Tameside General Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Our rating of safe stayed the same. We rated safe as good.

The service had enough staff to care for children and young people and keep them safe. Staff had training in key skills, understood how to protect children and young people from abuse, and managed safety well. The service controlled infection risk well.

The service had made significant improvements around staff training and processes for managing deteriorating health and sepsis management following child deaths during 2023. Action plans were in place to further improve this.

Staff assessed risks to children and young people, acted on them and kept good care records. They managed medicines well. Premises and equipment were clean and well-maintained. The service managed safety incidents well and learned lessons from them.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses on an electronic incident reporting system, in line with the hospital's policies. Staff used the Patient Safety Incident Response Framework (PSIRF) to aid learning and improvement. Incidents were reviewed and investigated by staff with the appropriate level of seniority, such as clinical leads, ward managers and matrons.

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Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to people's care during daily safety huddles, handover meetings and during routine departmental and divisional staff meetings so shared learning could take place. Learning from incidents was also shared through hospital-wide alerts and newsletters.

Staff understood the duty of candour. They were open and transparent, and gave people who used the service and families a full explanation if and when things went wrong. Parents and young people who used the service told us they felt safe and did not have any concerns around safety incidents.

There had been 1,048 incidents relating to children and young people's services reported during the past 12 months. Most (99%) resulted in no or low harm. There had been 4 incidents of moderate harm and 1 severe harm incident reported during this period.

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There had been no never events reported by the service during this period. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.

The severe harm incident related to radiology / X-ray services and was being investigated at the time of our inspection. We looked at the investigation report for a moderate harm incident (relating to delays in medical treatment) and this showed the incident had been appropriately investigated and improvement actions were identified to aid learning and minimise reoccurrence.

The hospital previously reported 5 deaths relating to children and young people's services during December 2023. Two of these incidents were graded as serious incidents and investigations identified common themes in both incidents around infective causes and sepsis management. We saw evidence these incidents had been investigated and improvement actions relating to managing deteriorating health and sepsis management had been put in place.

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During the past 12 months, there had been 4 further deaths relating to children and young people's services. We looked at the investigation reports for two death incidents. These contained appropriate information, actions and evidence of learning and improvement. The incident reports detailed the involvement and support provided for staff involved in the incidents as well as support for people who used the service and relatives (such as duty of candour principles).

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There had also been 5 neonatal deaths reported during the past 12 months. This included 4 stillbirths and 1 late foetal loss. Each incident had been investigated and learning shared. A preterm optimisation group involving neonatal and midwifery staff commenced in August 2024 to identify process improvements and education for staff.

The hospital's policy for the review of deaths in children and young people under the age of 18 provided guidance for staff and outlined roles and responsibilities for undertaking investigations. The records we looked at showed individual deaths were reviewed and investigated as part of a multidisciplinary team involving medical and nursing leads with support from children's safeguarding leads, the paediatric mortality lead clinician and the sudden unexplained death in children (SUDIC) lead. Deaths were reviewed as part of routine mortality and morbidity meetings.

The children's service operational policy, the discharge policy for children and the neonatal intensive care unit (NICU) operational policy provided guidance for staff around admission, transfer and discharge processes. Parents and young people who used the service told us they were kept informed about their care and treatment at all stages from admission to discharge from hospital.

The children's observation and assessment unit (COAU) was situated within the children's unit. Children and young people up to 16 years of age could be admitted through a number of routes, such as children and young people's emergency department admissions, elective surgery admissions requiring overnight stay and referrals from community nurses, midwives, health visitors, GP's and child and adolescent mental health service (CAMHS) referrals.

The children's unit mainly admitted people with lower acuity. The unit had a high dependency room; however this was mainly used to stabilise and transfer people with complex health needs who required emergency transfer to a specialist regional children's hospital.

The hospital had a separate children and young people's emergency department for people up to 16 years of age. Young people aged 16 to 18 years of age attended the adult emergency department and were admitted to adult wards.

