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Provider: Walsall Healthcare NHS Trust Requires improvement

On 25 July 2019, we published a report on how well Walsall Healthcare NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Reports


Inspection carried out on 19 Mar 2019

During a routine inspection

  • The acute site at Manor Hospital were rated as requires improvement.
  • Overall community services were rated as good.


CQC inspections of services

Service reports published 25 July 2019
Inspection carried out on 19 Mar 2019 During an inspection of Community health sexual health services Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Service reports published 20 December 2017
Inspection carried out on 31 May & 21 June 2017 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 1 May 2017, 20 – 22 June 2017 and 4 July 2017 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 1 May 2017, 20 – 22 June 2017, 4 July 2017 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
See more service reports published 20 December 2017
Service reports published 26 January 2016
Inspection carried out on 8-10 September 2015 During an inspection of Community end of life care Download report PDF (opens in a new tab)
Inspection carried out on 8-10 September 2015 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 8-10 September 2015 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
See more service reports published 26 January 2016
Inspection carried out on 31 May 2017 (unannounced) 20 – 22 June 2017 (short notice announced)

During an inspection looking at part of the service

Walsall Healthcare NHS Trust provides acute hospital and community health services for people living in Walsall and the surrounding areas. The trust serves a population of around 270,000. Acute hospital services are provided from one site, Walsall Manor Hospital. Walsall Manor Hospital has 550 acute beds. There is a separate midwifery-led birthing unit and the trust’s palliative care centre in Goscote is their base for a wide range of palliative care and end of life services.

Following the 2015 inspection, we rated this trust as ‘inadequate’. We made judgements about eleven services across the trust as well as making judgements about the five key questions we ask. In 2015 we rated the key questions for safety, effective and well led as ‘inadequate’. We rated the key questions, for caring and responsive as 'requires improvement’.

The trust was placed in special measures by the Secretary of State for Health in February 2016 following our announced comprehensive inspection on 8 to 10 September 2015 followed by three unannounced inspection visits after the announced visit on 13, 20 and 24 September 2015. We wanted to ensure services found to be providing inadequate care at the trust did not continue to do so.

After this inspection period ended, the Care Quality Commission served the trust with a Section 29a Warning Notice of the Health and Social Care Act 2008. This outlined the quality of healthcare provided by Walsall healthcare NHS Trust for the following regulated activities required significant improvement:

  • Diagnostic and screening procedures

  • Maternity and midwifery services

  • Surgical procedures

  • Treatment of disease, disorder or injury

The warning notice set out the points of concern and timescales to address this and was wholly related to maternity services. The trust responded to this with a detailed plan for remedial action.

For this inspection, we undertook an unannounced inspection on 31 May 2017 where we inspected community services for adults, children and young people and end of life care. On the day of the unannounced inspection, we announced to the trust we would be returning for a short notice announced inspection on 20 to 22 June 2017. We conducted an announced visit to eight core services at Walsall Manor Hospital, which included: emergency department; medical care services; surgery; critical care; maternity; children and young people services; end of life care and out-patients and diagnostic image services. The inspection team included CQC inspectors and clinical specialist advisors for each service.

We held staff focus groups in the hospital and across community settings before and during the inspection. These included consultants, junior doctors, midwives, nurses, student nurses, healthcare assistants, administrative and clerical staff, and community staff. We also analysed data we already held about the trust to inform our inspection planning.

At this inspection, we saw improvements in ratings for all acute services at Manor Hospital with the exception of maternity and gynaecology services which remained inadequate overall and critical care which remained requires improvement overall. In the community, community health services for adults and children and young people remained at a good rating overall whilst community end of life care improved from good at our last inspection to outstanding overall.

We have rated this trust as requires improvement overall. We made judgements about eleven services across the trust as well as making judgements about the five key questions we ask. We rated the key questions for safety, effective, responsive and well led as requires improvement. We rated the key question for caring as good.

We saw several areas of good practice including:

  • Staff and patients’ relatives told us the dementia lead nurse for the emergency department had made significant improvements for patients living with dementia while they were being cared for in the department.
  • The end of life care service provided access to care and treatment in both the acute and the community settings 24-hours a day, seven days a week.
  • The culture within the outpatients department had changed considerably for the better. Local staff took responsibility and ownership for their own areas and specialities.
  • We saw community engagement by the Walsall Palliative Care Centre was exemplary. A panel of patients and patient relatives to reflect the needs and wishes of the local population had reviewed all the advanced care plan and the individualised care plan. A number of documents senior managers had produced had won national recognition and awards.
  • The teenage pregnancy service had developed a website called ‘Easy SRE’, a toolkit of resources to support sex and relationships education.
  • Within the community health services for children, young people and families, the speech and language therapy team, nursery nurses and transition team had been nominated for national awards.
  • Within community health services for adults, an alert system had been developed to immediately notify the long-term condition teams when vulnerable adults presented in accident and emergency or any of the wards at Walsall Manor Hospital.

