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Reports


Inspection carried out on 08/08/2016 to 11/08/2016

During a routine inspection

Tameside General Hospital is part of Tameside and Glossop Integrated Care NHS Foundation Trust and provides a full range of hospital services, including general and specialist medicine, general and specialist surgery and full Consultant led obstetric and paediatric hospital services for women, children and babies.

Tameside General Hospital is situated in Ashton-under-Lyne. The hospital services a population of approximately 250,000 residing in the surrounding area of Tameside in Greater Manchester, and the town of Glossop in Derbyshire. In total, the trust has 528 beds.

We carried out this inspection to see whether the hospital had made improvements since our last inspection in April 2015. Following our inspection in April 2015 we rated the hospital as requires improvement overall. We judged the hospital to be requires improvement for safe, effective and responsive and good for caring and well led.

We visited the hospital as part of our comprehensive announced inspection on 8 to 11 August 2016. We also carried out an out-of-hours unannounced visit on 18 August 2016. The inspection team inspected the following core services:

  • Urgent and emergency services
  • Medical care services (including older people’s care) including the Stamford Unit
  • Surgery
  • Critical care
  • Maternity and gynaecology
  • Children and young People
  • End of life care
  • Outpatients and diagnostic services

The Stamford Unit is a recently opened community facility to support patients who are determined to be medically fit for discharge. The patients require further support in a non-acute setting to be assessed and discharged into the community. However, we did not rate the service provided as the unit had only been opened for three weeks prior to the inspection and we did not have sufficient data to fully consider this.

A separate report is available with regard to this service.

Overall, we rated Tameside General Hospital as ‘good’. We noted that there had been significant improvements in some areas since our last inspection

Our key findings were as follows:

Access and Flow

  • Access and flow in the emergency department remained a continuous challenge.
  • From March 2015 to April 2016, the trust did not meet the Department of Health Standards to

Transfer or discharge patients within four hours of arrival and the decision to admit patients within four to 12 hours for nine out of 12 months.

  • Data showed the percentage of patients leaving before being seen was consistently worse than the England average for same period.
  • Again, from March 2015 to April 2016, the total time patients spent in the emergency department (average per patient) was consistently worse than the England average.
  • There were 211 black breaches from May 2015 to May 2016. Black breaches occur when the time from an ambulance’s arrival to the patient being handed over to the department staff is greater than 60 minutes.
  • The trust had an escalation process in place for periods when there was increased demand. The purpose of this process was to ensure the effective management of the trust’s bed capacity and to give staff clear processes and triggers to follow. We found that the actions set out in this process were followed when increased pressure was experienced.
  • There were bed meetings held three times a day. These meetings were attended by senior nursing staff from the ward areas, patient flow team and the emergency department team.
  • Between February 2016 and July 2016, there were a total of 526 medical patients admitted across the three surgical wards (medical outliers). Medical outlier patients were seen daily by medical doctors. In the course of the inspection, we were informed by ward managers that it was very rare for a surgical patient to be placed on a medical ward.
  • There was a focus on discharge planning on all the wards. Following multi-disciplinary meetings discharge plans were made for each patient based upon their progress.
  • The trust had made significant improvements with regard to Referral to Treatment (RTT) waiting. In terms of RTT standards, the trust was now at mid-table level in terms of achieving standards and had previously been in the bottom six trusts nationally.

Cleanliness and Infection control

  • Generally patients were cared for in a visibly clean and hygienic environment.
  • Staff followed the trust’s policy on infection control and adhered to the ‘bare below the elbows’ policy.
  • Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
  • There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There was a suitable supply of hand wash sinks and hand gels available.
  • Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.
  • Patients identified with an infection were isolated in side rooms. We saw that appropriate signage was used to protect staff and visitors.
  • Public Health England data for surgical site infections showed the hospital performed similar to or better than the national average for the proportion of patients that acquired surgical site infections following surgery.
  • However, in maternity and gynaecology quarterly infection prevention and control audits were completed and ward 27 had scored 83% in April 2016. Issues remained during the inspection, which had not been identified or rectified following the ward audits. These included scuffed wooden surfaces, doorways and equipment which could not be thoroughly cleaned, tears in a seat cover, chipped paint and loose plaster, rusty waste bins and a perished area on a cot mattress. At the unannounced inspection a more thorough audit had been completed and some items had been removed or replaced. A programme of deep cleaning refurbishment was planned.

