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North Manchester General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 1 March 2018

Our rating of services improved. We rated it them as requires improvement because:

A summary of our findings about this location appears in the overall summary.

Inspection areas

Safe

Requires improvement

Updated 1 March 2018

Effective

Requires improvement

Updated 1 March 2018

Caring

Good

Updated 1 March 2018

Responsive

Requires improvement

Updated 1 March 2018

Well-led

Good

Updated 1 March 2018

Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 12 August 2016

We judged  the service as Good because

   

·        

Mandatory training levels were good and the environment was visibly clean and tidy. Equipment was checked regularly and there was evidence to support this. Staff knew how to report incidents and the learning from these incidents was followed up through regular staff meetings.

·         

 

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Staff were using national guidelines which were being reviewed for compliance by the trust. There were good opportunities for staff development and evidence of effective multi-disciplinary team working. Leadership was good at an operational level  in both OPD and radiology and information was shared at all levels in the division; however some allied health professionals were unhappy with the lack of leadership for their professions in the trust.

 

·        

Pathology services were efficient with patient blood test results being available during clinics. The service  was provided a 24 hour, seven day per week service.

 

However

·

The did not attend for appointment (DNA) rates in OPD were higher than the England average and the trust did not have anything in place to address this. DNA rates were also high in the radiology department.

·

There were issues around the storage of medicines in OPD clinics but the trust were working to change this with pharmacy colleagues.

Maternity and gynaecology

Good

Updated 1 March 2018

We previously inspected maternity jointly with gynaecology, so we cannot compare our new ratings directly with previous ratings.

Maternity services had improved since the last inspection in several areas. We rated maternity services as good, however further work was still needed in some areas:

  • Maternity Early Warning Scores assessments were not always completed within the prescribed timescale to detect deterioration in a woman’s condition. This included when assessments indicated there was a risk to the woman.
  • Staff did not consistently follow the trust schedule for checking all equipment was present and in working order. This included resuscitation equipment for women and babies.
  • Appropriate records of patient’s care and treatment were not kept in a way in which they could be shared with other health professionals.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness except in one area of maternity services. There was no guideline for the admission of women into the maternity triage area despite this being an action required following a serious incident.
  • There was no formal system of support for midwives regarding safeguarding practice. There was no clear record to show women had been asked the required questions to identify safeguarding concerns at every interaction.

However:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. There had been significant improvements in the midwifery staffing numbers since the last inspection.
  • The service managed patient safety incidents well. Since the last inspection a new system for the management of incidents had been introduced. The investigations were completed within the trust’s timescales and learning was shared with changes made to prevent recurrence.
  • The service provided mandatory and obstetric specific training in key skills to all staff and most staff had completed it. Practice education midwives had been introduced. The mandatory training compliance had improved and was meeting the trust’s target.
  • Women could access the service when they needed it. Systems were in place to reduce delays in the discharge of women from the post-natal ward. This included specific staff to co-ordinate the required checks prior to discharge.
  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There had been changes in the leadership of the maternity services at the trust since the last inspection.
  • Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff reported an improvement in the culture since the last inspection.
  • The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service had suitable premises and equipment.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

Medical care (including older people’s care)

Requires improvement

Updated 1 March 2018

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

  • Patient records were not consistently completed in order to monitor the care provided. The records did not consistently show what care patients had received or plans in place to meet their individual needs.
  • The environment on many of the wards and areas we visited meant that they were not consistently suitable to meet the complex needs of patients and promote infection control. This was particularly noticeable on the Ambulatory Care Unit where the environment restricted the maintenance of privacy and dignity and did not assist staff to meet best practice in preventing the spread of infection.
  • The service did not consistently have enough staff with the right qualifications, skills, training and experience to mitigate risks to patients and to provide the right care and treatment. Staffing arrangements did not always take into account where patients required additional support from nursing staff.
  • The service did not store medicines well. Medicines were stored in areas where the temperature had exceeded the manufactures recommendations.
  • The arrangements to ensure that patients’ mental capacity was appropriately assessed and their individual rights protected were not consistently applied in order to make sure that a valid consent was obtained for care and treatment.
  • Handovers of care, in which staff discussed patients’ needs between shift changes, were not always consistent. Handovers were medically orientated and not person centred.
  • Patients waited for beds on a ward suited to their needs. Patients were delayed from discharge and bed moves at night took place on a regular basis, which was not in line with trust policy.
  • Managers did not always make sure that staff had completed training they needed as part of their job roles.