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

Action the hospital MUST take to improve

Maternity and Gynaecology

  • Risks are explained when consenting women for procedures.
  • The service uses an acuity tool to evidence safe staffing.
  • Action plans are monitored and managed for serious incidents.
  • Lessons are shared effectively to enable staffing learning from serious incidents, incidents and complaints.
  • Staff follow best practice national guidance.

Urgent and Emergency Services

  • Take action to improve ED staff’s compliance with mandatory training.
  • ED completes the action plan compiled following the CQC inspection carried out in September 2015.

Critical care

  • Plans are in place for staff within the critical care unit to complete mandatory training. This includes appropriate levels of safeguarding training.
  • All staff working within the outreach team are competent to do so.

Children and young people

  • All local guidelines are updated and regularly reviewed for staff to follow.

Outpatients and Diagnostic Imaging

  • Staff undertake required mandatory and safeguarding training as required for their role.
  • All staff within outpatients have the required competencies to effectively care for patients, and evidence of competence is documented.
  • All staff receive an appraisal in line with local policy.
  • Patients medical records are kept secure at all times.
  • All outpatient clinics are suitable for the purpose for which they are being used.

End of life care

  • Attendance for mandatory training is improved.
  • Undertake required safeguarding training as required for their individual role.
  • All staff are trained and competent when administering medications via syringe driver.

Medical care

  • Mandatory training is up-to-date including safeguarding training at the required level.
  • There are sufficient numbers of suitably qualified, competent, skilled and experienced staff to keep patients safe.

Surgery

  • All professional staff working with children have safeguarding level 3 training.
  • All staff are up-to-date with safeguarding adults.
  • The safeguarding adults and safeguarding children policies are up-to-date and include relevant references to external guidance.
  • Patient records are completed, that entries are legible and each entry is signed, dated with staff names and job role printed.
  • All shifts have the correct skill mix for wards to run safely.
  • All staff are up-to-date with mandatory training.

Community Services for Children and Young People

The trust must:

  • Ensure blind cords are secured in all areas where children and young people may attend.
  • Ensure patient records remain confidential and stored securely.
  • Continue to follow standard operating procedures with medicines in special schools.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 8 – 10 September 2015

During a routine inspection

Walsall Healthcare NHS Trust provides acute hospital and community health services for people living in Walsall and the surrounding areas and the trust serves a population of around 260,000. Acute hospital services are provided from one site, Walsall Manor Hospital which has 606 inpatient beds made up of 536 acute and general beds, 57 maternity beds and 13 critical care adult beds. There is a separate midwifery-led birthing unit and a specialist palliative care centre in the community.

We carried out this announced comprehensive inspection on 8 to 10 September 2015. We held two public listening events in the week preceding the inspection visit and met with individuals and groups of local people and analysed data we already held about the trust to inform our inspection planning. Teams, which included CQC inspectors and clinical experts, visited Walsall Manor Hospital and inspected eight core services: emergency department, medical services, surgery services, critical care services, maternity services, children and young people services, end of life services and outpatients and diagnostic services. We also inspected three out of four community services: adult services, children, young people and families and end of life care services. We did not inspect community inpatient services as this service was registered with the local authority. We also carried out three unannounced inspection visits after the announced visit on 13, 20 and 24 September 2015.

We have rated this trust as ‘inadequate’. We made judgements about eleven services across the trust as well as making judgements about the five key questions we ask. We rated the key questions for safety, effective and well led as ‘inadequate’. We rated the key questions, for caring and responsive as 'requires improvement’.

Our key findings were as follows:

  • Maternity services had multiple issues with staffing, delivery of care and treatment and people were at high risk of avoidable harm. The service had limited capacity and staffing resources which impacted negatively on patient experience and compromised patient safety.

  • The latest MBRRACE report presented results for still births, neonatal mortality and extended perinatal mortality rates for 2013. Standardised results for Walsall were slightly higher than their comparator group. MBRRACE recommended that Walsall should consider a local review to better understand factors that may contribute to these results. In response to this the trust with its partners in the CCG and Public Health had participated in a detailed local study and agreed an action plan both of which have been shared with the Trust Board in public following our inspection.

  • The Emergency Department (ED) triage process was ineffective, there was a shortage of qualified paediatric nurses and no paediatric consultant based in ED. There were regular delays with patient handover from ambulance to ED. The trust had been consistently performing worse (5 to 9 minutes) than the England average (median 3 to 6 minutes) for the time to initial assessment of patients between January 2013 and April 2015.

