Trafford General Hospital

Updated 19 March 2019

The hospital provides district general health services to the local population.

The service includes the urgent care service at Trafford general hospital and the minor injuries service at Altrincham. These services were staffed mainly by advanced nurse practitioners and emergency nurse practitioners providing services for adults and children with non-life-threatening injuries.

The hospital provided a range of day case and in-patient surgery for a range of conditions including dental surgery, urology, ear nose and throat. There were also orthopaedic beds with 20 in-patient beds and 25-day case beds.

Medical care is provided across five wards at Trafford Hospital, including three dedicated rehabilitation wards (neurological rehabilitation, complex rehabilitation and stroke) plus an acute medical unit incorporating an ambulatory care unit.

The neurological rehabilitation unit provided care for patients from across Greater Manchester including patients from Wigan, Bolton and Salford.

There were also outpatient services, a children’s ward and services for people at end of life.

Updated 19 March 2019

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

Updated 19 March 2019

We had not previously inspected medical care services at this site. We rated it as good because:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. The services were safe because there were systems to ensure staff completed mandatory training and safeguarding training. The trust had systems and processes to ensure staff completed training as the year progressed.
• The service controlled infection risk well. The ward environment was visibly clean with good infection control in all areas visited. The environment was clutter free, wheelchair accessible with enough equipment for staff to perform their role.
• Staff had access to records which were stored securely. Medicines, including intravenous fluids, were stored and managed safely. Staff knew how to report incidents and tools such as the safety thermometer were used to keep patients safe.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. The services were effective because processes were in place to ensure that guidance used by staff complied with national guidance, such as that issued by National Institute for Health and Care Excellence.
• Patients’ food, hydration and pain management needs were met. The service used audits within the specialities we visited to improve patient outcomes. Staff received training to assess if they were competent. Staff worked effectively as a multi-disciplinary team and had good knowledge about consent and mental capacity.
• Staff cared for patients with compassion. The services were caring, with response rates in the friends and family test better than the England average. The inpatient score for recommending the service to friends and family from October 2017 to June 2018 was above 90%.
• Staff supported the emotional needs of patients and could, for example, arrange psychological support. Staff tried to understand and involve patients and their carers where it was safe to do so, such as in family meetings.
• The trust planned and provided services in a way that met the needs of local people. The services were responsive, with a process in place at hospital to trust level to plan services. Wards had link nurses to champion the needs of patients with additional needs. Wards used various approaches to respond to challenges with access and flow.
• The service was responsive to complaints and had made changes to services, such as changes to the endoscopy services.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The senior leadership team running the specialities were new in post but staff reported they were visible, approachable, and responsive and worked as a cohesive team to promote a positive culture.
• The trust had clear governance processes in place to drive patient safety forward; these were implemented and monitored at division level.
• Staff and the public were engaged through meetings and surveys. The specialities we visited had access to division dashboards to help monitor patient sensitive indicators and act when necessary. The specialities we visited all had examples of innovation, learning and continuous improvement.

However

• 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.

Updated 19 March 2019

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

• The trust provided mandatory training for staff and managers ensured staff completed this.
• Staff were aware of safeguarding issues and responded promptly, following trust procedures when these were identified.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean and implemented control measures to prevent the spread of infection.
• Managers monitored staffing levels to ensure sufficient nursing staff were available to keep children safe and provide the right care.
• Staff kept appropriate records of care and treatment and ensured these records were securely stored.
• Clinical staff followed systems for medicines management appropriately.
• Staff reported incidents when they arose and managers shared any learning from incident investigations with staff.
• Managers made sure staff were competent for their roles and completed staff appraisals
• The service used audits to benchmark against other services and identify improvements.
• Staff worked well together in a multidisciplinary team approach.
• Staff treated children with care and compassion during their treatment and reassured patients and families when they were anxious.
• Staff supported children to assist their understanding and help them make decisions regarding their treatment and care.
• The service received positive feedback from children and families and complaints were at a low level.
• 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.
• Managers had the skills and abilities to deliver services providing high-quality sustainable care.
• Staff had a positive outlook in the service and the culture was open and supportive.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

However

• Trolleys used to transfer children to theatre for surgery did not have paediatric resuscitation equipment available. We raised this during inspection and the trust took immediate action.
• Paediatricians were not based on the unit and there was no paediatric cover after 7pm.
• Systems for sharing important patient information such as safeguarding details, were not always consistent, although we saw a related incident was well managed at the time of inspection.
• Environmental temperatures were identified as a frequent issue in the children’s resource centre.
• Systems for governance and managing risk were not yet fully integrated across the managed clinical services.
• Scheduling systems were not always robust and this had resulted in cancellations on the day of surgery.