Nurse staffing

  • Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services.
  • The expected and actual staffing levels were displayed on a notice board on each unit/ward and these were updated on a daily basis.
  • Staffing levels were planned to ensure an appropriate skill mix to provide care and treatment for patients.
  • The ward managers carried out daily staff monitoring and escalated staffing shortfalls due to unplanned sickness or leave.
  • The number of midwives were appropriate to meet the needs of the patients in both maternity and gynaecology services.
  • However, nurse staffing levels, although improved, remained a challenge in some areas. This was particularly the case in medical care services.
  • We were able to review a report produced on the 27 April 2016. The report showed a number of wards in the medical directorate which were below 80% fill rates for qualified day staff. The report highlighted issues in ward 41, 44 and 46 where qualified fill rates were between 79% to 74%.
  • During the unannounced inspection, there was a shortage of two qualified nurses on 41, one bank nurse was deployed and the band seven nurse in the unit moved a member of staff from their ward to cover the remaining shortfall. This meant they were unable to carry out the quality safety round conducted by the band seven nurse each evening to ensure their ward remained safe. They had informed the wards and were available for telephone contact.
  • 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.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff who worked well with other disciplines to deliver safe quality care.
  • The proportion of middle career doctors and junior doctors within the trust was greater than the England average. The proportion of consultants was below the England average (37% compared with the England average of 42%). The proportion of registrars was also below the England average (27% compared with the England average of 36%).
  • These figures were an improvement from last year and the urgent and emergency care department had slightly above the England average number of consultants.
  • Staff rotas were maintained by the existing staff and through the use of agency or locum consultants when needed. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The majority of locum and agency doctors had worked at the hospital on extended contracts so they were familiar with the hospital’s policies and procedures.

Mortality rates

  • Following concerns that the trust was either a risk or an elevated risk for the some mortality outliers including gastroenterological and hepatological conditions and procedures, infectious diseases, nephrological conditions, vascular conditions and procedures, a process to review every death had been started by the trust. This provided an assurance of safe and quality care delivery and was recognised by the clinicians as not just a box ticking exercise.
  • Mortality review outcomes were discussed at a mortality steering group chaired by the medical director, which fed into the service quality and operational governance group and the quality and governance group for oversight and scrutiny. Lessons learned were disseminated through the divisional governance structure to enable appropriate actions to be embedded and learning from mortality reviews to be shared by divisional teams.

Meeting the needs of disabled patients

During the inspection, we carried out a pilot inspection looking at how the trust met the needs of disabled people. The main findings are contained in the responsive section of the provider report. However, below is a summary of our findings:

  • A bespoke system electronically tracked every patient with learning disabilities in the hospital, which was overseen by a named lead nurse in learning disabilities.
  • All patients with a learning disability were referred to the learning disabilities nurse by fax on admission.
  • When a patient with a disability was moved, an email would be sent to ward managers reminding them to be mindful of reasonable adjustments for that patient. Patients would also be put on a reasonable adjustments care pathway, and where necessary their carer had their own care pathway.
  • There was a team of volunteers who provided mobility scooters by request and supervised their use throughout the trust so patients with mobility difficulties could move through the site easily. There were also volunteers who would sit with sensory impaired patients to guide them through their hospital journey on request. Volunteer help could be booked in advance by phone or at any reception desk.
  • The hospital had two wards designed for dementia patients, which included dementia friendly ‘reminiscence rooms’. Material and information was also available throughout the rest of the hospital, such as ‘twiddle-muffs’ to keep patients occupied and engaged. Every ward we saw had a comprehensive information board on dementia with contact details for the admiral nurse. However, there were no set activities for dementia patients at the time of inspection.

We saw several areas of outstanding practice including:

Urgent and Emergency Services

  • The department’s practice development nurse provided excellent support and education to the staff within the department.
  • The department’s handling or the major incident, which occurred during the inspection, was excellent and ensured that patients were treated in the most appropriate and safe manner.
  • The divisional leaders made great efforts to ensure that they were visible at all times, especially during times of pressure.

Surgical Services

  • Ward staff applied ‘reasonable adjustment’ principles for patients with learning disabilities and specific care plans were in place to provide guidance for staff. The care plans took into account factors such as the environment, communication (e.g. use of communication books or easy read leaflets), staffing, equipment requirements and procedures (such as booking patient first or last on list).

Maternity and gynaecology

  • A programme for supporting and informing pregnant women with alcohol consumption problems had been developed. MAMA (Maternal Alcohol Management Algorithm) was managed by the safeguarding lead midwife. This provided pathways into related services in the community including rehabilitation day services, community support and detoxification support.

End of life care

  • The trust had direct access to electronic information held by community services, including GPs. This meant hospital staff could access up-to-date information about patients, for example, details of their current medicine.

Outpatients and diagnostics

  • The radiology department offered a “Virtopsy Service”. This virtual post-mortem service was used when a CT scan could determine the cause of death. This speeded up the process of determining cause of death and respected the religious and cultural needs of some of the local population. Scans were carried out at night and reporters were experts in reporting on virtual post-mortems. Deceased persons were transported to the unit via a private corridor. The trust were one of the first in the North West to offer this service.

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

Action the hospital MUST take to improve

Urgent care

  • Ensure that patients can access emergency care in a timely way.
  • Ensure all staff receive mandatory training at the required level and within the appropriate time frame.
  • Ensure that fridges used to store medications are kept at the required temperatures and checks are completed on these fridges as per the trust’s own policy.

Medical Services Including Older People

  • Ensure there are appropriate numbers of nursing staff deployed to meet the needs of patients.

Children and Young People

  • Ensure all equipment used to provide care or treatment to a service user is properly maintained.
  • Ensure that there is one nurse on duty on the children’s ward trained and up to date in Advanced Paediatric Life Support on each shift.

In addition the trust should:

Action the hospital SHOULD take to improve

Urgent and emergency care

  • Ensure that staff receive their annual appraisal.