The neonatal unit was a level 2 (high dependency) unit and admitted babies at all gestations that could require all levels of care. The unit cared for both term and preterm infants. Infants born after 27 weeks (or 28 weeks if twins) and over 800g were cared for on the unit. Infants outside of these criteria were resuscitated and stabilised prior to transfer to regional specialist hospitals. Extremely premature infants or those requiring surgical intervention were also stabilised prior to transfer to regional services.

There had been 246 transfers from the children and young people's emergency department and 23 transfers from the inpatient children's unit to specialist regional centres during the past 12 months. Where children and young people were transferred, they were clinically assessed and staff completed a transfer record detailing their condition and any treatment they had received. The transfer of intubated or unstable infants was undertaken by a dedicated neonatal transfer team.

Most staff (88%) had completed paediatric or newborn life support training. There was at least 1 nurse on each shift with advanced paediatric life support training.

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Shift changes and handovers included all necessary information to keep people safe. Nursing and medical staff handovers took place during daily shift changes and these included discussions about people's needs and any staffing or capacity issues. Staff also took part in a daily `safety huddles' where discussions took place around safety, capacity and risks.

The children and young people's services carried out routine care record audits at least once a year. Recent audit records showed high levels of staff compliance in completing care records. Care records we looked at were complete and up to date, with few errors or omissions. Staff in the neonatal unit carried out routine baby identification band audits. The most recent audit (February 2025) showed 100% compliance had been achieved.

The service had processes to support young people with long-term conditions transitioning to adulthood. The paediatric and adolescent diabetes transition policy provided guidance for staff and specialist diabetes nurses were in post to support young people transitioning to adult services with routine joint clinics involving paediatric and adult diabetes specialists.

The respiratory nurse specialist and `Roald Dahl' transition epilepsy nurse specialist held routine clinics and followed the `Ready Steady Go' programme, which was designed to help young people develop the knowledge and skills to manage their health condition as they moved into adulthood. Care records showed young people transitioning to adulthood underwent detailed assessment and their needs were discussed.

Service partners spoke positively about the service's processes for supporting safe transition between children and adults services.

The safeguarding adults policy and safeguarding unborn babies, children and young people policy provided guidance for staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team.

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Parents and young people told us they felt safe and had not experienced any safeguarding issues. They told us if they had any safeguarding concerns, they would raise them with the staff.

Staff told us they had received safeguarding training and understood how to identify abuse and report safeguarding concerns. They told us learning from any reported safeguarding incidents was shared as part of daily huddles, handovers and during routine staff meetings.

The hospital's electronic system flagged if a child was thought to be at risk or had a known safeguarding history (such as looked after children).

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There had been 25 safeguarding incidents reported by the children and young people's services in the past 12 months.

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Staff completed training specific for their role on how to recognise and report abuse, in line with current intercollegiate guidance for adults and children. Records showed 100% of staff across the children and young people's services (including children's radiology and theatre teams) had completed adult safeguarding training (level 2) and children's safeguarding training (level 1 and 2).

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Most staff (70%) had completed children's safeguarding level 3 training, however training compliance was below the hospital's training targets. The combined safeguarding training strategy and proposed implementation plan 2024/2026 included action plans to improve staff training compliance.

Most staff (over 84%) across the children and young people's services had also completed training in female genital mutilation, preventing radicalisation, identifying and supporting victims of modern slavery, mental capacity, child sexual exploitation and domestic violence and abuse.

The children's safeguarding lead had completed the higher level of safeguarding training (level 4). Staff in the children and young people's service received support and guidance from the hospital's safeguarding team, which included 3 specialist children's safeguarding nurses, a multi-agency safeguarding hub (MASH) practitioner and a complex safeguarding nurse.

The children's safeguarding lead told us monthly safeguarding supervisions took place. The safeguarding nurses attended monthly governance meetings and the safeguarding lead was involved in serious incident and child death investigations and attended serious case review meetings.

Staff completed risk assessments for each person on admission, using a recognised tool, and reviewed this regularly, including after any incident. Care records included up to date risk assessments for venous thromboembolism (blood clots), pressure ulcers, nutritional needs, moving and handling risks, risk of falls and infection control risks.

