Archived: Wythenshawe Hospital

Wythenshawe Hospital is one of two locations providing care as part of University Hospital of South Manchester NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

We carried out an announced inspection of Wythenshawe Hospital on 26-29 January 2016 as part of our comprehensive inspection of University Hospitals of South Manchester NHS Foundation Trust.

Overall, we rated Wythenshawe Hospital as ‘Requires Improvement’. However, we rated the service as good for children and young people services, end of life and critical care. We found that services were provided by dedicated, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe and responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

• The trust had infection prevention and control policies in place which were accessible to staff.

• We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.

• Overall, patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.

Nurse staffing

• Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.

• Across medical services nurse staffing levels were variable. There were vacant posts on all wards that were being filled by either staff working extra hours, or bank and agency workers. Staffing had been identified as a risk on the divisional risk register and all staff highlighted this as an area of concern. Actions had been identified to mitigate the risk.

• The neonatal unit did not consistently meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM). Additionally, nurse staffing levels on starlight ward did not reflect Royal College of Nursing (RCN) standards; an acuity tool on the starlight ward was not in use at the time of the inspection.

• There were four vacancies in paediatric nurse staffing within the emergency department at the time of the inspection but recruitment was in progress.

• Within the diagnostic and imaging department there were challenges with regard to recruitment and retention of nurses and radiographers within the diagnostic and imaging department.

Medical staffing

• There was a reliance on locums within the emergency department to fill 28% of medical shifts. There were four vacancies in paediatric nurse staffing within the department but recruitment was in progress.

• During our inspection we found the critical care services had a sufficient number of medical staff with an appropriate skill mix to ensure that patients received the right level of care.

Leadership and Management

• The senior team, in the majority of core services, were visible and accessible and well known to the staff.

• There was a lack of engagement and leadership from senior clinicians within the maternity services. This lack of engagement had resulted in a significant delay in investigating incidents and reviewing and updating clinical guidance.

• Within children and young people’s service the local leaders on the ward and units were visible and managers were actively involved in the day to day running of the paediatric areas. However we noted that managers undertook clinical duties to increase staffing numbers which consequently meant they had limited time for managerial duties.

Access and Flow

• Access and flow was identified as a concern in the emergency department. The ED had not met the target to see, treat, admit or discharge patients within four hours at all in the last 12 months. Initiatives were in place to try to address this.

• Bed occupancy rates, delayed transfers of care and discharges had an impact on the flow of patients throughout the hospital due to the demand for medical services. Between January 2015 and December 2015, bed occupancy rates across medical services were over 100%, ranging from 101% to 104%. Due to the shortage of beds in medical services, patients were being treated on wards not best suited to their needs (also known as outliers). The trust ensured that all outliers were seen by a consultant, and each ward had a named consultant to carry out this role on a daily basis.

• There were challenges with access and flow through surgical services; however services were responsive to individual needs of patients. We observed numerous examples where staff adapted services to the needs of patients, including delivering medication through sign language to a deaf patient. The trust had considered the changing needs of its population and had trained staff to be ward leaders in care for people with dementia.

• Within critical care there was insufficient capacity to meet patient need which meant patients were not always admitted promptly to receive the right level of care. The high bed occupancy levels in the critical care services meant operations were cancelled due to the lack of available critical care beds.

• As part of the trust’s escalation policy, patients were transferred to the main ‘theatres recovery area when there were no critical care beds available. There had been 59 occurrences of patients being nursed overnight in theatre recovery from April 2015 to October 2015. Patients kept overnight in recovery were assessed by critical care consultants. However, they were cared for by recovery nurses that had not completed all the relevant competencies to treat critically ill patients. There were plans in place to provide training for recovery staff by the end of March 2016.

• Patients were not always discharged from critical care in a timely manner due a lack of available ward beds and capacity constraints across the trust. ICNARC data up to September 2015 showed the number of reported delayed discharges (within and greater than four hours) was worse than other comparable units nationally. The data showed the delayed discharges were consistently 10% to 20% above the average since January 2013.

• The smooth flow of patients on ward F16 was interrupted by limited access to sonography. The shortage of scanning sessions available in the early pregnancy assessment unit led to unnecessary admissions to the ward.

• Diagnostic waiting times were worse than the England average from August 2014 onwards, with performance particularly poor during the second half of 2014. Between June 2015 and September 2015 the proportion of radiological investigations reported on within 10 days ranged from 68% to 75.5%. The did not attend (DNA) rate at Wythenshawe Hospital was higher than the England average each month since February 2015.

We saw several areas of outstanding practice including:

• The bereavement midwife had been nominated for the national Butterfly awards two years running. These are awards celebrating survivors and champions of baby loss. The bereavement midwife was also runner up in the Royal College of Midwifery awards for her work providing bereavement support.

• A rapid access clinic had been introduced for menstrual disorders and post-menopausal bleeding to meet demand and allow for the development of innovative out-patient treatments such microwave endometrial ablation and hysteroscopy sterilisation.

• The cystic fibrosis team were awarded the quality improvement award by UK cystic fibrosis registry annual meeting in July 2015. The paediatric CF team won the first National Cystic Fibrosis Registry Quality Improvement Award in recognition for innovative use of the Port CF database, which provided focussed and early intervention to prevent further deterioration in their patient’s condition.

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

Importantly, the trust must:

In Urgent and Emergency Care:

• Ensure equipment checks in resuscitation areas are completed daily in line with trust requirements with a clear pathway for reporting associated concerns and actions such as missing equipment and subsequent replacement.
• Ensure staff appraisal rates consistently meet the trust target.
• Ensure the safety of reception staff at all times and take steps to mitigate current risks associated with the reception environment such as no protective screens and open desk areas.
• Ensure that the temperatures of fridges storing medicines at low temperature, are recorded in line with guidance on a daily basis, and that required issues are consistently reported.
• Ensure action is taken to remove the risk of ligature from ceiling vents in the mental health room, in line with guidance from the Royal College of Emergency Medicine (CEM6883 Mental Health in EDs toolkit February 2013)
• Consistently improve patient waiting times in line with Department of Health targets.

