Archived: University Hospital of South Manchester NHS Foundation Trust

The University Hospital of South Manchester (UHSM) NHS Foundation Trust provides services for a population of around 570,000 people who live in the south and south west of the Greater Manchester area. Manchester is in the top quintile for deprivation in England and is ranked as the fifth most deprived out of all areas in England.

Services are provided from Wythenshawe Hospital, Withington Hospital and community services for adults are also provided including three community in-patient services from Wellington House, Ringway Mews; Buccleuch Lodge and the Dermot Murphy Centre.

The trust has 915 beds in total of which 838 are general and acute; 64 are maternity and there are 42 critical care beds. There are 5,478 (out of an establishment of 5,757) staff overall with 740 (out of an establishment of 768) being medical staff; 1,858 (out of an establishment of 2,059) being nursing staff and 2,880 (out of an establishment of 2,930) others.

We inspected the trust as part of the comprehensive inspection programme between 26 and 29 January 2016. We visited the Wythenshawe Hospital, Withington Hospital, Wellington House, Ringway Mews; Buccleuch Lodge; the Dermot Murphy Centre and community services for adults .

We rated the trust overall as requires improvement although there were areas of excellent practice. There were improvements required in both the safe and effective domains. However, care was delivered by a strong, caring and compassionate multidisciplinary team and patients regarded the staff and the care they received as good.

There was a visible leadership team

Our key findings were as follows:

Nurse and midwifery staffing

Nurse staffing vacancies rate was high as was the turnover rate. Sickness absence rates had increased since October 2015 to 4.29%. These rates were higher than the England average but had shown evidence of decreasing over the last three years.

Midwifery staffing was at a ratio of 1:31 at the time of the inspection, worse than the expected rate, but they were maintaining a 1:1 ratio in labour.

Recent changes in community services, which had resulted in the integration of community nursing services, had resulted in a reduction in senior roles and experienced staff leaving the service. We were not assured that staff that had been redeployed into new roles had the competencies to fulfil their role and at the time of our inspection the trust had not performed a training needs analysis to understand the gaps.

Medical Staffing

There was high medical locum use in medicine and urgent care.

The staff skill mix showed the proportion of consultants and junior grades was higher than the England average. There was a positive culture amongst all grades of medical staff who felt supported by managers and their seniors.

Mortality and morbidity

In the latest publication, UHSM had a SHMI value of 1.02 for the period April 2014 to March 2015.This places the Trust 76th out of 137 acute trusts in England. The Trust was within the top 56% of hospital trusts in England .

Their HSMR for the latest twelve available months was not considered significantly higher than the expected relative risk (when compared to the national average), taking into account Trust case-mix. This was an improvement on the previous performance.

However, over the last twelve months the Trust’s HSMR for patients who had a non-elective admission at the weekend was significantly higher than expected for patients admitted on a Saturday and on a Sunday.

Incident reporting

The trust had a strong focus on patient safety especially in the nursing and therapy services. There was an open culture for reporting incidents and systems to support this including Duty of Candour. However, the trust had reported three Never Events in the previous 12 months.

There were also concerns regarding the cross team working and robustness of the safeguarding processes and practices for young people in transition between children's and adult services.

Cleanliness and infection control

The trust locations were seen to be clean, staff adhered to infection control policies and training uptake was good. The rate of cases of Clostridium Difficile was within the expected range. However the trust had reported two cases of MRSA bacteraemia.

Nutrition and hydration

Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team. There was a system in place that identified patients who needed assistance with eating and drinking. Support with eating and drinking was given to patients in a sensitive and discreet way.

Patient Outcomes

There were strong multidisciplinary working practices observed within the trust. In most cases peoples needs were assessed and care and treatment was delivered in line with legislation, standards and evidence based guidance. Action plans and actions taken in response to audits were generally good and learning could be seen.

In urgent care services although some improvements had been seen in the sepsis pathway we were less assured about the work done to improve audit results in other areas such as care for children suffering fits, or mental healthcare. This was because action plans shown to us did not always acknowledge requirements to improve or include deadlines for implementing changes and senior medical staff were not always aware of areas requiring improvement.