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Children and young people at high risk were placed on care pathways so they received the right level of care. We saw care pathways were in place for a number of conditions such as diabetes, skin integrity and asthma and these were completed and regularly reviewed by staff.

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Parents and young people told us staff routinely discussed and updated risk assessments and care plans. They told us staff carried out regular observations and kept them informed about any changes to their care or treatment.

Staff used national paediatric early warning score system (PEWS) and carried out routine monitoring and vital observations based on peoples' individual needs so that any changes to their medical condition could be promptly identified. Staff also conducted hourly intentional rounding checks to monitor people's condition and well-being. If a person's health deteriorated, staff were supported with medical input and were able to contact specialist support if needed. Care records we looked at showed people who used the service had regular timely observations and were escalated appropriately when required.

Investigations following child deaths in December 2023 identified further improvements were required in relation to identifying and managing people with deteriorating health and those with suspected infections such as sepsis. Action plans were put in place to make improvements and we found improvements had been made.

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Most staff (93%) across the children and young people's services had completed PEWS training. The 2024 PEWS audit (2023 data) showed high levels of compliance (above 90%) across most audit indicators. The most recent audit (December 2024) showed 90% of documented PEWS scores were calculated correctly. The audit showed 60% of escalations were undertaken correctly or not required. An action plan was in place to improve compliance. This included on-going monitoring as well as additional staff training to aid learning and improvement.

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The service had guidelines, pathways and screening tools that were based on national guidelines for the management of children and young people with sepsis, including neonatal sepsis. Staff understood how to identify and manage sepsis in line with policies and national guidelines.

Training in aspects of sepsis management was included in paediatric life support training and paediatric acute illness management courses undertaken by staff. Additional in house paediatric sepsis training had been developed and was planned for roll out during March 2025.

Staff in the children and young people's emergency department participated in regular sepsis simulation activities. These involved multi-disciplinary teams managing scenarios to develop skills and identify learning. A number of doctors and advanced clinical practitioners had also been trained as sepsis fellows, who worked with clinical teams to champion learning and improvement.

A children and young people's sepsis audit was undertaken during August to September 2024, following a previous audit in May 2024. The audit was based on 7 indicators and showed improved compliance in 5 audit indicators since May 2024. These were for taking blood cultures, administering IV fluids within 1 hour, use of sepsis screening tools, implementing sepsis care bundles and completing full set of observations on admission. The audit showed further improvement was still required in 2 audit indicators; antibiotics prescribed within 1 hour of suspected sepsis and full set of observations undertaken at triage.

The emergency department also undertook a separate monthly sepsis audit, based on 10 random adult and children's records. This showed an improving trend in compliance between April 2024 and December 2024.

A sepsis action plan was in place to improve processes. This included actions planned or undertaken relating to continued audit and monitoring of compliance, further staff training and raised awareness through shared learning.

The design, maintenance and use of facilities, premises and equipment kept people safe. All the areas we inspected were well maintained and free from clutter. There was sufficient space for storage of equipment and consumables. All areas were easily accessible, including for wheelchair access.

The service had policies in place for the abduction, removal, or absconding of infants, children, and young people and a protocol for missing and absconded persons. Access to the children's unit, outpatient department and neonatal unit was secure, with swipe card access and video monitoring. The children's unit had enhanced security and access arrangements by installing swipe only access to an intermediate door in the unit as an extra security barrier and planned to relocate the doctors' office and the observation and assessment area closer to the entrance to enable greater staff visibility at the entrance to the unit.

We found there was appropriate segregation between children and adults. Young people over 16 years of age were assessed to determine where they would be placed before admission to adult wards. There were a range of age appropriate games, toys and play activities for children and young people admitted to the services. The children's unit had a sensory room to support children with a learning disability and and children with autism. Most areas we inspected had a child-friendly environment. An initiative to paint ceiling tiles in the children's unit was very popular with children and young people.

