Wythenshawe Hospital

Updated 28 July 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Wythenshawe Hospital.

We inspected the maternity service at Wythenshawe Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The inspection was carried out using a pre-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.  

Following the site visit, we conducted interviews with senior leaders, specialist staff and stakeholders. We held focus groups for staff of all grades and roles and reviewed feedback from women and families about the trust. We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We analysed the results to identify themes and trends.  

Wythenshawe Hospital is 1 of 3 sites for maternity services for the trust. It comprises of a delivery suite with 12 birthing rooms, with 1 room with a birthing pool and adjacent maternity theatres. There are 3 high dependency rooms within the delivery suite. There are post and antenatal wards, an antenatal assessment unit and early pregnancy assessment unit. The service has a maternity triage unit. The service also has a fetal medicine unit which provides services to women and birthing people from across Greater Manchester and the Northwest region. There is an alongside midwifery led unit called Manchester Birth Centre with 5 birthing rooms. Ante and postnatal clinics are also provided at this location.

The local maternity population come from higher levels than deprivation than the national average with 30% in the most deprived decile compared to 14% nationally. A higher proportion of mothers were Asian or Asian British compared to the national averages. 

Our rating of this hospital ​went down​. We rated it as ​requires improvement​ because:

• Our ratings of the maternity service changed the ratings for the hospital overall. We rated maternity services as ​inadequate​ in safe and requires improvement in well-led ​ and the hospital as ​requires improvement​.

We also inspected 2 other maternity services run by Manchester University NHS Foundation Trust. Our reports are here:

Saint Mary’s Hospital – https://www.cqc.org.uk/location/R0A05

North Manchester General Hospital – https://www.cqc.org.uk/location/R0A66

Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 19 March 2019

We had not previously inspected medical care services at this site under this trust.

At this inspection, we rated the services as good because:

• Staff used national tools to monitor and assess patients so that they could keep patients safe from avoidable harm.
• Staff knew how to report incidents to ensure the service could learn from any errors or poor practice. Actions and improvements from identified themes were displayed across the service.
• Staff ensured records were stored securely.
• Staff followed national guidance when providing care and treatment, we that the service actively audited their compliance to national guidance to ensure that staff complied with it.
• Patients’ pain, food and hydration was managed appropriately, staff used tools to record food and hydration and pain, these were evident in patients’ records.
• New staff received inductions and took part in a preceptorship programme, we also saw staff training was offered to all staff to ensure they were competent.
• Staff cared for patients with kind, compassionate and respectful. They involved patients with care plans and offered a variety of support channels such as counselling, bereavement support and charities.
• The trust planned and provided services in a way that met the needs of local people. We saw that provisions were in place to support patients with dementia. Link nurses in the acute medical unit championed clinical subjects to become subject matter advisors on the ward.
• Senior leadership team for the division had the right skills and abilities to run a service providing high-quality sustainable care. The leadership team were new in post, but staff across all wards reported they were visible, approachable, and receptive to patient and staff needs.
• There were clear governance processes in place to oversee patient safety. Senior management met regularly to review and monitor the division’s performance.
• The division was continuously looking at innovative ways to improve the service. We heard of examples of where patient safety had improved because of the ongoing learning and innovative projects underway at the trust.

However

• The service did not always have sufficiently robust procedures in place to meet the needs of patients with additional support needs. We saw examples of where staff were not responsive to ensuring the patients’ needs were documented and followed.
• We found that not all patients had decision specific capacity assessments completed for care and treatment decisions. Information in assessments did not always record if staff had considered advocacy involvement, patients individual needs and if care and treatment was in the patient best interests.
• Although the service had systems in place to manage safe staffing, there were challenges particularly during the day times, to deploy the planned number of registered nurses.
• Staff did not always keep accurate records in accordance with trust policy for controlled drugs.
• Not all staff had received an appraisal at the time of inspection.
• At the time of the inspection the medical division had no escalation wards available; this meant there was no temporary ward that patients could be placed on if the hospital received a high number of inpatients.
• The service was not responsive to completing and closing complaints; at the time of inspection the reported taking an average of 46 days to close a complaint.

Updated 19 March 2019

We had not previously rated this service. We rated it as good because:

• The hospital provided mandatory training for staff and managers ensured this was completed. Local records we reviewed of mandatory training showed high levels of compliance.
• Staff had good understanding of safeguarding issues and followed trust procedures correctly when needed.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean and implemented control measures to prevent the spread of infection.
• Staff ensured equipment was appropriately maintained and kept records of equipment cleaning.
• Managers monitored staffing levels to ensure sufficient staff were available to keep children safe from avoidable harm and abuse and to provide the right care and treatment.
• Staff kept appropriate records of care and treatment and ensured these records were securely stored.
• Staff were aware of the types of incident which could occur and reported these if they occurred. Managers completed incident investigations and there were systems for sharing this learning with staff.
• The service planned for emergencies and staff understood their roles if one should happen. Staff followed escalation plans during periods of high patient demand.
• The service made sure staff were competent for their roles and staff appraisals were completed.
• The service monitored the effectiveness of care and treatment and used the findings to improve them.
• Staff worked well together in an extensive multidisciplinary team approach
• We consistently saw staff taking time to communicate with children in ways which they would understand, providing support and reassurance for patients, relatives and carers.
• Staff had good awareness of assessing children’s capacity to understand and make decisions regarding their treatment and care.
• The service had undertaken wide development in providing appropriate support for children and young people with mental health needs.
• Patients we spoke with were full of praise for the staff and treatment they received.
• The service took account of children’s needs, with numerous examples of individually tailored plans to support patients.
• Children’s services were inherently child-focussed and routinely considered the child’s holistic experience of care.
• The service responded to concerns at an early stage and there were low numbers of complaints in the service overall
• The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. Managers had access to data to monitor performance and identify improvements.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
• The neonatal service had completed communications training to focus support for mothers who may be at risk from domestic violence.