Medical services including Older people

  • Ensure children’s safeguarding training across all professions within the medical directorate is up to date.
  • Look to reduce the number of medical patients being cared for on surgical wards.
  • Continue to monitor staffing arrangements on wards.

Surgical Services

  • Take appropriate actions to improve mandatory training compliance rates.

  • Take appropriate actions to reduce the number of cancelled elective operations.

Maternity and gynaecology

  • Ensure the improvements in the infection prevention and control measures and the environment on ward 27 should continue.
  • Emergency medicines should be safely stored in the obstetric theatre in line with trust’s policy for the safe use of emergency medicines.
  • Appropriate actions should be taken to improve the mandatory training compliance rates for infection control and children's safeguarding.
  • Records should be securely stored in the ward areas.
  • Ensure that a deteriorating patient‘s care was managed in line with the trust’s policy.
  • Continue to make improvements in the completion of the safer surgery checklists.
  • Develop a system to ensure patients received required home visits by the community midwives.

Children and Young People

  • Ensure recording of fridge checks include the maximum and minimum temperatures in accordance with national guidance.
  • Ensure dates of cleaning and safety checks are legible on equipment.
  • Review documentation for infants when intervention is reduced to high dependency or special care.
  • Ensure the security and confidentiality of medical records in the paediatric outpatients department.
  • Ensure PEWS documentation is completed and audited to improve compliance.
  • Ensure the neonatal unit consistently collect patient feedback using the NHS Friends and Family Test.
  • Ensure inpatient discharge summaries and outpatient clinic letters are sent in a timely way.
  • Ensure regular staff meetings take place on the neonatal unit.

End of life care

  • Consider how it can increase uptake of the use of the individual care plan for end of life care patients.
  • Consider how it can encourage improvement in the accuracy and completeness of DNACPR forms, including the undertaking and recording of mental capacity act assessments, the recording of best interests decisions, and discussions with patients and their relatives.
  • Consider reviewing information held within the palliative rapid discharge link nurse files held in wards and units across the trust to ensure the information held is accurate, up to date, and in line with prescribing and dosage guidelines for anticipatory medicines.
  • Consider what actions it could take to further increase the proportion of end of life care patients dying in their preferred place of care.
  • Consider what actions it can take, within its control and where requested, to increase the percentage of end of life care patients discharged within the timescales of the rapid and fast discharge process.

Outpatients and Diagnostics

  • Continue the active recruitment of radiologists to meet actual WTE requirements and maintain safe staffing levels.
  • Resolve the issue of allied health professionals being unable to accurately record mandatory training levels.
  • Carry out an infection control risk review of positioning aids foam pads in radiology, to ensure that the risk of infection is minimised.
  • Ensure that all entries on patient notes are signed and dated.
  • Continue to increase the numbers of staff who have undertaken children’s safeguarding training to meet trust targets.
  • Review version controls on Local Rules for Radiation Protection and ensure that all staff have signed them to indicate that they have read and understood them.
  • Continue to seek a solution to the lack of an electronic system that interfaces with local GP surgeries.
  • Continue to seek viable solutions to reduce “Did Not Attend” (DNA) rates.
  • Continue to seek solutions to improve “Referral to Treatment” (RTT) times so that all clinical pathways met national standards.
  • Review the consultation room in clinic nine where the door opens outwards to improve privacy and dignity for patients.
  • Review the children’s play area in outpatients clinic’s six to nine to see whether this could be better located or children observed and kept safer.
  • Improve patient knowledge of how to access PALS should they need to do so.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 28-29 April 2015 and 14 May 2015

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

Tameside General Hospital is part of Tameside Hospital NHS Foundation Trust and provides a full range of hospital services, including general and specialist medicine, general and specialist surgery and full Consultant led obstetric and paediatric hospital services for women, children and babies.

Tameside General Hospital is situated in Ashton–under-Lyne. The hospital services a population of approximately 250,000 residing in the surrounding area of Tameside in Greater Manchester, and the town of Glossop in Derbyshire. In total, the trust has 524 beds.

We carried out this inspection to see whether the hospital had made improvements since our last inspection in May 2014. Following our inspection in May 2014 we rated the hospital as ‘Inadequate’ overall. We judged the hospital to be ‘Inadequate’ for safe and responsive and ‘Requires improvement’ for effective and well led. CQC was specifically concerned about the critical care services, but also about Medical, Surgical and Outpatients services.

We visited the hospital as part of our announced inspection on 28-29 April 2015. We also carried out an out-of-hours unannounced visit on 14 May 2015. The inspection team inspected the following core services:

• Urgent and emergency services

• Medical care services (including older people’s care)

• Surgery

• Critical care

• Outpatients and diagnostic services

In our 2014 inspection we rated urgent and emergency services as good; but since that visit the CQC A&E survey showed that the services had the worst response in the country. We visited this service during this inspection to understand the reason for this change and to provide an assurance on the current position.

Overall, we rated Tameside General Hospital as ‘requires improvement’. We have judged the service as ‘good’ for caring and well led. We noted that there had been significant improvements in some areas since our last inspection, most notably in critical services and outpatient services. However, improvements were needed to ensure that services were safe, effective and responsive to people’s needs.

