Manor Hospital

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 Board was aware that the organisation faced significant quality and performance challenges and had launched an Improvement Plan in June 2015 to seek to address these.

• The Trust described to us 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.

Importantly, the trust must:

• ensure there are adequately qualified staff across all services to meet the needs of patients and protect them from abuse and avoidable harm.

• improve the embedding of governance of incident reporting systems trust wide.

• ensure medication is stored, administered and recorded appropriately across all services.

• ensure patient confidentiality is maintained at all times across all services.

• ensure all fire exits are kept clear.

• ensure the birthing pool in maternity services is always accessible and available for use and the birthing pool room is free from clutter and non- essential equipment.

• ensure there is an adequate supply of equipment in good working order and fit for purpose across all services. Any decision not 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.

• ensure equipment is stored appropriately without compromising patient and staff safety and that staff can access equipment when required.

In addition the trust should:

The Emergency department SHOULD:

• consider redesigning the seating arrangement in the ED general waiting area to provide some personal space between the seats.
• improve staff annual appraisal rates within the ED.
• ensure all staff can be easily identified by patients and visitors at all times when on duty.
• better inform patients and their relatives/carers about the streaming systems in operation in the ED and how patients are going to be seen.
• review the purpose and use of the ED log sheets.
• consider setting out its overarching vision for the ED.

Medical services SHOULD:

• provide a protected, suitable environment for physiotherapy.
• review its stock of equipment including, but not limited to syringe pumps and weighing scales.
• ensure that feedback is given on all reported incidents.
• ensure that the patient safety dashboards on display in medical wards are maintained with up-to-date and accurate information.
• inspect its physiotherapy equipment to ensure that it complies with infection prevention and control guidelines.
• arrange for a patient group directive to be written for the administration of saline flushes.
• ensure that fluid balance front sheets are consistently completed for any patient having their fluid intake and output monitored.
• review the contents and layout of its nursing assessment documentation booklet.
• reinstate a programme of acute illness management training for nurses working on medical wards.
• review its major incident training and the method of its delivery to improve understanding among staff.
• take action to improve staff understanding of the meaning of the butterfly symbol to indicate patients living with dementia and the purpose of butterfly bays on wards.
• ensure that it consistently reports on its performance against the NHS 18-week referral-to-treatment target.
• ensure that robust translation services are used to communicate with patients who do not understand English.

Surgery services SHOULD:

• review the low uptake of medical devices training across the trust.

• review the environment in recovery for children post-surgery to promote a child safety area.

• ensure operating theatres are deep cleaned on a regular basis and should review how equipment is stored in the theatre environment

• ensure equipment used specifically for children in the operating theatres is up to date

• ensure intravenous fluids are stored in secure environments

• ensure easier access to translation services.

• review the provision of physiotherapy services to ensure initiatives such as the ‘joint school’ can be re-established.

Critical care Services SHOULD:

• review its morbidity and mortality review process to ensure all deaths are reviewed.

• review its checking system for fridge temperatures so that if temperatures are out of range, they are rechecked to ensure medicines are stored at the correct temperature.

• review infection control procedures to ensure staff wash their hands after removing gloves and aprons rather than just using sanitising gel.

• review junior medical cover to ensure doctors are available to attend consultant ward rounds in critical care and document contemporaneous patient plans in notes.

• review multidisciplinary team working in critical care to enable multidisciplinary team ward rounds and effective multidisciplinary team working.

• review systems to improve flow throughout the hospital to reduce the number of delayed discharges in critical care.

• ensure patients have access to patient information leaflets in languages other than English.

Maternity and gynaecology services SHOULD:

• ensure fridges used for the storage of medicines are kept locked and secure from unauthorised access.

• ensure that medicines that look similar are not stored next to each other.

• consider how it enables staff to attend required training and supports staff to gain additional qualifications to support the service.

• consider how it can improve care records to ensure that risk assessment and safeguarding issues are easy to locate.

• consider the use of specialist midwives to improve the experience of families including :bereavement, teenage pregnancy and diabetes,

• consider ways to support and improve active birth.

• consider ways to reduce the induction of labour and caesarean section rates.

• consider ways of improving the sharing of information and improving engagement with midwifery staff, so they are aware of and involved in future developments.

• consider ways to improve breastfeeding support to new mothers.

• consider involving patients fully in care decisions by developing a ward round on delivery suite to incorporate every woman present.

• consider ways to improve relationships between maternity and gynaecology to allow the joint use of the gynaecology theatre.

• evaluate the management of outliers on the gynaecology ward.

• consider NICE and best practise recommendations and ensure guidelines reflect up-to-date guidance.

• consider individual feedback to staff reporting incidents.

• consider the ways to inform patients of the role of Supervisors of Midwives.

• consider the use of an assessment tool for the prevention of pressure ulcers for all maternity patients.

• consider the use of the maternity safety thermometer tool.

• consider a way to identify when a piece of equipment is clean and ready for use.

• improve the cleanliness of the delivery suite and delivery suite theatres.

• consider the use of disposable straps for the CTG machines.

• consider the use of wireless CTG monitoring.

• consider trialling the child abduction policy.

• consider increasing audits to improve practice such as the audit of one to one care in labour.

• consider the use of a debrief for patients following a caesarean section to discuss suitable mode of birth if they choose to have more children

• consider the need for a policy for transferring women to a tertiary unit.

• consider the need for a transition care ward for babies needing extra care.

• consider a pool evacuation policy and suitable equipment to evacuate patients in all areas where pools are used.

• improve the consistency of checking resuscitation equipment on the delivery suite.

• consider a strategy for capping bookings for the service as the number of births increases.

Children and young people services SHOULD:

• take steps to further improve the safety of, and reduce risks to CAMHS (patients receiving care on the children’s ward.

• ensure the neonatal unit is suitable for the service provided and is large enough to accommodate the number of babies using the service at any one time.

• review the scope of root cause analysis investigations and the process used to review mortality and morbidity to ensure all possible contributory factors are considered.

• take action to maintain the standards of hygiene and cleanliness within the Starfish suite along with equipment within the suite, and ensure it is appropriate for the purpose for which it is used.

• ensure patient records and referral documents are available in a timely way for children’s outpatient attendances.

• ensure action plans are in place to improve practice in relation to national quality audits and monitor progress against these.

End of Life Care services SHOULD:

• take action to ensure that there are sufficient mortuary fridges in working order.

• ensure that all patients approaching end of life have their spiritual and religious needs assessed and are offered support.

• ensure both amber care bundles and advance care planning are being used consistently.

• consider how the trust provides dedicated bereavement care.

• consistently identify a patient’s preferred place of death and support them to achieve this.

• ensure there are appropriate areas for patients in the last days and hours of life that provide privacy and dignity for them and their relatives.

Outpatient and diagnostic imaging services SHOULD:

• have a clear plan to replace ageing equipment in the radiology unit.

• consider improving the post-operative procedure facilities for patients attending the day surgery unit and the endoscopy unit.

• ensure all staff have access to trust policies and procedures.

• ensure receptionists are available to meet and book in patients when they are attending for appointments and procedures.

• ensure staff handling food for patients have attended basic food hygiene training.

• ensure resuscitation trolleys are checked daily as recommended by the Royal College of Anaesthetists.

In response to these concerns, the Care Quality Commission issues Walsall Healthcare NHS Trust with a section 29a warning notice on 26 October 2015 setting out concerns and significant improvement required.

Since issuing the section 29a warning notice we have seen the trust take significant action to address these issues.

Professor Sir Mike Richards

Chief Inspector of Hospitals