Tameside and Glossop Integrated Care NHS Foundation Trust is a major provider of hospital services in Tameside and Glossop, providing care to a population of approximately 250,000. Care was provided from a single acute hospital site situated in Ashton-under-Lyne.
In 2013, the trust was identified nationally as having high mortality rates and it was one of 14 hospital trusts to be investigated by Sir Bruce Keogh (the Medical Director for NHS England) as part of the Keogh Mortality Review in July that year. After that review, the trust entered special measures because there were concerns about the care of emergency patients and those whose condition might deteriorate. There were also concerns about staffing levels (particularly of senior medical staff at night and weekends), patients’ experiences of care and, more generally, that the trust board was too reliant on reassurance rather than explicit assurance about levels of care and safety.
We carried out a comprehensive inspection of the trust in 2014 and followed up our inspection findings in a focused inspection April 2015. As part of this inspection a number of improvements were recognised particularly in critical care.
However, in April 2015 we remained concerned in respect of the safety, effectiveness and responsiveness of some services particularly in medical care (including frail elderly).
This inspection was a fully comprehensive inspection to ensure improvements had been continued and sustained.
We inspected Tameside and Glossop Integrated Care NHS Foundation Trust on 8-11 August 2016.
We inspected
- Urgent and Emergency Care Services
- Medical Care (including Frail Elderly)
- Surgical Services
- Critical Care Services
- Maternity and Gynaecology
- Children and Young Peoples Services
- End of Life Care
- Outpatient and Diagnostic Imaging Services.
Our key findings were as follows:
We were pleased to note that the trust had continued to make improvements in a number of key areas particularly in urgent and emergency care.
Good progress had been made that resulted in the ‘requires improvement’ rating for urgent and emergency care services being increased to ‘good’.
Vision and Leadership of the trust
- The trust was led and managed by a stable, visible and accessible executive team. The senior team led the trust with a good focus on service quality and positive patient experience. Staff confirmed that it was commonplace to see the senior team and Chief Executive in the wards and departments.
- The trust's aim was ‘to deliver, with our partners, safe, effective and personal care, which you can trust’. This was underpinned by a set of values and behaviours that were based on safety, care, respect, communication and learning.
- The trust's aims, values and behaviours were well understood and adopted by all staff groups.
Culture within the trust
- There was, in the main a very positive culture throughout the trust.
- Staff of all grades were committed to the continuous improvement regarding the quality of care and treatment delivered to patients.
- Staff felt comfortable and confident in respect of raising matters of concern. In addition staff felt that they could share ideas for improvement and innovation with managerial support.
- There was a range of reward and recognition schemes that were valued by staff. Staff were supported to be proud of their service and celebrate achievements.
Governance and risk management
- The trust's governance arrangements were centred on the divisional structure of services. Each division was managed by a triumvirate of manager, nurse and doctor. The triumvirates reported to the board through a committee structure.
- Mechanisms were in place to ensure that committees were managed and reported appropriately so that performance was challenged and understood. There was challenge and scrutiny by non-executive directors in respect of quality and risk.
- The Board Assurance Framework (BAF) was suitably aligned to strategic objectives and was linked appropriately to divisional risk registers.
- There were divisional governance meetings where performance, risks and learning was discussed and shared. Staff had access to management information to support good performance which included trends and correlation of data to promote identification of poor performance and support timely action planning.
Mortality rates
- Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by robust and well understood review and escalation procedures. All deaths were reviewed. Key learning points were cascaded to staff appropriately.
- Lessons learned were disseminated through the divisional governance structure to enable appropriate actions to be embedded and learning from mortality reviews to be shared by divisional teams. The review of every death provided an assurance of quality care delivery and provided valuable information and learning regarding avoidable deaths.
- The mortality review proforma incorporated recommendations and guidance from NHS England, PRISM2 study and the Mazars report (2015).
- Monitoring arrangements were in place at board level to ensure that opportunities for learning and improvement were implemented.
- The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The December 2014 to December 2015 SHMI of 115 was above the ‘expected’ level (100). The trust’s HSMR for the latest 12 month period (to February 2016) is 92.6. The trust investigated the reasons for the divergence in these indicators performance the action put in place were
- A mortality review process of the care provided for all inpatient deaths.
- A Trust Mortality Steering Group, where improvement is tracked through monthly performance monitoring and national benchmarking tools, are used to flag areas of concern.
Safeguarding
- The trust had safeguarding policies and procedures in place which were readily available on the trust’s intranet site. Policies were supported by staff training. The trust had improved its performance with regards to adult safeguarding staff training, 98% of staff having received training in 2015-16 raising awareness.
- The majority of staff were aware of how to refer a safeguarding issue to protect adults and children from suspected abuse.