Our key findings were as follows:

Access and Flow

  • Access and flow in the emergency department was a continuous challenge. The trust had a mixed performance against the four hour target over the year. Performance declined over the winter period, and they had regularly not achieved the standard since December 2014.
  • Between July 2013 to January 2015 there were 32 black breaches at the hospital. ‘Black breach’ refers to failure to hand over a patient from the ambulance within 60 minutes of arrival at the emergency department. In the majority of cases, no reason was given for the breach.
  • The total time in the emergency department per patient was worse than the England average over the period January 2013 to September 2014,
  • Patient flow through the hospital and discharge had improved but improvements were still needed. Due to continual bed pressures there were occasions when patients had been transferred from the Acute Medical Unit during the night and medical outliers were still common place. This meant that some patients were not placed in the area best suited to their needs. In such instances, the hospital had systems in place to ensure the timely review of these patients.
  • In critical care the number of patients that were admitted within four hours of referral ranged between 29.4% and 78.6% between April 2014 and March 2015. This meant the trust’s target to admit 95% of patients within four hours of referral had not been achieved. During this period, a total of 46 patients had been discharged during out-of-hours. The hospital’s target was for zero out-of-hours patient discharges. The service reconfiguration (due June 2015) aimed to improve capacity by separating the intensive care and high dependency into two separate units, with each unit having six allocated beds.
  • There were improvements to the access for patients in the outpatient department since the last inspection. This included reduced waiting lists and the service was better than the England average in meeting the two week cancer wait targets and urgent GP referrals. However, there remained long waits for patients in some clinics.

Cleanliness and Infection control

  • Patients were cared for in a visibly clean and hygienic environment.
  • Staff followed the trust policy on infection control and adhered to the ‘bare below the elbows’ policy.
  • Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
  • There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There was a suitable supply of hand wash sinks and hand gels available.
  • Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.
  • Patients identified with an infection were isolated in side rooms. We saw that appropriate signage was used to protect staff and visitors.
  • Public Health England data showed 4.7% of patients acquired surgical site infections following fractured neck of femur (hip) surgery at the hospital between January 2014 and December 2014. This was worse than the national average of 1.3%.
  • There was an action plan to improve surgical site infections. This included additional surveillance of the monitoring of patients temperature in theatre by the infection prevention surveillance nurse, additional training for theatres staff regarding the recording of patient temperature in theatre and recovery and the purchase of additional patient body warmer equipment for use during surgery.

Nurse staffing

  • Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services.
  • The expected and actual staffing levels were displayed on a notice board on each unit/ward and these were updated on a daily basis.
  • Staffing levels were planned to ensure an appropriate skill mix to provide care and treatment for patients.
  • However, nurse staffing levels, although improved, remained a challenge in some areas. This was particularly the case in medical care services and critical care. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff. Where possible, regular agency and bank staff were used which meant they were familiar with policies and procedures. Any new agency staff received an induction prior to working on the wards.
  • The trust had implemented a number of initiatives to address shortages in nurse staffing including: monthly assessment centres, actively recruiting nursing staff from overseas and linking with local universities.

Medical staffing

  • Medical treatment was delivered by skilled and committed medical staff.
  • The proportion of middle career doctors and junior doctors within the trust was greater than the England average. The proportion of consultants was below the England average (35% compared with the England average of 40%). The proportion of registrars was also below the England average (20% compared with the England average of 37%).
  • Despite ongoing recruitment campaigns, the overall numbers of medical staff had only increased marginally in 12 months. Difficulties remained in recruiting medical staff particularly in urgent and emergency services, acute medicine and radiology.
  • The emergency department was funded for 17 middle grade doctors. Eight doctors were currently in post with the remaining vacancies covered through agency locums.
  • The number of medical staff in some clinical specialities had increased, such as respiratory medicine. Consultants told us this meant they could do more outpatients clinics because there were enough middle grade doctors to cover the wards, out of hours work and the outpatient clinics.
  • There was one consultant haematologist in the hospital. This resulted in a shortfall in provision, particularly out of hours cover, which had been included on the risk register since September 2014. There were plans to develop a shared post with other hospitals in the area and in the meantime locums were used with a rotational on call system for consultant cover which included other hospitals. We were told this temporary arrangement was not ideal, but it had not resulted in any patient safety incidents.
  • Staff rotas were maintained by the existing staff and through the use of agency or locum consultants. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The majority of locum and agency doctors had worked at the hospital on extended contracts so they were familiar with the hospital’s policies and procedures.
  • The existing on-call consultant rota for critical care services included a combination of critical care specialist and surgical consultant anaesthetists. The on-call consultant cover was not always provided by a consultant in intensive care medicine. This meant a consultant in intensive care medicine was not available 24 hours a day, seven days a week, to attend a patient within 30 minutes as set out in the ICS standards. The hospital planned to address this by splitting the rota so on-call cover for the critical care services was provided by specialist consultants only but this was not yet in place.
  • The hospital was looking at different ways to recruit medical staff for example, international recruitment and joint recruitment with other trusts.

