community & mental health inspection reports for Tameside General Hospital can be found at Tameside and Glossop Integrated Care NHS Foundation Trust.