However

• Actions had not been followed up when fridge temperatures went out of range on the neonatal unit.
• There was a risk that medicines stored on resuscitation trolley in the outpatient department could be accessed by children or members of the public.
• Trolleys used to transfer children to theatre for surgery did not have paediatric resuscitation equipment available. This was addressed at the time of inspection.
• There were vacant posts and challenges to recruitment for medical and nursing staff in neonatal services.
• Out-of-hours medical cover was dependent on one clinician to cover two services in case of emergency.
• Some guidelines in reference folders were significantly out of date and staff were unable to direct us to current guidance for paediatric head injury and neonatal jaundice.
• Results for the national neonatal audit programme indicated breastfeeding rates were significantly below the national average.
• Although nursing assessments were comprehensive in identifying additional needs, there was limited use of hospital passports and electronic patient records did not always flag patients who had complex needs.
• Whilst managers had the skills to lead high quality and sustainable service, the leadership structures lacked clarity in some areas and strategy development was at an early stage.
• Systems for governance and managing risk were not yet fully integrated across the managed clinical services and local managers of the neonatal service were not involved in the service wide process.
• We observed a mixed culture in different parts of the services, with very different experiences of the trust change for some staff. Although managers across the trust promoted a positive culture to support and value staff, there was a variation in staff outlook regarding future developments.
• Information technology systems were not fully aligned across the trust and staff continued to use pre-existing IT systems for some processes.

Updated 19 March 2019

We had not previously rated this service. We rated it as outstanding because:

• The critical care services were provided in a safe way by sufficient numbers of passionate staff who had the appropriate skills, knowledge and training to deliver safe, effective and compassionate care to their patients. Staff understood how to protect patients from abuse, how to appropriately assess risks, and how to keep people safe from infection.
• Staff kept clear records about the care and treatment provided that ensured safe management of the prescription and administration of medicines. When things went wrong staff knew how to record incidents so that learning from incident investigations could be used to improve services.
• The care provided by the critical care services was evidence-based and delivered effectively by a multidisciplinary team of professionals. Patient outcomes were positive and the services benchmarked their performance against other similar units. There was a good understanding of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, and staff sought consent from patients appropriate in line with these.
• Staff were outstanding in their delivery of compassionate and kind care and treatment to patients in their care. Patient-centred care was at the heart of all the critical care services, and staff went out of their way to support patients physical, emotional and spiritual needs, and to give patients a voice in decisions about their own care and treatment.
• The critical care services were outstanding in their proactive response to the understanding and meeting the needs of the local population, and to the wider regional needs, including patients that required treatment for burns, cardiac arrest and ventilation support. The services worked well with local and specialist commissioners, and other healthcare providers, to plan their services. Staff proactively took into account patients’ individual needs, including those with protected characteristics and complex needs.
• There was a strong and visible leadership within the critical care services that had workable plans for the service and which promoted a positive culture for patients and staff. The leadership team supported its staff to deliver high-quality and safe care through an effective governance structure, that identified, monitored and mitigated risks to the services.
• There was effective engagement between the services, staff, patients and local support groups, with active involvement of the outreach teams. Learning and improvement through research was well supported by the service, its staff and its leaders.

However,

• New ways of working, including the development and implementation of new policies, procedures, and monitoring systems (such as mortality and morbidity reviews) were still embedding in the service. Some staff remained anxious about the future plans for and direction of their services within the newly merged organisation.

Updated 19 March 2019

We rated it as good because:

• There were end of life care link nurses and healthcare assistants on every ward.
• There was good understanding of infection prevention and control.
• The service followed appropriate processes for the prescription, administration, recording and storage of medicines.
• There was a comprehensive audit programme and evidence that outcomes were acted upon and used to improve practice.
• A wide variety of training took place across the trust in relation to end of life care.
• There was evidence of multidisciplinary working.
• Staff demonstrated a high level of caring and compassion towards patients.
• Staff gave several examples of the extreme lengths they went to in order to facilitate a dying person’s wishes.
• Patients and carers were very complimentary about the care they received and staff attitude towards them.
• The cultural and religious needs of the deceased and their family were respected.
• The specialist palliative care team treated all palliative care patients and not just those with cancer.
• The multi-faith room provided a place of worship, quiet time and prayer for people of all faiths and none.
• There were robust governance systems in place for identifying risk and monitoring quality against national standards.
• End of life care was well represented at trust board level which was reflected throughout the hospital.
• All staff spoken with were positive about the divisional leadership team and the local SPCT.
• Staff told us they felt listened to, their opinions were valued and they got recognition for their work. There was general consensus amongst managers and staff about what the departmental top risks were.