Mortality rates

  • In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures because there were concerns about the care of emergency patients and those whose condition might deteriorate.
  • Our intelligent monitoring report highlighted the trust as being either a risk or an elevated risk for the following mortality outliers and in-hospital mortality indicators: Summary Hospital-level Mortality Indicator, gastroenterological and hepatological conditions and procedures, infectious diseases, conditions associated with mental health, nephrological conditions, vascular conditions and procedures. On request, the trust had provided the Care Quality Commission’s outliers panel with the relevant information requested and could evidence that a full investigation had taken place to understand the mortality data and identify areas for improvement.
  • During our inspection, we found that patient deaths were reviewed by individual consultants within their specialty area. These were also presented and reviewed at monthly mortality meetings, attended by multidisciplinary staff. The meetings identified the circumstances of the patient, the initial and follow-up care and treatment they had received and the circumstances of the death. We saw evidence of how learning from such situations was shared with teams.
  • Since February 2014 a systematic review of all inpatient adult deaths had been completed. There was a Commissioning for Quality and Innovation (CQUIN) target for all eligible deceased case notes to be triaged by senior nurses and clinicians in the Quality and Governance Unit, and a mortality review to be completed within two weeks of the initial triage by a senior nurse/consultant/staff grade doctor. These cases were checked for coding accuracy with a senior coder. The clinical director for medicine told us the coding system was under scrutiny at the time of our inspection as the trust believed it was not coding all comorbidities for patients admitted.

Nutrition and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.
  • Patients told us they were offered a choice of food and drink and spoke positively about the quality of the food offered.
  • Data provided by the trust showed it had rated itself as ‘amber’ against the 10 key characteristics of good nutritional care (Nutrition Alliance) and as ‘green’ against use of the malnutrition universal screening tool (MUST).
  • Wards operated a red tray system which identified patients who were assessed as being at nutritional risk and who needed support to eat and drink.
  • However, the trust performed worse than the English average for the majority of indicators in the National Diabetes Inpatient Audit (NaDIA) September 2013. It was not clear what action the trust had taken to improve as a result of this audit. However, the trust acknowledged that it had improvements to make against key characteristics of good nutritional care including diabetes care.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that medical staffing is sufficient and appropriate to meet the needs of patients at all times including out of hours.
  • Improve patient flow throughout the hospital to reduce the number of patients transferred at night and ensure timely access to the service best suited to meet the patient’s needs, particularly in A&E and medical care services.
  • Improve the completion levels of mandatory training and appraisals for nursing and medical staff.
  • Ensure that medicines, particularly controlled drugs are stored, checked and disposed of in line with best practice in all areas but particularly in A&E and Outpatients.

Action the hospital SHOULD take to improve

In urgent and emergency care services:

  • Ensure staff are trained in assessing patients using NEWS and MEWS and accurately record scores.
  • Ensure all action plans in relation to CEM audits are specific and measurable.
  • Ensure pain scores are routinely recorded for all patients and pain relief is prescribed and administered in a timely manner.
  • Ensure all staff are aware of their responsibilities in relation to safeguarding and consent in relation to the mental capacity act and deprivation of liberties.

In medical care services:

  • Take action to improve outcomes for patients particularly those with diabetes, heart failure and patients who have had a stroke.

In surgery:

  • Improve surgical site infection rates for patients following orthopaedic surgery.
  • Improve theatre efficiency to reduce delays in theatre session start times.
  • Improve the timeliness of responses to patient complaints.
  • Improve compliance against 18 week referral to treatment standards for ENT and trauma and orthopaedics for admitted patients.
  • Improve the number of patients whose operations were cancelled and were not re-booked within the 28 days.

In critical care:

  • Improve the number of patients admitted to the critical care services within four hours.
  • Reduce the number of out-of-hour patient discharges.
  • Improve the timeliness of responses to patient complaints.

In outpatients and diagnostic imaging services:

  • Continue to take action in improving waiting times in all clinics.
  • Ensure there is a system in place to audit changes to practice and procedures in order to monitor their effectiveness.
  • Ensure all staff are familiar with, suitably trained and competent to use resuscitation equipment.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 7, 8, 13, 16 and 17 May 2014

During a routine inspection

In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce Keogh (the Medical Director for NHS England) as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures because there were concerns about the care of emergency patients and those whose condition might deteriorate. There were also concerns about staffing levels (particularly of senior medical staff at night and weekends), patients’ experiences of care and, more generally, that the Trust Board was too reliant on reassurance rather than explicit assurance about levels of care and safety.

We inspected Tameside NHS Foundation Trust in May 2014 and visited the trust on five separate days both announced and unannounced visits.

The announced visits were 7 and 8 May and the unannounced visits were 13, 16 and 17 May 2014.

This was a full comprehensive inspection.

The inspection team inspected the following core services :

  • Accident and Emergency (A&E)
  • Medical care (including older people’s care)
  • Surgery
  • Intensive / Critical care
  • Maternity and Family Planning
  • Children and young people’s care
  • End of life care
  • Outpatients

This inspection was a comprehensive inspection, which took note of the previous inspection in January 2014, to monitor the trust’s improvements in meeting the regulations.

We noted that there was a positive culture towards improvement and change amongst senior and service managers. We witnessed services beginning to address the challenges they faced. This report recognises many of those challenges the services face and some of the work already underway to address these.