Services were delivered by caring, committed, and compassionate staff that treated people with dignity and respect. Patients and their families and carers were treated with kindness and were involved in their care and treatment.

Performance in the Friends and Family Test was better than the England average between November 2014 and May 2015 however performance fell below the average in the next two months. The trust also performed as expected in the CQC in patient survey and in the 2013/14 Cancer Patient Experience Survey, the trust was in the top 20% of trusts in England for 15 of the 34 questions and the middle 60% for the remaining questions.

Access and flow

Bed occupancy rates were lower than the England average between July 2013 and March 2015. However, rates have increased over time and were reported to be above the England average between July and September 2015. Delayed discharges were also higher than expected and this had resulted in access and flow issues which had resulted in patients being cared for in service areas which are different to the patient requirements especially on to the surgical areas. A number of patients had also experienced numerous bed moves during their stay in hospital.

The trust did not meet the national waiting time target of 18 weeks from referral to treatment (RTT) for the period from September 2014 to August 2015. However, trust performance against the 90% target was variable across surgical specialities. The paediatric RTT was 75% and the RTT for paediatric surgery admitted pathways was 82%, both areas were not achieving the trust’s RTT standards of 85%.

Providing responsive services

However, the trust performed better than the England average for cleanliness, food, hygiene and privacy/dignity/wellbeing in the Patient-led assessments of the Care Environment in 2013, 2014 and 2015. There was also a good strategy and care for patients living with Dementia.

The trust averaged around 580 complaints per year between 2010/11 and 2014/15 with only small variances each year. They were meeting targets for responding to complaints and were trying to reduce the number of formal complaints received.

Vision and Strategy

Historically there had been a number of significant senior executive changes which had limited the long term stability of the Board and had negatively affected the general morale.

The trust executive team was in a phase of transition being led by an interim CEO who had only been in the organisation for a week at the time of the inspection. There were some new appointments to executive and non-executive positions and this meant the team had not had an opportunity to build cohesion.

It was acknowledged that the trust had lost the clarity of its strategic direction. Actions were being taken to regain the clarity against the backdrop of the regional changes underway within the greater Manchester area including the "Devolution Manchester" and "Healthier Together" programmes.

Governance processes were in place but there remained a disconnect between the Board Assurance framework and the Risk Register despite recent review of both.

The unsettled culture within the executive team was evident at the inspection. However staff were proud and positive about the services and staff engagement was being further developed as it had been recognised as an area requiring further input.

Fit and Proper Persons

There were formal procedures under development but the trust had a framework in place including a template to record compliance with the Fit and Proper Persons regulation. We reviewed the personnel records of relevant staff and found they contained the relevant information which was current and appropriate.

We saw several areas of outstanding practice including:

At Wythenshawe Hospital in Maternity:

• The bereavement midwife had been nominated for the national Butterfly awards two years running. These are awards celebrating survivors and champions of baby loss. The bereavement midwife was also runner up in the Royal College of Midwifery awards for her work providing bereavement support.

• A rapid access clinic had been introduced for menstrual disorders and post-menopausal bleeding to meet demand and allow for the development of innovative out-patient treatments such microwave endometrial ablation and hysteroscopy sterilisation.

Also in Children's services:

• The cystic fibrosis team were awarded the quality improvement award by UK cystic fibrosis registry annual meeting in July 2015. The paediatric CF team won the first National Cystic Fibrosis Registry Quality Improvement Award in recognition for innovative use of the Port CF database, which provided focussed and early intervention to prevent further deterioration in their patient’s condition.

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

Importantly, the trust must address the lack of strategic direction for the organisation in line with the changing landscape of health care within the Greater Manchester area. The executive team requires stability and needs to strengthen its leadership and engagement with staff regarding the future direction of the organisation.

The trust also needs to ensure that there are robust systems, processes and personnel to lead and support the community service through the transitional changes that are undergoing.