However:

• Nursing staff were not fully compliant with some components of their mandatory training, including infection prevention levels 1and 2 and dementia awareness level 2.
• Medical staff were not fully compliant with infection prevention level 2 and dementia awareness level 2.
• There was inconsistent documentation of patient capacity to reach a decision about resuscitation.
• Patients did not always get pain-relieving medication when they needed it.
• Audit results showed that patients at end of life did not always have their hydration assessed.
• Rapid discharges were occasionally delayed due lack of capacity in the local hospice where that was the patient’s preferred place of death.

Updated 28 July 2023

Updated 19 March 2019

We had not previously rated this service for this provider. We rated it as good because:

• We rated safe, caring, responsive and well-led as good; effective is not rated for outpatients.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service had suitable premises and equipment and looked after them well.
• Risk at service level was monitored and acted upon.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.
• Staff cared for patients with compassion.
• People could access the service when they needed it.
• Managers had the right skills and abilities to run a service providing high-quality sustainable care.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
• The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However:

• Although staff kept detailed records of patients’ care and treatment, not all patients’ records were available for appointments.
• The department did not always measure the outcomes of patients’ care and treatment.

Updated 19 March 2019

We had not previously rated this service for this provider.

We rated it surgery as good because:

• Remedial actions and changes in practice had been implemented as a result of learning from two ‘never events’ that occurred between October 2017 and September 2018. The theatre teams followed the ‘five steps to safer surgery’ procedures and staff adherence was monitored through routine audits.
• Staff kept themselves, equipment and the premises clean. The service followed best practice when prescribing, giving, recording and storing medicines. Patient records were clear, up-to-date and easily available to all staff providing care.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• The surgical services performed in line with similar sized hospitals and performed within the England average for most clinical performance and patient outcome measures.
• The service took account of patients’ individual needs. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• The service planned and provided services in a way that met the needs of local people. People could access the service when they needed it.
• Managers across the service had the right skills and abilities to run a service providing high-quality sustainable care. A significant proportion of divisional and departmental leads were new in post. However, most staff were positive about the leadership changes.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.

However,

• Appraisal completion for medical staff was below the hospital’s internal target of 90% across some surgical specialties.
• The number of patients that had elective and non-elective general surgery or non-elective trauma and orthopaedic surgery and were readmitted to hospital following discharge was worse than the England average.
• The majority of staff had completed their mandatory training; however, training compliance in some topics (such as safeguarding adults and children, information governance and infection control) was below the hospital’s internal 90% compliance target.
• The anaesthetic machine check log records were not always completed appropriately by theatre staff.
• There were 210 items of equipment beyond their routine maintenance due dates including 182 high risk items. This included 110 beds and 72 other items of equipment. The back-log had been identified as a risk on the risk register and there was an action plan in place to prioritise and complete servicing for these items.
• Divisional leadership and routine meeting structures were still being imbedded as a result of personnel changes and new reporting structures.
• Referral to treatment times for admitted patients were below the England average for five surgical specialties.

Updated 19 March 2019

We rated it as requires improvement because:

• Planned staffing levels were not consistently achieved. Staff reported concerns about staffing levels. The department had robust plans in place to improve staffing levels.

• Assessment documentation for safeguarding information for both adults and children was not consistently completed by staff. This was also the finding of a recent trust audit.

• During our inspection, we saw paper records left unattended on a work station which could be accessed by patients. We also found several computers in the department which had not been locked by the previous user and patient information was visible when the screens were activated.

• The service managers were aware they needed to improve patient outcomes. Action plans were in place based on audit results and recommendations.
• Staff did not always ensure patients had food and drink to meet their needs.

• The departments unplanned re-attendance rate within seven days was consistently worse than the national standard and worse than the England average.

• Capacity assessments and Deprivation of Liberty Safeguard applications were not always fully completed.

• The trust consistently failed to meet the standards for waiting times from referral to treatment and arrangements to admit, treat and discharge patients within four hours and the trust’s monthly median total time in the department for all patients was consistently longer than the England average.

• Although, the service treated concerns and complaints seriously as well as investigating them, the response time to complaints was not timely and did not meet the trust’s policy.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• Although the service was undergoing building work, the service controlled infection risk well.
• 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.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
• Staff of different kinds worked together as a team to benefit patients.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance.
• Feedback from patients confirmed that staff treated them well and with kindness. At all times during the inspection, we observed staff to be polite, respectful, professional and non-judgmental in their approach to patients.
• Staff provided emotional support to patients to minimise their distress. We observed staff providing effective emotional support to several patients who were anxious.
• Managers in the department had skills and abilities to run a sustainable service. They promoted a positive culture that supported staff and most staff felt valued.
• The department had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff.
• Managers were aware of the risks to the service and were taking a pro-active approach to addressing these, for example staff recruitment.