However

  • The service had improved on many of the issues for action highlighted in the previous inspection. There was a clear vision and strategy, which was available throughout the service that staff members were aware of.
  • The medical division had governance, risk management and quality measures in place to improve patient care, safety and outcomes.
  • Staff recognised incidents and knew how to report them. Lessons learned were shared amongst staff.
  • The use of arrangements to recognise and act on changes to the patients’ medical condition was effectively used. Deteriorating patients were appropriately referred for medical review so they received timely and appropriate treatment.
  • Complaints were investigated and completed in a timely way with the learning discussed and changes to the service provided influenced by the findings of the complaints.
  • Many leaders at ward level and above were new in post and their leadership was continuing to develop. Staff were enthusiastic and passionate about the changes being implemented to improve the services for patients.
  • Patients were cared for by staff that were observed to be kind, caring and compassionate. Patients spoke positively about the support and care that they received from staff.
  • There were systems and processes in place to reduce the risk of harm to patients.

Urgent and emergency services (A&E)

Good

Updated 1 March 2018

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

  • The service managed patient safety incidents well. Staff knew how to report incidents and there was an investigation process in place.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. Patients were routinely reviewed in accordance with national targets.

  • The service planned for emergencies and staff understood their roles if one should happen. The service had coped well with a recent major incident and staff had delivered an outstanding service to patients resulting in positive patient outcomes.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment. The leadership had reviewed the way the unit was staffed and introduced new roles to alleviate some of the pressures; staff were positive about the changes and the improvement this had made.
  • The service made sure staff were competent for their roles. Nursing appraisal numbers had improved since the last inspection.

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. There were systems to ensure effective training, development and education of staff.
  • Staff cared for patients with compassion, treating them with dignity and respect. Feedback from patients confirmed that staff treated them well and with kindness.
  • Learning from complaints and incidents was cascaded to staff and there was a clear focus on quality and continuous improvement.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff told us they were proud to work in the department.
  • There was strong leadership at departmental, divisional and directorate level. The new leadership teams had delivered positive improvements in a short space of time. Staff were positive about the leaders and the work they had done.
  • The department had a strong vision and strategy. Both the adult and paediatric urgent and emergency care service had plans and innovations to improve the quality of care.

However:

  • There were still some issues with staffing; work was still needed to embed the new team and fill short notice gaps that arose in the rota.
  • There was consultant presence seven days a week. Work was continuing to meet national guidelines of consultant presence for 16 hours per day.
  • There were still issues with meeting national targets and standards in relation to patients waiting for treatment and admission to hospital, however, there was a positive trajectory to meet these targets and figures had significantly improved in the past 12 months.

Surgery

Requires improvement

Updated 1 March 2018

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

  • Incident reporting was inconsistent across the service and learning from serious incidents was not effective across sites.
  • The service did not always assess or respond to risk. Implementation of the World Health Organisation Surgical Safety Checklist was not consistently implemented in theatres.
  • Medical and nurse staffing remained a challenge.
  • North Manchester General Hospital had a higher than expected risk of readmission for elective admissions when compared to the England average.
  • Consent for surgery was taken on the day of the procedure in the majority of cases which does not comply with accepted best practice.
  • Staff did not completely understand their roles and responsibilities under the Mental Capacity Act 2005.
  • Over the last two years the percentage of cancelled operations was generally higher than the England average.
  • Although the trust had managers at all levels with the right skills and abilities to run a service the divisional management structure was very new and still in its infancy
  • The trust collected, analysed, managed and used information to support its activities yet omissions observed in completion of the World Health Organisation Surgical Safety Checklist had not been recognised in the audit process.

However:

  • The wards and clinical areas were visibly clean and measures were in place to prevent the spread of infection.
  • The service prescribed, gave and recorded medicines well. Patients received the right medication at the right dose at the right time.
  • Appropriate records of patients’ care and treatment were available to staff.
  • Staff were competent for their roles and had opportunities to develop.
  • Good multidisciplinary team working was noted in areas we visited. Healthcare professionals supported each other to provide good care to patients.
  • The hospital had introduced a nursing and accreditation system to improve quality and safety on the wards.
  • Staff involved patients and those close to them in decisions about their care and treatment. Patients were kept informed of their plan of care.
  • People could access the service when they needed it. Between August 2016 and July 2017 the trust’s referral to treatment time for admitted pathways for surgery was consistently better than the England average.

Managers promoted a positive culture that supported and valued staff.