We saw that the trust was on a journey of improvement. We saw that the staff at many levels were committed to that improvement and were beginning to work as part of a cohesive team.

We were impressed by the integration of working. This reputation had spread and the trust was recruiting staff from other trusts on the back of a growing reputation.

Overall however, we found that the services provided by the trust were currently inadequate.

Our key findings were as follows:

  • We found a service improved from the assessment made at the time of the Keogh Review
  • We found that caring was good across all areas of the organisation.
  • We found staff to be committed to making improvements.
  • We found a strong and visible Executive Team providing leadership to the organisation and driving delivery of the improvement plan.
  • We found that A&E, maternity services and children’s/young people’s services were good.
  • We found that critical care services were inadequate including: lack of availability of national audit (ICNARC) data, incident reporting and feedback, record keeping, equipment and patient monitoring.
  • We found that parts of medical care services required improvement, including: aspects of medication processes, record keeping and medical staffing.
  • We found some elements of surgical care required improvement including monitoring and management of preoperative patients.
  • Despite many improvements already made we found that elements of outpatient care required improvement including clinic organisation and efficiency of booking processes. The implementation of the new Lorenzo record system was of most concern.

We saw several areas of outstanding practice including:

  • The children’s unit development that included significant user and community involvement in its design.
  • The trust had an outside garden area for patients which was dementia-friendly.
  • The trust welcomed visits by patient groups, such as Healthwatch or Tameside Hospital Action Group, to see for themselves how the hospital was performing.
  • Patients were assessed regarding their rehabilitation needs and the physiotherapy team were available seven days a week to contribute to meeting the goals for each patient’s recovery.  The physiotherapy team was led by a consultant in physiotherapy so that a senior person was available regarding complex issues.
  • One of the hospital’s community midwives had recently won the British Journal of Midwifery’s Community Midwife of the Year Award. This midwife had been recognised for recently supporting four women with cancer during their pregnancies and reportedly, “Continually goes that extra mile to support women and their families”, said the head of midwifery.
  • In 2012, the maternity unit launched a fundraising campaign called the Bright Start appeal. This highly successful campaign had funded the development of the birthing pool room and would fund the future development of the midwifery-led birth room.
  • The maternity service actively participated in national research and audit projects. This included: “The Healthy Eating and Lifestyle in Pregnancy Study” which was being undertaken with Cardiff University and Slimming World; “The Building Blocks: A trial of Home Visits for first time mothers” in partnership with University Hospital South Manchester and “The Bumpes Trial” which was being undertaken by the University College London.
  • The facilities for bereaved parents included a private room, garden and en suite bathroom. The room contained a television, lounge, kitchen and hot beverage facilities. A midwife, usually bereavement trained, was allocated to the family whilst in hospital. After being discharged from hospital, the nurse visited the family at home or contacted them by telephone.  The trust held an annual forget-me-not remembrance service.
  • The maternity service had developed a teenage pregnancy reduction initiative in response to local need which had a positive impact in reducing the number of teenagers who were expecting their second child. The trust appointed a specialist teenage pregnancy midwife, created a more teen friendly environment and improved the continuity of care from staff.
  • The trust worked creatively with commissioners and other trusts to plan new ways of meeting the needs of children and young people. Together, they developed integrated pathways of care, particularly for children and young people with multiple or complex needs.
  • The trust had a dedicated children’s safeguarding team which evidenced proactive outreach programmes and service adaptations aimed at meeting the needs of people in vulnerable circumstances.
  • The trust developed an observation and assessment unit and community nursing team for children and young people, which significantly reduced hospital admissions and accident and emergency department attendance.
  • The trust raised the profile of end of life care by appointing an end of life care facilitator who worked with other staff and external agencies to implement best practice in the mortuary and chaplaincy service, improve care on the wards and facilitate rapid discharge.
  • The trust had adapted the equipment used for transporting deceased patients to resemble an empty bed. This was discreet and made for a dignified journey through the hospital to the mortuary.
  • The trust had three syringe drivers available for the sole purpose of facilitating a rapid discharge for any patient who required this equipment, which was normally supplied by community services. 
  • The trust’s paediatric outpatient department provided a stimulating and interesting environment in the waiting, consultation and treatment areas. This environment had been designed as a result of consultation with a local primary school so that it appealed to children and young people. This included small details, such as a glass cabinet in the reception desk where a toy replica of a hospital was placed to reduce the boredom of children when they were waiting at the desk.
  • The trust had an electronic system for logging and identifying patient records, which resulted in improved access to records for outpatient clinics.

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

Importantly, the trust must:

  • take action to ensure that within critical care they have safely stored adequate supplies of medication and that staff regularly check this.
  • take action to ensure that staff, particularly in maternity, safely administer and dispose of medications, that staff accurately record this, and that staff regularly check these records.
  • take action to ensure that patient records, such as nursing assessments, procedure books, patient group directives or discharge letters, are accurate and fit for purpose.
  • take action to ensure that staff promptly assess all patients and ensure their welfare and safety, particularly in A&E.
  • take action to ensure staff accurately and regularly check equipment such as resuscitation trolleys across all areas of the trust's building on the good practice in many areas.
  • take action to ensure that the practice of learning from complaints is embedded across the trust, building on the good practice already in place in some areas as they learn from complaints and concerns .
  • take action to ensure that staff adequately assess and respond to changes in patient condition or risk.
  • take action to ensure that the environment for interventional procedures in coronary care are safe and suitable for treatment.

