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We are carrying out checks at Leigh Infirmary using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 22 June 2016

The medical care services at the Leigh Infirmary provide neurological rehabilitation care for those with an acquired brain injury or neurological illness and elective diagnostic procedures such as gastroscopy, colonoscopy and flexible sigmoidoscopy. Taylor ward has 20 beds including 3 side rooms. The endoscopy unit was opened in May 2013 with decontamination facilities on the same site. There are two surgical wards, wards two and three, providing day case and short stay services.

At the Hanover Diagnostic Centre, the hospital offers an extensive range of urology services. The urology department is located in the Richmond unit and offers a range of services for patients including rapid access clinics, prostate assessment, vasectomy, haematuria, one stop and out of hours evening clinics.

The main outpatient clinic areas are situated on the ground floor of the infirmary in six ‘areas’. These areas house a range of clinics covering colorectal, breast and orthopaedic surgery, diabetes, lipids, renal, urology, neurology, anti-coagulation, cardiology, chest, obstetrics and gynecology. The Hanover Diagnostic and Treatment Centre provide clinics for women’s health, urology and endoscopy patients.

Diagnostic imaging and haematology services are also provided at Leigh Infirmary including ultrasound, plain film x-ray, barium enemas, and barium swallows with video-fluoroscopy and video-urodynamics.

We inspected the hospital between the 8 and 11 December 2015 as part of the comprehensive inspection of Wrightington, Wigan and Leigh NHS Foundation Trust.

Overall we found the hospital provided good services across the four domains of effective, responsiveness, caring and of being well led. However they required improvement in safety in medicine and effectiveness in maternity and gynaecology.

Our key findings were as follows:

  • Staffing levels were adequate to meet the needs of patients at the time of the inspection.

  • Staff received training appropriate to their role however uptake of some training could be improved especially in Mental Capacity Act training.

  • Care was provided in clean and tidy surroundings and infection control practice was good. However the environment on Taylor ward did not fully meet the needs of the patients and were not conducive with safe patient care and the storage of waste was not always safe.

  • Food and drinks were available and suitable to meet the varied needs of patients.

  • Discharges from Taylor ward were not always timely.

  • Care was not always supported by robust policies, procedures and guidance and not always adhered to.

  • The use of restraining lap belts on one ward had become custom and practice and individual risk assessments had not been completed.

We saw several areas of outstanding practice including:

  • Urology staff offered ‘one-stop’ appointments for haematuria patients which enabled patients to undergo biopsies during initial appointments rather than having to re-attend on another day.
  • A trust ‘pioneering staff engagement’ programme was in place across a multi-disciplinary team with a number of innovating programmes in progress. The service had received several awards over the past two years.

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

Importantly, the trust must:

  • Ensure safeguarding, mental capacity act (2005) and deprivation of liberty safeguards are in place and followed to ensure patients safety at all times. Processes must be clearly defined, understood and followed by staff.

  • Improve mandatory training uptake particularly mental capacity act training.

  • Ensure that there is adequate space on the wards for patients to receive safe and effective care.

  • Ensure that there are adequate facilities to store clinical waste safely.

  • Ensure care is delivered as per evidence based guidance.

In addition the trust should:

  • Improve the timeliness of patient discharges from Taylor ward.
  • Improve staff annual appraisal rates.
  • Keep trolleys containing patients notes locked
  • Improve the completeness of records particularly with name and designation always clearly recorded and printed and consent forms available to review.
  • Review local rules held in the radiology department and ensure staff can locate them if required.
  • Review dosage instructions for adrenaline administration to treat anaphylaxis and ensure they are satisfied instructions are easy to interpret in an emergency.
  • Review the benefit of documenting processes for organising staffing for outpatient clinics.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 22 June 2016

Effective

Good

Updated 22 June 2016

Caring

Good

Updated 22 June 2016

Responsive

Good

Updated 22 June 2016

Well-led

Good

Updated 22 June 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 22 June 2016

The maternity and gynaecology services at Leigh Infirmary required improvement in the effective domain but were good in the other domains.

