Tameside General Hospital

Tameside General Hospital is part of Tameside and Glossop Integrated Care NHS Foundation Trust and provides a full range of hospital services, including general and specialist medicine, general and specialist surgery and full Consultant led obstetric and paediatric hospital services for women, children and babies.

Tameside General Hospital is situated in Ashton-under-Lyne. The hospital services a population of approximately 250,000 residing in the surrounding area of Tameside in Greater Manchester, and the town of Glossop in Derbyshire. In total, the trust has 528 beds.

We carried out this inspection to see whether the hospital had made improvements since our last inspection in April 2015. Following our inspection in April 2015 we rated the hospital as requires improvement overall. We judged the hospital to be requires improvement for safe, effective and responsive and good for caring and well led.

We visited the hospital as part of our comprehensive announced inspection on 8 to 11 August 2016. We also carried out an out-of-hours unannounced visit on 18 August 2016. The inspection team inspected the following core services:

• Urgent and emergency services
• Medical care services (including older people’s care) including the Stamford Unit
• Surgery
• Critical care
• Maternity and gynaecology
• Children and young People
• End of life care
• Outpatients and diagnostic services

The Stamford Unit is a recently opened community facility to support patients who are determined to be medically fit for discharge. The patients require further support in a non-acute setting to be assessed and discharged into the community. However, we did not rate the service provided as the unit had only been opened for three weeks prior to the inspection and we did not have sufficient data to fully consider this.

A separate report is available with regard to this service.

Overall, we rated Tameside General Hospital as ‘good’. We noted that there had been significant improvements in some areas since our last inspection

Our key findings were as follows:

Access and Flow

• Access and flow in the emergency department remained a continuous challenge.
• From March 2015 to April 2016, the trust did not meet the Department of Health Standards to

Transfer or discharge patients within four hours of arrival and the decision to admit patients within four to 12 hours for nine out of 12 months.

• Data showed the percentage of patients leaving before being seen was consistently worse than the England average for same period.
• Again, from March 2015 to April 2016, the total time patients spent in the emergency department (average per patient) was consistently worse than the England average.
• There were 211 black breaches from May 2015 to May 2016. Black breaches occur when the time from an ambulance’s arrival to the patient being handed over to the department staff is greater than 60 minutes.
• The trust had an escalation process in place for periods when there was increased demand. The purpose of this process was to ensure the effective management of the trust’s bed capacity and to give staff clear processes and triggers to follow. We found that the actions set out in this process were followed when increased pressure was experienced.
• There were bed meetings held three times a day. These meetings were attended by senior nursing staff from the ward areas, patient flow team and the emergency department team.
• Between February 2016 and July 2016, there were a total of 526 medical patients admitted across the three surgical wards (medical outliers). Medical outlier patients were seen daily by medical doctors. In the course of the inspection, we were informed by ward managers that it was very rare for a surgical patient to be placed on a medical ward.
• There was a focus on discharge planning on all the wards. Following multi-disciplinary meetings discharge plans were made for each patient based upon their progress.
• The trust had made significant improvements with regard to Referral to Treatment (RTT) waiting. In terms of RTT standards, the trust was now at mid-table level in terms of achieving standards and had previously been in the bottom six trusts nationally.

Cleanliness and Infection control

• Generally patients were cared for in a visibly clean and hygienic environment.
• Staff followed the trust’s policy on infection control and adhered to the ‘bare below the elbows’ policy.
• Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
• There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There was a suitable supply of hand wash sinks and hand gels available.
• Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.
• Patients identified with an infection were isolated in side rooms. We saw that appropriate signage was used to protect staff and visitors.
• Public Health England data for surgical site infections showed the hospital performed similar to or better than the national average for the proportion of patients that acquired surgical site infections following surgery.
• However, in maternity and gynaecology quarterly infection prevention and control audits were completed and ward 27 had scored 83% in April 2016. Issues remained during the inspection, which had not been identified or rectified following the ward audits. These included scuffed wooden surfaces, doorways and equipment which could not be thoroughly cleaned, tears in a seat cover, chipped paint and loose plaster, rusty waste bins and a perished area on a cot mattress. At the unannounced inspection a more thorough audit had been completed and some items had been removed or replaced. A programme of deep cleaning refurbishment was planned.