In addition the trust should:

  • ensure that all staff (particularly in medical care services and A&E) receive suitable structured supervision building on the work already in place.
  • ensure that all staff, patients and visitors know how to respond to any allegation of abuse.
  • ensure that staff provide external identification for patients, such as a wristband, when patients arrive in the A&E department.
  • ensure that the trust improves the routine monitoring of the care and treatment of patients waiting in the A&E department.
  • ensure that staff (particularly in medical care services) have adequate plans in place to care for people with mental health conditions, including dementia, or challenging behaviour.
  • ensure staff are aware of all appropriate equipment in critical care and how to ensure this is available and promptly repaired if broken.
  • ensure that their Intensive Care National Audit & Research Centre data is kept up to date and used proactively to help monitor the safety, effectiveness and responsiveness of the service.
  • ensure there are robust systems in place to obtain the views of patients and carers regarding care at the end of life and bereavement support.
  • consider how they support staff to quickly identify clean versus dirty equipment; particularly in maternity, children's services and medical care services.
  • consider how they work together with the local community to facilitate safe and prompt discharges.
  • consider how staff in the MHDU/CCU adequately monitor the weight of patients who cannot easily stand.
  • consider the impact of having nurses with combined anaesthetic and recovery responsibilities .
  • consider how their plans for re-developing the critical care service meets the needs of staff and patients. 

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 3, 4, 6, 7, 8, 10 January 2014

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

We have found eight breaches of the regulations which would normally lead to enforcement action. This Trust however is in Special Measures and it is the responsibility of the Trust working with Monitor to ensure that any non- compliance is addressed in a timely way. We will report on this following our next inspection.

In the hospital, we talked to over 75 patients, over 20 relatives or carers and over 50 staff, as well as 24 senior managers. At our listening event held off site, we spoke with twelve people who had used the hospital’s services or who cared for someone who had. We also spoke with a range of stakeholders before and during the inspection.

Most patients, relatives, carers and staff spoke positively about the recent changes to the governance of the hospital. Although the systems were not yet fully implemented, we found that the hospital was responsive to concerns raised during the course of the inspection. The hospital had taken reasonable steps to put an effective system in place, given the resources available, and had suitable plans in place to meet the requirements of other regulations. We will be following up to see whether these improvements have been sustained.

Staff said that the culture was now “changing quite quickly” which was challenging for some staff. One senior manager said: “For the first time, I feel like I’m able to be [a senior manager]”.

The patients, relatives or carers we spoke with described staff as friendly, patient, caring, hands-on, and courteous, even while reporting concerns about their experience.

One patient said that, because of their previous experience, they had delayed their current admission to hospital, which made their condition worse. They told us that so far they had “brilliant care”, “much better” than their previous experience. Another patient said the hospital was “better than it used to be. I still think they need more staff.” One patient on the medical assessment and admissions unit (MAAU) said: “[MAAU is] a bit of a madhouse – nurses and staff run off their feet.”

One patient said: “I’m fed up of waiting to hear something from a doctor.” Another patient said: “I’m frustrated by the lack of information from doctors….They don’t seem to talk to each other.”

Staff said: “the new processes are working well and improving patient flow.” One junior doctor in the emergency department told us the senior cover had improved and there was more support than there used to be, stating: “Things are so much better now.” A nurse on an adult medical ward said “we sometimes have to wait quite a while when we have requested a doctor to come to the ward.”

Senior managers told us that the hospital’s aim was to encourage staff on the wards to “recognise what ‘good’ looks like.”

We found adequate systems in place to manage medicines, to maintain cleanliness, and to control the risk of infections. Generally, we found that people consented to and received appropriate care and treatment in the paediatric and surgical units. Paediatric patients and their relatives or carers were safe and adequately involved.

In the adult medical wards, however, we found that staff did not demonstrate an adequate understanding of the legal processes established by the Mental Health Act 1983 and Mental Capacity Act 2005. Staff disclosed that some patients were restrained without safeguards in place.

We observed that adult medical patients were not protected against the risks of inappropriate or unsafe care and treatment, because staff did not adequately assess their needs. Patients’ medical records were inaccurate and incomplete. Care and treatment did not reflect guidance issued by appropriate professional and expert bodies.

We saw that there were not enough staff to meet the needs of patients in the MAAU and some adult medical wards. Supervision of staff, including doctors, was variable, although some staff felt there had been improvements since the change in senior and ward management. Staff spoke positively about their induction and mandatory training. We observed poor staff competencies in other areas, such as caring for patients with dementia.

We observed variation in how staff interacted with adult medical patients, relatives and carers. Some staff did not ensure the dignity and privacy of patients or involve them in their care and treatment. Several people raised concerns about communication with the hospital. Although the hospital had a number of programmes in place to engage with people who used the service, most of the people we asked did not know how to provide feedback or make a complaint.