Intensive/critical care

Good

Updated 12 August 2016

We have judged  the critical care services provided were good because.

  • There were systems in place for reporting and learning from incidents.There were sufficient numbers of suitably skilled nursing and medical staff to care for the patient Care and treatment was planned and delivered in accordance with evidence based guidance.Critical care services were delivered by caring, compassionate and committed staff.We saw patients, their relatives and friends being treated with dignity and respect.There was a positive culture with staff and the public being engaged in the development of the service.

However

  • It was rare for there to be a supernumerary clinical co-ordinator on duty as set out in the national service specification for intensive care (D16).There was a problem with delayed and out of hours discharges.Governance processes were present but yet to be embedded.

Services for children & young people

Requires improvement

Updated 1 March 2018

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

  • Nurse staffing numbers in post were less than children’s services had planned for and staffing pressures were a concern. The service had to fill gaps with agency or bank staff and staff were transferred from the wards to cover gaps. Sickness levels for nursing were worse than the trust target. However we did not see any adverse impact on patient care and treatment.
  • Mandatory training levels were variable for certain training modules particularly for medical staff. There were plans to improve these levels.
  • Staff did not always keep appropriate records of patients’ care and treatment. Audits showed the quality of record keeping was variable. The small sample of records we looked at were however, were clear and available to staff providing care.
  • At the last inspection the use of the Manchester Children’s Early Warning scores had been identified as an area for improvement. During this inspection we found that an audit process was in place however the scores showed that more work was needed to improve compliance against standards.
  • A number of clinical guidelines had not been reviewed in line with trust timescales.
  • The service had not achieved all areas of compliance with Facing the Future: Standards for Acute General Paediatric Services.

  • The trust target for appraisal was 90%. Staff in most services, particularly neonatal services, were lower than required.
  • At times the working environment became over crowded with patients. Staff felt that waiting areas, wards and clinical spaces were sometimes cramped.

However

  • The service had made improvements since our last inspection in 2016.The changes had occurred despite a management restructure and a move to a new care organisation for its staff.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. Improvements had been made in the auditing of infection prevention and control.
  • The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time.
  • The service had recruited to medical posts. The increased medical staffing numbers had made a positive impact on patient care and the ability of wards and units to carry out their roles. There was a reduction in shifts covered by agency medical staff.

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. In some cases staff took the initiative to go beyond what was expected of them in terms of ensuring management of risk.

  • The service monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Data showed that the service had England average outcomes in most of the national audits it participated in.
  • Staff were competent for their roles.

  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress.
  • The service planned and provided services in a way that met the needs of local people. The service reviewed data regarding its local population and took this into account when developing services.

  • The service had recognised the needs of its population particularly regarding cultural diversity. It had set up a number of groups and projects to improve the service provided by them to individuals from those communities.

  • The leadership, governance and culture had improved since our last inspection. The service had restructured its leadership model. We found systems were in place to identify risk and challenges in the service. We found meetings were in place where information was shared and disseminated.

  • Senior managers and staff were aware of the findings of the previous CQC inspection in 2016 and many of the issues in that inspection such as medical staffing cover had been prioritised. The staff and managers showed a determination to reshape the service and improve its outcomes.

End of life care

Good

Updated 12 August 2016

Overall we judged the service as Good because.

 

Incident reporting systems were in place and learning from incidents was discussed 

 We saw assessment information from occupational therapy and physiotherapy and good comprehensive nursing assessments in the records. Appropriate risk assessments were in place. Th

e service had developed an individual plan of care and support for the dying person (IPOC) to guide care and support documentation in the last days of life in line with current evidence-based guidance and best practice. 

    

There was an audit plan in place and the reports we saw included appropriate recommendations and action plans to address the delivery of care where standards were not met. 

The service held a weekly multi-disciplinary team (MDT) meeting where cases and new referrals were discussed. 

  

End of life care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill

However

·T

he rapid transfer process was in its infancy and the service was taking steps to put improvements in place. T

here were numerous new systems in place or in planning to improve the provision of EOLC including the new steering group, the new reporting operational policy and the proposals for a new bereavement service, seven day working and an electronic palliative care co-ordination system (EPaCCs).  

·        

Some patients were not prescribed all of the recommended anticipatory end of life medications. 

There was no seven day service in place and although the potential risks of the impact on patients had been identified, assurance around the management of these risks was not clear. 

 

 

Other CQC inspections of services

Community & mental health inspection reports for North Manchester General Hospital can be found at The Pennine Acute Hospitals NHS Trust.