- Overall, safeguarding training was above the trust's target of 95% and across the trust averaged 98% for safeguarding adults and 99% for safeguarding children. However, there were departments within the trust where safeguarding children's training compliance levels were below the trust's target. These areas included medical and nurse staffing within A&E, the medical division and women's services.
- The trust had an internal safeguarding team who could provide guidance and support to staff in all areas. This team were easily accessible by telephone and email. During out of hours periods staff had access to senior nursing staff within the hospital management team to seek advice and guidance on safeguarding issues.
- The team worked with staff, patients and families to develop plans of care in order to fully meet the patient's individual needs. This included support for people living with dementia, a learning disability, and autism spectrum conditions, patients with physical disabilities and patients with mental illness.
Nurse Staffing
- Nurse staffing levels, although improved remained a challenge in a number of areas particularly in the medical directorate. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff.
- Where possible, regular agency and bank staff were used which meant they were familiar with policies and procedures. Any new agency staff received an induction prior to working in the hospital.
- We reviewed a report produced on the 27 April 2016. The report indicated that a number of wards in the medical directorate were below 80% staff fill rates for qualified day staff. The report highlighted issues in ward 41, 44 and 46 where qualified nurse fill rates were between 79% to 74%. This was escalated to board level and in the the safer staffing report of July 2016 it was noted that getting the correct numbers of nurses, midwives and healthcare assistants in place was essential for the delivery of safe and effective patient care and the chief nurse was providing scrutiny, leadership and oversight of this essential area of quality and safety.
- The trust was actively recruiting nationally to address the nursing vacancy rates currently at 89% for day staff and 98% for night staff (June 2016) .
- The trust was working with other agencies to fill rota gaps to maximise nurse staffing capacity. Never the less, there were times when wards were not fully staffed.
Midwifery Staffing
- A review of midwifery staffing numbers had been undertaken in January 2016 using birth-rate plus criteria and calculation tool, in line with the NICE guidance for Safe Midwifery Staffing for Maternity Settings (NICE, 2015). This identified a growing number of births with impact on the required number of midwives which was to be monitored via the maternity dashboard.
- We saw when midwife numbers were below those planned for a shift additional staff were sourced and put in place. The labour ward coordinator was responsible for monitoring any shortage of staff and capacity issues.
- Recruitment of midwives was not difficult for the trust. 13 midwives which represented 9.7 whole time equivalent midwives had been recruited to start work between August and October 2016. This would meet the vacancy rate of 9.8 full time posts.
- The midwife to birth ratio had been 1:30 in June but had improved to 1:28 with new midwives starting employment.
- We were told one to one care in labour was achieved.
- Two midwives were on call to assist at any home births out of hours.
- A new manager for the community midwives had been appointed in June 2016. The current systems of working were under review and a new model was being considered.
- Community midwives and the community midwife manager were unable to tell us how many patients they had on their caseload. Therefore there was no management of the equity or suitability of the size of community caseload. During the inspection one midwife had accepted seven visits which they could not complete. Managers were aware of this and a scoping exercise to address it had begun.
- There was a midwife from the enhanced team based in the hospital Monday to Friday 9am to 5pm and one on call in the community. Out of these hours safeguarding support was provided by the on call supervisor or the children’s safeguarding team.
Medical Staffing
- The proportion of middle career doctors and junior doctors within the trust was greater than the England average. The proportion of consultants was below the England average (37% compared with the England average of 42%). The proportion of registrars was also below the England average (27% compared with the England average of 36%).
- These figures were an improvement from last year and the urgent and emergency care department had slightly above the England average number of consultants. The trust continued to work with other trusts to look at innovative ways to recruit and retain staff, including overseas recruitment and talent management. At the time of our inspection in surgical services there were appropriate numbers of medical staff to meet the needs of patients.
Cleanliness and infection control
- Clinical areas at the point of care were visibly clean, the trust had infection prevention, and control policies in place that were accessible to staff and staff were knowledgeable about their role in controlling and preventing infection.
- Staff followed good practice guidance in relation to the control and prevention of infection in accordance with established trust policies and procedures.
Competent Staff
- Newly appointed staff had an induction for up to four weeks and their competency was assessed before working unsupervised. Agency and locum staff also had inductions before starting work.
- Practice educators that oversaw training processes and carried out competency assessments based on national competency guidelines.
- Staff told us they routinely received supervision and annual appraisals. Records up to June 2016 showed the appraisal rate was 95.6%. This showed the majority of staff had completed their annual appraisals and the hospital’s internal target of 90% appraisal completion was achieved across all
- The nursing and medical staff we spoke with were positive about on-the-job learning and development opportunities and told us they were supported well by their line management.
We saw several areas of outstanding practice including:
- The main Hartshead building was designed with input from a disabled patient user group. Access to the building was good with clear signposting. There was a team of volunteers that provided mobility scooters by request and supervised their use throughout the hospital so patients with mobility difficulties could move through the site easily.