In Medicine:

• The trust must ensure that staffing levels are appropriate to meet the needs of patients across the medical services and ensure there is an appropriate skill mix on each shift.

• The trust must ensure that all records are stored securely when not in use.

• The trust must take action to improve the bed occupancy rates across medical services to ensure the safe care and treatment of patients.

In Maternity:

• The trust must improve mandatory training for midwifery staff in terms of safeguarding level three training to ensure it is in line with the trust target.

• The trust must ensure all clinical policies are regularly reviewed and kept up to date.

• The trust must ensure incidents are investigated in a timely manner to ensure lessons are learned and recommendations implemented.

In Children and Young People:

• The service must ensure safe staffing levels are sustained in accordance with National professional standards and guidance.

• The service must ensure that staff are reporting risks and incidents to the senior leaders of the service actions being taken in a timely manner.

• The service must ensure that all treatment, assessments, diagnostics and any other care relating to the patient is recorded appropriately in patient records.

• Ensure that transition arrangements for children between 16 and 18 years meet the needs of the individuals without prejudice.

In addition the trust should:

In Emergency Department:

• Review the security of the paediatric ED entrance to ensure children are safe at all times
• Introduce recording of completed cleaning to ensure contemporaneous records are available
• Improve the cleanliness of areas found to have dust and debris on the floor (store room and mental health room)
• Review the storage of equipment in open packaging, or without packaging in the resuscitation area.
• Improve the uptake of mandatory training for medical and nursing staff where there are pockets of low compliance.
• Reduce locum usage in the ED whilst maintaining appropriate staffing levels.
• Improve service for patients and relatives in relation to food and refreshments in the ED.
• Put appropriate actions in place to improve services following local or national audit and ensure that relevant staff are aware of findings.
• Review the role of the discharge lounge in ensuring access and flow through the ED.

In Medicine:

• The trust should take action to ensure that all necessary patient risk assessments are completed across medical services in accordance with the National Institute for Health Care Excellence (NICE) guidance.

• The trust should ensure that all ligature risks are identified and risks mitigated to ensure patients at risk of harming themselves are protected.

• The trust should ensure that patients are discharged as soon as they are medically fit.

• The trust should ensure that patients are not moved ward more than necessary during their admission and are cared for on a ward suited to their needs.

• The trust should take action to ensure that all staff receive annual appraisals.

• The trust should take action to provide the necessary mandatory training for medical staff.

• The trust should cascade major incident planning information to all staff across medical services.

In Surgery:

• The provider should ensure that there are adequate numbers of suitably qualified staff to ensure safe patient care and maintain a safe environment.

• The provider should ensure that it develops a recovery plan to address the bed capacity difficulties that surgical services are experiencing, in order to resolve the high number of late cancelled surgical procedures and improve referral to treatment times.

• The provider should ensure that any difficulties with clinical leadership, including nursing and medical leaders, should be fully resolved in order that all surgical services should be well-led.

In Critical Care:

• Take appropriate actions to reduce the number of delayed discharges.

• Take actions to ensure patients kept in theatre recovery receive appropriate care and treatment.

In Maternity:

• Consider the number of scans available to prevent women having to be admitted to the ward or to the emergency department after 18:00.

• Improve the uptake of mandatory training for medical and nursing staff.

• Review all guidance and ensure it is in date and fit for purpose.

• Review the number of sonography sessions available in the early pregnancy unit to prevent unnecessary admissions to the ward.

• Staff should receive feedback from incidents.

• Review midwifery staffing levels to reach trust targets with midwifery staffing ratios.

In Children and Young People:

• The service should consider how sufficient time for the ward manager to perform managerial tasks associated with the role can be supported.

• The service should consider protecting nurse training time to develop staff.

• The service should consider improving their CAHMS pathway.

• The service should consider training on incident reporting with emphasis on informing staff what the trust constitutes as an incident.

In End of Life:

• The trust should ensure that all staff groups have access and are trained to use the trusts electronic reporting system.

• The trust should consider requesting feedback about the quality of mortuary services from partner agencies such as funeral directors.

• The trust should consider developing a work schedule in relation to narrowing the gap between preferences and place of death.

• The trust should set targets for completing all action plans.

• The trust should consider making testing major incident plans.

• The trust should consider ensuring audits reach the appropriate target audience so that senior clinicians are able to comment on their area of responsibility such as use of the individual plan of care booklet.

• The provider should ensure all doctors who sign DNACPR include their position and GMC number as requested on the form.

• The trust should ensure the leadership structure for all services involved in palliative and end of life care is clearly defined.

• The trust should consider completing a staff survey to enable staff to comment on the quality of the service and future developments.

• The trust should consider making the use of the most effective end of life care planning tool mandatory or develop a policy and risk assessment which supports two systems currently in use.

• The trust should review the medication policy to ensure management of prescription forms in the community is in line with best practice guidance.

• The trust should ensure the pain scoring assessment tool is used in conjunction with the pain plan of care.

In Outpatients and Diagnostic Imaging:

• The trust should take action to ensure that equipment is available and fit for use with minimal disruption to the service.

• The trust should ensure a record is maintained of the minimum and maximum of fridge temperatures for each medication fridge.

• The trust should take action to address the issue of x-ray requests being completed using the log in of another referrer.

• The trust should put measures in place to allow patients to book in to outpatient and diagnostic areas without being overheard.

Professor Sir Mike Richards

Chief Inspector of Hospitals