  • The percentage of patients seen within the national four hour target to see, treat and admit or discharge 95%, was worse than the standard or national average for almost all of the period between April 2014 and May 2015. We saw the percentage of emergency hospital admissions waiting four to twelve hours from the decision to admit until being admitted (18 to 50%) was consistently above the England average of 5 to 15% between April 2014 and April 2015.

  • Incident reporting, particularly feedback to staff was variable across the trust. There was a mixed approach to incident reporting which differed between services. The trust promoted incident feedback to staff through various methods. However, this was dependent upon individual service managers to disseminate lessons learned and staff’s capacity to engage.

  • Previous concerns relating to the trust’s management of duty of candour had improved. We looked at several serious incident records which demonstrated the trust had adopted a more open and rigorous approach to the duty of candour regulation and its process.

  • Staff were caring and compassionate towards patients and their relatives. We did however see that in both ED and Maternity the excessive workload led to the standards of caring falling below that we would expect. Patient’s dignity and privacy was largely ensured and we saw many examples of good care across the trust from staff at all levels.

  • Community services for Adults, Children, Young people and Families and End of Life Care, were rated as good overall. Governance structure and risk management were well embedded and general leadership of community teams was supportive and nurturing.

  • The trust took part in all the national clinical audits they were eligible for, and had a formal clinical audit programme, where national guidance was audited and local priorities for audit were identified.

  • The Summary Hospital-level Mortality Indicator (SHMI) is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die. It was recognised that the SHMI for Walsall Manor Hospital had increased over an extended period of time, March 2015 was 107.41, April 2015 was 110.54 and May was 102.64. This represented a risk to patient safety.

  • The trust was still seeing the effects of implementation of the new electronic patient administration system nearly 18 months previous. Improvements had been made however, the trust was still struggling with simple tasks, (e.g. making patient appointments) as well as experiencing difficulties in gathering accurate information for decision making and performance management.

  • The culture of the trust was described by many staff as poor. Morale was low across many wards and departments and we heard examples of senior managers and in some cases executive members taking a heavy handed approach to problem solving. Despite ‘low morale’ staff demonstrated a positive approach to patient care and a genuine compassion to deliver the best care possible.

  • Divisional and corporate risk registers did not accurately reflect identified risks trust wide.

  • The trust had failed to implement the new checks and tests necessary to fulfil the requirement for all directors to be ‘fit and proper’ persons. This statutory requirement came into effect in November 2014. We saw no checks had been carried out for any directors within the trust and there was no Fit and Proper Person Policy in place. Following the announced inspection, the trust had taken remedial action to satisfy statutory requirements which demonstrated compliance with the Fit and Proper Person Regulation before the inspection period ended.

  • The Trust described to us what they referred to as a “perfect storm” in 2014 as a result of significant increases in emergency and obstetric activity and problems following the replacement of the patient administration system. The Trust Board recognised that the organisation faced significant quality and performance challenges in 2015 and had launched an Improvement Plan (“Improving for Patients; Improving for Colleagues; Improving for the Long-Term”). The plan included a programme of work to develop the two to five year strategy for the Trust and its services. The plan had been launched in June and as in its early stages at the time of our inspection in September 2015.

Importantly, the trust must:

  • Improve the governance of incident reporting systems to ensure that processes are embedded across the Trust.
  • Improve duty of candour training to ensure staff have a clear understanding of the process.

  • Implement systematic training for complaints investigation,improve the RCA process and dissemination of lessons learned to front line staff and their managers.

  • Ensure there are adequate numbers of qualified staff across all services, particularly in: maternity services, emergency department and medical services to meet the needs of patients to protect them from abuse and avoidable harm.

  • The trust must ensure there is an adequate supply of equipment in good working order and fit for purpose across all services. Any mitigation to replace equipment must have clear reasons, regular review and an up –to-date action plan clearly demonstrating alternative options and timescales to support actions.

  • The trust must ensure equipment is stored appropriately; all fire exits must be kept free without compromising patient and staff safety and staff can access equipment when required.

  • Mental Capacity Assessments (MCA), Deprivation of Liberty Safeguards (DoLS) and Do Not Attempt CPR (DNACPR) assessments to be carried out in a timely manner and supported by appropriate documentation.

  • Review the patient administration system to minimise problems associated with missed patient appointments. Ensure data is accurate and the system is a reliable resource for staff to use which meets the need of patients using the service.

  • Ensure health records are completed appropriately and patient data is confidentially managed. Patient confidentiality is maintained at all times across all service.

After the inspection period ended, the Care Quality Commission issued the trust with a Section 29a warning notice outlining there was significant improvement required. This set out the points of concern and timescales to address this. The trust has responded to this with a detailed plan for remedial action.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.