- The radiology department offered a “Virtopsy Service”. This virtual post-mortem service was used when a CT scan could determine the cause of death. This speeded up the process of determining cause of death and respected the religious and cultural needs of some of the local population. Scans were carried out at night and reporters were experts in reporting on virtual post-mortems. Deceased persons were transported to the unit via a private corridor. The trust was one of the first in the North West to offer this service.
However, there were also areas of practice where the trust must make improvements.
Importantly, the trust MUST:
Urgent care
- Ensure that patients can access emergency care in a timely way.
- Ensure all staff receive mandatory training at the required level and within the appropriate time frame.
- Ensure that fridges used to store medications are kept at the required temperatures and checks are completed on these fridges as per the trust's own policy.
Medical Services Including Older People
- Ensure there are appropriate numbers of nursing staff deployed to meet the needs of patients
Children and Young People
- Ensure all equipment used to provide care or treatment to a service user is properly maintained.
- Ensure that there is one nurse on duty on the children’s ward trained and up to date in Advanced Paediatric Life Support on each shift.
In addition the trust SHOULD:
Urgent and emergency care
- Ensure that staff receive their annual appraisal.
Medical services including Older people
- Ensure children’s safeguarding training across all professions within the medical directorate is up to date.
- Look to reduce the number of medical patients being cared for on surgical wards.
- Continue to monitor staffing arrangements on wards.
Surgical Services
- Take appropriate actions to improve mandatory training compliance rates.
- Take appropriate actions to reduce the number of cancelled elective operations.
Maternity and gynaecology
- Ensure the improvements in the infection prevention and control measures and the environment on ward 27 should continue.
- Emergency medicines should be safely stored in the obstetric theatre in line with trust’s policy for the safe use of emergency medicines.
- Records should be securely stored in the ward areas.
- Appropriate actions should be taken to improve the mandatory training compliance rates for infection control and children's safeguarding.
- Ensure that a deteriorating patient’s care was managed in line with the trust’s policy.
- Continue to make improvements in the completion of the safer surgery checklists.
- Develop a system to ensure patients received required home visits by the community midwives.
Children and Young People
- Ensure recording of fridge checks include the maximum and minimum temperatures in accordance with national guidance.
- Ensure dates of cleaning and safety checks are legible on equipment.
- Review documentation for infants when intervention is reduced to high dependency or special care.
- Ensure the security and confidentiality of medical records in the paediatric outpatients department.
- Ensure PEWS documentation is completed and audited to improve compliance.
- Ensure the neonatal unit consistently collect patient feedback using the NHS Friends and Family Test.
- Ensure inpatient discharge summaries and outpatient clinic letters are sent in a timely way.
- Ensure regular staff meetings take place on the neonatal unit.
End of life care
- Consider how it can increase uptake of the use of the individual care plan for end of life care patients.
- Consider how it can encourage improvement in the accuracy and completeness of DNACPR forms, including the undertaking and recording of mental capacity act assessments, the recording of best interests decisions, and discussions with patients and their relatives.
- Consider reviewing information held within the palliative rapid discharge link nurse files held in wards and units across the trust to ensure the information held is accurate, up to date, and in line with prescribing and dosage guidelines for anticipatory medicines.
- Consider what actions it could take to further increase the proportion of end of life care patients dying in their preferred place of care.
- Consider what actions it can take, within its control and where requested, to increase the percentage of end of life care patients discharged within the timescales of the rapid and fast discharge process.
Outpatients and Diagnostics
- Continue the active recruitment of radiologists to meet actual WTE requirements and maintain safe staffing levels.
- Resolve the issue of allied health professionals being unable to accurately record mandatory training levels.
- Carry out an infection control risk review of positioning aids foam pads in radiology, to ensure that the risk of infection is minimised.
- Ensure that all entries on patient notes are signed and dated.
- Continue to increase the numbers of staff who have undertaken children's safeguarding training to meet trust targets.
- Review version controls on Local Rules for Radiation Protection and ensure that all staff have signed them to indicate that they have read and understood them.
- Continue to seek a solution to the lack of an electronic system that interfaces with local GP surgeries.
- Continue to seek viable solutions to reduce “Did Not Attend” (DNA) rates.
- Continue to seek solutions to improve “Referral to Treatment” (RTT) times so that all clinical pathways met national standards.
- Review the consultation room in clinic nine where the door opens outwards to improve privacy and dignity for patients.
- Review the children’s play area in outpatients' clinics six to nine to see whether this could be better located or children observed and kept safer.
- Improve patient knowledge of how to access PALS should they need to do so.
Professor Sir Mike Richards
Chief Inspector of Hospitals