Policies were not always clear or followed current guidelines. Staff knew how to report incidents. Lessons were shared and, however; there was no integrated trust wide learning system. All areas were visibly clean and tidy and staff followed hygiene procedures.

Daily checks of equipment were completed, but systems for monitoring the maintenance of equipment were not robust. Safeguarding processes were in place and under review. Medicines were stored in secure cupboards and daily checks completed. Records for patients receiving surgical care and termination of pregnancy were reviewed and completed appropriately.

Staff had received mandatory training relevant for their role however there was room for improvement in the uptake of Breastfeeding for midwives, basic life support training by medical staff and delirium training by all staff. Medical staffing numbers were adequate for the patient’s needs. Any shortfall in staffing levels was supported by bank nurses.

Trust guidelines were in place; however these were not always clear or adhered to. Two guidance documents for the management of termination of pregnancy gave differing guidance. Guideline reviews were not robust in that they did not always include reviewing the references on the document. The trust participated in a number of local and national audits.

Women were assessed for pain relief and supported individually postoperatively. Patients breast feeding was supported in the community, however; the numbers decreased after discharge from postnatal care.

Midwives were annually assessed by their supervisors and other staff had been appraised to be competent although midwives did not rotate.

Services were available on weekdays only. Ward two carried out elective day-case surgery and clinics were at Leigh for routine antenatal and gynaecology appointments. Community staff had limited access to records due to a lack of computers.

We observed positive interactions between patients and staff. We observed staff actively engaging with patients in a kind and compassionate way. Patients were accommodated sensitively, where possible, if a side room was appropriate. Emotional support was available if needed.

The service had been planned across the geographical location. Gynaecology clinic services were based in the women’s centre at Leigh Infirmary. The antenatal clinics were being supported by main outpatients as they are in the process of relocating to refurbished premises in the former ward one. Each maternity patient was allocated a named midwife, in the community. Antenatal clinics were available across the Wigan and Leigh areas in GP surgeries.

There were specialist midwives including public health, safeguarding and a mental health nurse. Also diversity and dementia champions were available. Any patient identified with a learning disability or mental health issue were supported on an individual basis as needed.

Midwives were not clear about the trust vision and strategy. There were regular senior meetings that were cascaded to staff but staff felt that meetings with them needed to be more formal. Staff felt that they were supported by their managers; however hospital midwives felt there were fewer opportunities for them to develop than in the community.

A trust ‘pioneering staff engagement’ programme was in place across a multi-disciplinary team with a number of innovating programmes in progress. The service had received several awards over the past two years. Policies were not always clear or followed current guidelines.

Medical care (including older people’s care)

Good

Updated 22 June 2016

There were concerns in relation to staff understanding and processes around the Mental Capacity Act (2005) and the Deprivation of Liberty safeguards (DoLs). Completion of patients assessments on Taylor ward were inconsistent and trust policy was not always followed. Staff who had completed mental capacity act training was within the trust target although it was unclear as to which specific staff this included. The trust target was 95%.

There was limited space in some areas of Taylor ward. Clean equipment was stored in an unsecure sluice which increased the risk of cross infection and clinical waste was in an unlocked metal cage on the corridor accessible to members of the public. We found records were left unlocked on the wards we visited, a risk that personal information was accessible to members of the public.

There were governance structures in place which included a risk register. However there was no date for completion on the actions identified to lower the risk which meant it was unclear if the risks were being managed effectively. Incidents were reported through effective systems and lessons learnt or improvements made following investigations were shared.

Staff followed good hygiene practices and there were good systems for handling and disposing of medicines. The majority of areas on the wards were clean but there was equipment on Taylor ward that wasn’t.

Staffing levels were good across the ward and multidisciplinary team meetings were held on a regular basis to review patients. Team meetings were held on all wards to ensure that information was passed down to staff to improve patient care.