Nurse staffing

• Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services.
• The expected and actual staffing levels were displayed on a notice board on each unit/ward and these were updated on a daily basis.
• Staffing levels were planned to ensure an appropriate skill mix to provide care and treatment for patients.
• The ward managers carried out daily staff monitoring and escalated staffing shortfalls due to unplanned sickness or leave.
• The number of midwives were appropriate to meet the needs of the patients in both maternity and gynaecology services.
• However, nurse staffing levels, although improved, remained a challenge in some areas. This was particularly the case in medical care services.
• We were able to review a report produced on the 27 April 2016. The report showed a number of wards in the medical directorate which were below 80% fill rates for qualified day staff. The report highlighted issues in ward 41, 44 and 46 where qualified fill rates were between 79% to 74%.
• During the unannounced inspection, there was a shortage of two qualified nurses on 41, one bank nurse was deployed and the band seven nurse in the unit moved a member of staff from their ward to cover the remaining shortfall. This meant they were unable to carry out the quality safety round conducted by the band seven nurse each evening to ensure their ward remained safe. They had informed the wards and were available for telephone contact.
• Of the nine band 6 and 7 paediatric nurses on the children’s unit all had completed Advanced Paediatric Life Support (APLS) with the exception of two new staff. However, only three were up to date at the time of our inspection. Plans were in place for three staff to attend a course in September 2016 and three in January 2017. Risk was mitigated by the on-site presence of a paediatric registrar at all times. Advanced paediatric nurse practitioners, working in the paediatric emergency department had also completed APLS.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff who worked well with other disciplines to deliver safe quality care.
• 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.
• Staff rotas were maintained by the existing staff and through the use of agency or locum consultants when needed. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures. The majority of locum and agency doctors had worked at the hospital on extended contracts so they were familiar with the hospital’s policies and procedures.

Mortality rates

• Following concerns that the trust was either a risk or an elevated risk for the some mortality outliers including gastroenterological and hepatological conditions and procedures, infectious diseases, nephrological conditions, vascular conditions and procedures, a process to review every death had been started by the trust. This provided an assurance of safe and quality care delivery and was recognised by the clinicians as not just a box ticking exercise.
• Mortality review outcomes were discussed at a mortality steering group chaired by the medical director, which fed into the service quality and operational governance group and the quality and governance group for oversight and scrutiny. 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.

Meeting the needs of disabled patients

During the inspection, we carried out a pilot inspection looking at how the trust met the needs of disabled people. The main findings are contained in the responsive section of the provider report. However, below is a summary of our findings:

• A bespoke system electronically tracked every patient with learning disabilities in the hospital, which was overseen by a named lead nurse in learning disabilities.
• All patients with a learning disability were referred to the learning disabilities nurse by fax on admission.
• When a patient with a disability was moved, an email would be sent to ward managers reminding them to be mindful of reasonable adjustments for that patient. Patients would also be put on a reasonable adjustments care pathway, and where necessary their carer had their own care pathway.
• There was a team of volunteers who provided mobility scooters by request and supervised their use throughout the trust so patients with mobility difficulties could move through the site easily. There were also volunteers who would sit with sensory impaired patients to guide them through their hospital journey on request. Volunteer help could be booked in advance by phone or at any reception desk.
• The hospital had two wards designed for dementia patients, which included dementia friendly ‘reminiscence rooms’. Material and information was also available throughout the rest of the hospital, such as ‘twiddle-muffs’ to keep patients occupied and engaged. Every ward we saw had a comprehensive information board on dementia with contact details for the admiral nurse. However, there were no set activities for dementia patients at the time of inspection.

We saw several areas of outstanding practice including:

Urgent and Emergency Services

• The department’s practice development nurse provided excellent support and education to the staff within the department.
• The department’s handling or the major incident, which occurred during the inspection, was excellent and ensured that patients were treated in the most appropriate and safe manner.
• The divisional leaders made great efforts to ensure that they were visible at all times, especially during times of pressure.

Surgical Services

• Ward staff applied ‘reasonable adjustment’ principles for patients with learning disabilities and specific care plans were in place to provide guidance for staff. The care plans took into account factors such as the environment, communication (e.g. use of communication books or easy read leaflets), staffing, equipment requirements and procedures (such as booking patient first or last on list).

Maternity and gynaecology

• A programme for supporting and informing pregnant women with alcohol consumption problems had been developed. MAMA (Maternal Alcohol Management Algorithm) was managed by the safeguarding lead midwife. This provided pathways into related services in the community including rehabilitation day services, community support and detoxification support.

End of life care

• The trust had direct access to electronic information held by community services, including GPs. This meant hospital staff could access up-to-date information about patients, for example, details of their current medicine.

Outpatients and diagnostics

• 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 were one of the first in the North West to offer this service.

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

Action the hospital MUST take to improve

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:

Action the hospital SHOULD take to improve

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.
• Appropriate actions should be taken to improve the mandatory training compliance rates for infection control and children's safeguarding.
• Records should be securely stored in the ward areas.
• 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 clinic’s 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