Updated 19 March 2019

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

• The majority of mandatory training including safeguarding for nursing staff and the specialist palliative care team met the trust target.
• There were processes and systems to monitor equipment to ensure that it was working effectively and was accessible.
• Records were in place and appropriately written. The trust had introduced the relevant documentation for patients with end of life care needs.
• Comfort observations were in place instead of standard observations for people who had end of life care needs. These were based around more relevant and appropriate care needs.
• There were appropriate guidelines and processes, however due to the changes and merger of the trusts these were in the process of being reviewed.
• The trust was in the process of harmonising services across the sites, this included a review of all the facilities provided to streamline the end of life care service. A revised vision and strategy was in place and there was a positive culture about providing end of life care.
• There was evidence of staff working together and multi-disciplinary meetings occurred to review the patient’s care.
• There was 24-hour support through an advice telephone line and support from the specialist palliative care team seven days a week.
• There was positive feedback from patients and carers and staff told us examples where they supported patients and families. Patients were treated with respect and dignity and encouraged to bring in comforts from home.
• Patients and families were provided with emotional support for difficult conversations regarding diagnosis. These were discussed with respect and understanding. Staff were committed to providing end of life care with some taking on extra duties as end of life champions.
• There was 24-hour chaplaincy support for any individual and there was access to multi-faith services every day. Staff were aware of information for various faiths and cultural needs.
• The trust was engaged in providing end of life care and worked with other organisations to support people. Staff were actively involved in promoting the service through national agendas such as “Dying Matters” where several activities across the hospital took place.
• Various governance meetings were in place for end of life care including steering groups and an executive group. This allowed senior managers within the executive team to have an oversight of end of life care issues.

However:

• We saw that there were low levels of staff that had completed annual syringe driver training. This meant that there were some wards that had no staff with up to date training. The risk was not identified within the services risk register for end of life care.
• Medical staff did not meet the trust training target for some areas.
• Not all the recommended summary plan for emergency care and treatment forms we reviewed had the appropriate information. In 10 out of 20 forms we found there was no plan discussed with the patient which included detailed specific interventions they may or may not want.
• The trust was still in the process of making changes to redesign end of life care services. There was currently no non-executive director who led on end of life care.

Updated 19 March 2019

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

• The service provided mandatory training in key skills to staff.
• Services had suitable premises and equipment. They were kept clean to minimise the risk of infection.
• There were enough staff, with the right qualifications, skills and training so that patients were seen and assessed in a timely way and within the prescribed targets. However, managers had recognised a need to review the staffing establishment to meet additional and regular clinic demands and reduce dependency on bank and agency staff.
• The service provided care and treatment based on national guidance. There were processes in place to ensure that guidance was promptly reviewed, disseminated and embedded.
• The effectiveness of care and treatment was monitored regularly and reported to the trust board. Services were involved in the annual clinical audit programme. Audit results and patient outcome monitoring were used to drive improvements.
• Staff received role-specific training. They were encouraged to take up external training courses that were relevant to their roles.
• Staff worked collaboratively with GPs and other stakeholders to deliver effective care and treatment and support people to live healthier lives and manage their own conditions.
• Staff cared for patients with compassions and respected their privacy and dignity. They offered adequate emotional support and involved patients and their carers in decisions about their care and treatment.
• Complaints and concerns were treated seriously and lessons were learned and shared with staff.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action. The views of staff and patients were used to drive improvements.
• Staff were valued and supported by managers and a positive culture and the wellbeing of staff was promoted.

However:

• There were some mandatory training modules where completion rates were not high, for example, resuscitation training where there was a shortage of places on courses. Managers had made sure that all eligible staff were booked onto a course by the end of 2018.
• There were low completion rates in safeguarding children level three for outpatient nursing staff and for safeguarding adults level two for allied health professionals.
• There could be long waits for patients in the phlebotomy service where appointments were not required.

Updated 19 March 2019

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

• The service provided mandatory training for staff and managers ensured staff completed this training. Staff had completed safeguarding training as part of their mandatory training and were aware of their responsibilities in safeguarding patients.
• The service had enough staff in most areas with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• Staff maintained appropriate records of care and treatment both electronically and on paper. Both types of records were securely stored.
• The service had suitable premises and equipment and looked after them well.
• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural needs and other preferences.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment. The trust planned and provided services in a way that met the needs of local people.
• People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice.
• Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
• The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
• The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However

• Not all staff had achieved the trust training target for resuscitation, safeguarding level 3 training or moving and handling level 2 training.
• The surgical safety checklist was not always being completed at the time of sign in.
• The recovery area accommodated both adults and children with only a curtain to separate the two groups of patients. This was a safeguarding concern.
• The trust had a vacancy rate of 16.9% for medical staffing in surgery.

Updated 19 March 2019

We had not previously inspected this service. We rated it as requires improvement because:

• There were no ‘flagging systems’ within the department to immediately alert staff to looked after children, children who had previously been highlighted at risk or children with repeated presentations of injury.
• We saw an inconsistency in the completion of clinical risk assessments and records. We observed one patient that did not have any nursing documentation or risk assessments undertaken whilst being in the department for five hours.
• There was no suitable designated cubicle for patients with mental health needs, although this was in the process of being completed.
• Care and treatment within the department did not always reflect current evidence-based guidance and implementation of departmental guidance was variable.
• It was unclear whether the service monitored the effectiveness of care and treatment and used the findings to improve them. Managers told us the department was undertaking various audits, but were unable to obtain information relating to these audits.
• Managers and staff were unsure of the leadership and governance structure beyond the matron and nurse consultant. There was a lack of overview of compliance with important issues such as mandatory and safeguarding training for the department.

However

• 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.
• Waiting times from arrival to triage and for treatment were better than national standards and England average.
• Staff were caring and compassionate to patients and understood the impact that a person’s care could have on them. We saw staff ensured patients and their families understood the decisions about their care
• Staff were positive about their roles and the team working around them.
• A high percentage of staff within the department had received an annual appraisal.

• Staff of different kinds worked together as a team to benefit patients. advanced nurse practitioner’s emergency nurse practitioners, and other healthcare professionals supported each other to provide good care.