Staff had access to information they required and best practice guidance in relation to care and treatment was usually followed and medical services participated in national and local audits. All staff knew the trust vision and said they felt supported and that morale was good. Patients were observed receiving compassionate care and their privacy and dignity were maintained

Surgery

Good

Updated 22 June 2016

Staff were enthusiastic and proud of the services they provided. Staffing levels were sufficient and a safer nursing care staffing tool was utilised to ensure staffing levels were adequate. Medical staff rotas were in place and locum agency staff filled any gaps when the service was short staffed. Staff morale was good and staff felt well supported.

Incidents were reported and lessons learnt shared. Staff knew how to access the incident reporting system and could tell us about incidents they had reported. There were low incidents of pressure ulcers and infections. Risk assessments were completed and staff implemented measures to reduce risks.

The environment was clean and tidy and staff had access to the equipment they required to do their jobs. Medicines were managed safely and stored securely.

Referral and discharges worked well and staff shared relevant information. Services were coordinated and patients were appropriately referred to specialist services. Staff treated patients with respect and dignity, offered support and included them in their care planning. Patients received a caring service and staff discussed treatment plans with patients to ensure a person-centred approach. Referral to treatment times for the hospital were similar to or above the national average.

Risk registers were in place and discussed at team meetings. Staff were aware of the trust’s values and vison. Staff felt well-supported by managers and colleagues.

Outpatients

Good

Updated 22 June 2016

Whilst low numbers of incidents were recorded by the departments those that were reported were graded according to risk and shared to promote learning. There was an open and honest culture amongst staff. The environment differed depending upon location. Whilst the outpatient department was dated with little natural light, the Hanover Centre was light and spacious following refurbishment in 2013. The areas we inspected were visibly clean and tidy.

Safeguarding was managed by a central team who advised and supported staff who had been trained according to the level of contact with patients and those close to them. Patient risks were managed with resuscitation trolleys in departments.

Staffing was adequate with few vacancies and little or no use of agency staff. Staff used guidelines, procedures and policies to provide care for patients. Departments undertook audits and presented findings to colleagues to promote learning and improve services.

Staff received appraisals and were given opportunities to enhance learning. Radiology services were provided seven days a week. Outpatient clinics were not routinely provided on a seven day basis but clinics were held in the evenings and occasionally on a Saturday morning to manage waiting lists.

Patient records contained the necessary information. However medical signatures were not always legible and registration numbers and printed names were not always included. Approximately ten patient records per month were unavailable for clinic appointments. Staff accessed the electronic systems or contacted GPs if information was not available.

Staff understood consent and we saw evidence that written or verbal consent was obtained when required.

Outpatient services documented standards to maintain high levels of service and these were displayed for patients and visitors.

Patients were happy with the care they received and said staff had a polite and compassionate manner. Patients felt supported by staff during appointments.

A range of initiatives were in place to meet people’s needs.

The hospital met the department of health target of providing appointments for patients within 18 weeks. Ninety seven percent of patients referred for an urgent appointment for suspected cancer were seen within the department of health target time of two weeks. On average patients received appointments within 19 days for non-obstetric ultrasound scans, and two days for x-ray.

Waiting times following arrival in clinic varied depending on the type of appointment. At the time of our inspection there were no visible delays for patients waiting to be seen. Reporting time for scan results was one to two days. However, in September 2015, 1,367 x-rays were waiting for reports to be completed across all sites. Further staff were being recruited to manage this.

Verbal complaints were dealt with at the time through communication if possible, but verbal complaints were not always recorded by staff. Those that were recorded were monitored with results shared monthly to promote learning.

Staff had ideas about how to improve services. Trust values were evident in the areas we inspected. Governance meetings were held monthly. Risk was managed through a local risk register which documented the issue, mitigation, risk score and review date of each risk.

Staff felt supported by managers and services engaged with the public, through forums and questionnaires.

Urology staff offered ‘one-stop’ appointments for haematuria patients which enabled patients to undergo biopsies during initial appointments rather than having to re-attend on another day.