We saw that the hospital had made improvements to the system for managing complaints; however, the system was not yet effective.

Inspection carried out on 11, 15 May 2013

During an inspection in response to concerns

We carried out this responsive inspection of the trust’s emergency care pathway, risk management and incident reporting. We carried out the inspection after correspondence from the North Western Deanery and viewing a report of a review of urgent care commissioned by the trust raised concerns about patient safety and the quality of service provision in the accident and emergency department and escalation areas at the trust. We were told there was a culture of under reporting of incidents, problems of overcrowding and delays in ambulance handovers, poor implementation of discharge planning and a lack of regular team meetings for staff.

We spoke with people about their journey from accident and emergency to admission. We asked them about their understanding of what was happening and if staff had explained what was wrong with them, what treatment was needed and if discharge arrangements had been discussed. People told us “I can’t fault anything.” They told us staff had “put them at ease” and felt they had been given “excellent attention” when they arrived at the department. They told us that “everybody has been good” and that “the doctor talked me through everything’.

On both occasions we visited the trust the accident and emergency department was quiet. There were a number of beds available on wards and departments so escalation procedures were not operational. We observed the handover process for patients brought into the accident and emergency department by ambulance. We found that handovers took place in a corridor. This meant that the privacy of patients’ confidential information was not always respected.

We found that the trust had an escalation policy in place and the designated escalation area was fully equipped to manage escalated patients if required. We were told by staff, patients and the review of urgent care commissioned by the Trust that the application of the escalation policy was not always consistent. This meant that there was a risk that people could experience unsafe and inappropriate care.

We found that three bed management and discharge planning meetings took place every day but consultant input to ward rounds was limited to three days a week. This meant that there had been improvements to discharge planning but more work was needed to implement and manage discharge processes consistently across the trust.

Staff told us that there had been an increase in meeting frequency between ward based and senior staff. Some staff told us that staff meetings were sometimes cancelled when the ward was busy. This meant that learning from incidents, adverse events and errors was not always shared.

We found that the trust had systems in place to assess and monitor the quality of services. However these systems were not always robust enough to ensure that all risks were identified by the trust and effectively managed. This meant that timely action was not always taken to protect people who use the services.

Inspection carried out on 13 February 2013

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

People we spoke with were happy with the care that they were receiving at the hospital. They told us that they were well looked after and that they didn't have to wait for staff to help. Comments included, 'The staff here are great', 'I have no complaints about my care at all', ‘They tell you everything you need to know'; 'the staff are excellent and the ward is very clean'.

People we spoke to were happy with the time taken to see a doctor following admission to the hospital.

Inspection carried out on 20 August 2012

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

People we spoke to were mainly happy with the care that they were receiving at the hospital. They told us that they were well looked after and that they didn't have to wait for staff to help. Comments included, 'The staff are smashing', 'My care here has been excellent', ‘They tell you everything you need to know'; 'the staff are excellent and the ward is very clean'.

Information we received prior to our visit and people we spoke to during our visit identified that people who were transferred to sit out and escalation areas of the trust were not always monitored during and after transition. We were told, 'staff ignore you if you are in this bay', 'I think you get forgotten here'.

People we spoke to were happy with the time taken to see a doctor following admission to the hospital.

Inspection carried out on 20 April 2012

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

People we spoke with were very happy with the care that they were receiving at the hospital. They told us that they were well looked after and that they didn't have to wait for staff to help. Comments included, "The staff are lovely", "My care here has been excellent", "They've been very good; they get things for you right away when you ask", "The food is really good - lots of choices and there is more than enough", "The food has been excellent", and "We are regularly supplied with refreshments". People we spoke with were happy with the time taken to see a doctor following admission to the hospital.

Inspection carried out on 22 March 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 19 October 2011

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

People we spoke to were very happy with the care that they were receiving at the hospital. They told us that they were well looked after and that they didn’t have to wait for staff to help.

Comments included, ‘the staff are lovely’, ‘the foods really nice’, ‘my care here has been excellent’, ‘staff are so very kind’.

One person said that said that, although the hospital was very busy staff had taken time to explain things to her and reassure her. People we spoke to were happy with the time taken to see a doctor following admission to the hospital.

Inspection carried out on 9, 16 March 2011

During a routine inspection

Generally people we spoke to were very happy with the care that they were receiving at the hospital. They told us that they were well looked after and that they didn’t have to wait for staff to help them when they called.

Comments included, ‘It’s brilliant’, ‘Staff very nice – good to get along with’, ‘Superb’

One person said that her relative had been in the hospital 12 months ago. She said that, at that time, she was extremely unhappy with the way care and treatment was given to her relative. However, for this admission she said, “Much, much improved now – I’m very impressed with the way things are run now”.

Another person said “They’ve all done their best for me”. They said that care had been very good on every admission. She said she felt involved in her care and that staff listened to her.

One negative comment was received about care received a month ago.

There were two negative comments relating to the time that people had to wait for a bed: one in the medical admission and assessment unit (MAAU) and one who had been waiting for surgery.

People we spoke to were happy with the time taken to see a doctor following admission to the hospital.

Inspection carried out on 16 June 2010

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

This section was not completed for this inspection. More information about what we found during the inspection is available in the report below.