Parents and young people told us the service was safe and provided a suitable environment for their care and treatment. They told us they had not experienced any issues relating to equipment and premises.

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All the equipment we saw was clean, well maintained and within the service, calibration and electrical safety test due dates. Equipment such as trolleys and stands were visibly clean and staff used disinfectant wipes to clean and decontaminate equipment.

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Single use items and consumables were stored safely and were kept within expiry dates. Medical gas cylinders (such as oxygen) were stored securely. There were suitable arrangements for the safe handling, storage and disposal of clinical waste, including sharps.

The service had enough suitable equipment to help them provide safe care and treatment. There was a planned maintenance schedule in place that listed when equipment was due for servicing. Equipment servicing was managed by the hospital-wide maintenance and estates teams. Staff told us equipment needed for care and treatment was readily available and any faulty equipment could be replaced promptly.

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Emergency resuscitation equipment for children, neonates and adults was available in all the areas we inspected and this was checked daily by staff. Emergency resuscitation trollies were tagged to minimise the risk that items could be tampered with.

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The hospital had a ligature assessment policy. The children and young people's emergency department and children's unit had ligature-risk reduced cubicles in place and staff had complete and up to date ligature risk assessments in place.

Staff maintained up to date risk assessments in relation to premises and equipment, health and safety risks and control of substances hazardous to health (COSHH) assessments. There were suitable arrangements in place for fire safety, including clear instructions for staff to follow in the event of a fire.

Staff and people who used the service told us there were enough staff to provide safe care and treatment. We observed staff interacting with people and saw staff were friendly, calm and polite when communicating with them and delivering care and treatment. We saw staff responded promptly when called for assistance.

The children's unit, neonatal unit and the children's outpatient and emergency departments had enough medical, nursing and support staff to keep people safe.

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Nurse staffing levels were reviewed against minimum compliance standards every six months, based on a national acuity tool. The expected and actual staffing levels were displayed on notice boards in each area we inspected, and these were updated on a daily basis.

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Shift fill rate records between October 2024 and January 2025 showed the children's unit achieved average fill rates above 90% and the neonatal unit achieved average fill rates around 100% for nursing and healthcare staff during the day and night shifts.

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The children and young people's emergency department had a specialist paediatric consultant in place and there were at least 2 paediatric trained nurses on each shift. The neonatal unit staffing was in line with British Association of Perinatal Medicine (BAPM) standards. Staff rotated between the children's unit and the children's outpatient department and staffing levels were scheduled in advance based on outpatient clinic activity.

The current nursing establishment in the children's unit allowed for 1 nurse for every 5 people using the service. The paediatric matron told us a business case was planned with a proposal to increase the nursing and healthcare staffing establishment to achieve a 1 to 4 nurse to service user ratio.

There was sufficient on-site and on-call consultant cover over a 24-hour period including cover outside of normal working hours and at weekends.

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Sickness and leave cover was provided by the existing staff and through the use of bank and agency staff. Staff sickness and turnover rates were low. Where bank or agency staff were used, managers made sure they had a full induction and understood the service.

Staff received and kept up-to-date with their mandatory training. Most staff (94%) had completed mandatory training but compliance was slightly below the hospital's training completion target of 95%).

Staff received a full induction before they started work and had regular clinical competency checks. Most staff had completed annual appraisals within the past 12 months. There were 3 medical staff with overdue appraisals and they all had appraisal dates scheduled during March 2025.

Staff received competency-based training and development as part of their continual professional development. Competency-based training was provided by trained individuals (such as practice based educators). Training files were maintained by the practice based educators. Staff were positive about on-the-job learning and development opportunities and felt confident to do their role.

The hospital reported that General Medical Council (GMC) or Nursing and Midwifery Council (NMC) revalidations were up to date for all eligible staff across the children and young people's services.

All the areas we inspected were visibly clean and had suitable furnishings which were clean and well-maintained. Cleaning schedules and daily checklists were in place and up to date, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment. Children’s toys and play equipment was suitably cleaned and decontaminated as part of routine cleaning schedules.

There were enough hand wash sinks and hand gels. We observed staff following hand hygiene and 'bare below the elbow' guidance. Staff used personal protective equipment, such as gloves and aprons, while delivering care. Visitors were encouraged to wash their hands. People identified with an infection were isolated in side rooms.

Parents and young people told us the premises and equipment were visibly clean and tidy and they did not have any concerns relating to the cleanliness of the environment and equipment.

Staff understood the processes managing risks related to the infections. They were able to describe how they cleaned and decontaminated equipment. They told us they could seek advice and support from the hospital-wide infection control team when needed.

Most staff (99%) had completed mandatory training in infection prevention and control. Staff followed the national infection prevention and control manual (NIPCM) that provided further guidance.

There had been no healthcare-associated infections or outbreaks reported by the children and young people’s services during the past 12 months.

Routine infection control and hand hygiene audits were carried out to check compliance against infection prevention and control policies and guidelines.

Environmental infection control audits undertaken during November and December 2024 showed high levels of compliance (over 88%) across the children and young people’s services. Hand hygiene audits between August 24 and January 25 showed staff in the children and young people’s services consistently achieved 100% compliance. Managers told us shortfalls in hand hygiene or infection control compliance were discussed with individual staff members to improve compliance.

Staff followed policies for the safe and secure handling of medicines and paediatric antimicrobial prescribing guidelines. Medicines including controlled drugs were stored securely and in line with manufacturers guidance and legislation.

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Temperatures of treatment rooms where medicines were stored and medicine fridges were monitored electronically. Records showed fridge and room temperatures were mostly within expected temperature ranges during the past 3 months. Staff understood how to notify the maintenance or pharmacy teams where maximum temperature ranges were exceeded.

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A hospital-wide antibiotic audit was carried out every 6 months. The most recent audit (July 2024) showed 83% of eligible children and young people were on appropriate antibiotics for their indication, 83% had an indication for their antibiotics listed on their medication chart and 100% had received a review of their antibiotics at 72 hours. Staff identified as not fully compliant with policies and procedures were given individual feedback to aid learning and improvement.

We looked at recent monthly medicines audit records for the children's unit and neonatal unit undertaken as part of ward accreditation assurance visits and a separate paediatric medication audit (October 2024) of 15 people's records on the children's ward. These showed high levels of staff compliance with medicines management standards and policies. Action plans were in place where improvements were identified, such as incomplete staff signatures, and these were planned for follow up at subsequent audits.

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Staff mostly completed medicine administration records accurately. We reviewed 13 records and saw that medicines administration were recorded in a timely manner. Weights were recorded on all charts checked. Antibiotics were prescribed within guidance, including having indications and dates of review recorded. However, we saw one instance of oxygen not being recorded as prescribed in the children's unit, which was not line with national guidance.

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The October 2024 paediatric medication audit identified the prescribing of oxygen was not captured as part of the audit and this was planned for inclusion in future medication audits.

Pharmacists supported the service daily on weekdays and staff could access medicines and advice out of hours. Staff told us that pharmacists were available to speak to people and families if needed.

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Where medicines related incidents were reported there was evidence that these were reviewed and investigated, and learning fed back. Medicines management was discussed at monthly hospital-wide integrated medicines optimisation group meetings and children's clinical governance meetings.

Parents and young people told us staff gave them clear information around medicines and their medicines were prescribed and administered appropriately. Staff told us that if young people struggled to take their medicines then play teams would be utilised to reduce the need for covert administration of medicines.

Investigations following child deaths in December 2023 identified learning around the use of Ondansetron (used to prevent nausea and vomiting). The service developed guidelines for the use of Ondansetron in the children and young people's emergency department in July 2024 to provide further guidance for staff.

Staff in the children and young people's services used patient group directives (PGD's) for the administration of some topical creams and over-the-counter pain medicines. PGD's were authorised by the hospital-wide integrated medicines optimisation group and staff were trained and assessed as competent before they could use the PGD.