Importantly, at Wythenshawe Hospital the trust must:

In Urgent and Emergency Care:

• Ensure equipment checks in resuscitation areas are completed daily in line with trust requirements with a clear pathway for reporting associated concerns and actions such as missing equipment and subsequent replacement.
• Ensure staff appraisal rates consistently meet the trust target.
• Ensure the safety of reception staff at all times and take steps to mitigate current risks associated with the reception environment such as no protective screens and open desk areas.
• Ensure that the temperatures of fridges storing medicines at low temperature, are recorded in line with guidance on a daily basis, with a clear pathway for reporting associated concerns and actions such as temperatures outside of the required range.
• Ensure action is taken to remove the risk of ligature from ceiling vents in the mental health room, in line with guidance from the Royal College of Emergency Medicine (CEM6883 Mental Health in EDs toolkit February 2013)
• Consistently improve patient waiting times in line with Department of Health targets.

In Medicine:

• The trust must ensure that staffing levels are appropriate to meet the needs of patients across the medical services and ensure there is an appropriate skill mix on each shift.

• The trust must ensure that all records are stored securely when not in use.

• The trust must take action to improve the bed occupancy rates across medical services to ensure the safe care and treatment of patients.

In Maternity:

• The trust must improve mandatory training for midwifery staff in terms of safeguarding level three training to ensure it is in line with the trust target.

• The trust must ensure all clinical policies are regularly reviewed and kept up to date.

• The trust must ensure incidents are investigated in a timely manner to ensure lessons are learned and recommendations implemented.

In Children and Young People:

• The service must ensure safe staffing levels are sustained in accordance with National professional standards and guidance.

• The service must ensure that staff are reporting risks and incidents to the senior leaders of the service actions being taken in a timely manner.

• The service must ensure that all treatment, assessments, diagnostics and any other care relating to the patient is recorded appropriately in patient records.

• Ensure that transition arrangements for children between 16 and 18 years meet the needs of the individuals without prejudice.

In the community services they must:

• ensure they have robust systems in place to monitor safety performance across all community services to ensure patients are receiving harm free care.

• make all reasonable efforts to recruit to staff vacancies within a timely manner.

• determine safe staffing against clinical caseloads and ensure safe staffing levels are in place.

• ensure all clinical policies are reviewed and in date.

• ensure staff are trained to operate any equipment that they use to carry out their role

• ensure staff have the essential qualifications to fulfil their role

• ensure that risk assessments are being performed as per trust policy and findings are documented in the patient record.

and within the community in patient services they must:

• ensure all services are provided in suitable environments and that monitoring systems are robust and highlight any issues and risks in a timely manner.

• ensure that the nurse call bell system is fit for purpose and are readily available for all patients in each of the units.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service Good

We rated this service as good because:

The staff teams were positive and proud of the service they provided for the local community. The nurse staffing levels were found to be appropriate to meet the needs of patients at the time of our inspection.

We saw that good multidisciplinary working was in place. The units had input from therapists and dedicated pharmacists. Access to dieticians and speech and language therapists were available and staff were positive about their working relationships.

Patient care, including managing patients’ nutritional and mobility needs and pain relief, were well managed.

Staff were observed talking to patients in a kind, sensitive and caring manner. Staff used the Friends and Family test as a formal tool to obtain feedback from patients or their relatives as well as using locally devised surveys.

Staff were familiar with incident reporting procedures. The majority of staff were up to date with mandatory training. Records and medicines were appropriately audited. Information was available in different languages, staff stated they could access an interpreter as necessary and patient’s cultures were respected and supported.

The units were visibly clean, in a good state of repair and staff were observed following appropriate infection prevention practices.

Pain relief and nutrition and hydration needs were assessed appropriately. Patients at Dermot Murphy Centre stated that they were not left in pain. Records relating to patient care were detailed to identify their individual needs but legibility was not consistent. Medical cover for the community units was provided by the consultant geriatrician team, the patients General Practitioners (GP’s) or out of hour’s provider, if required. Reviews of patients’ progress, including multidisciplinary reviews which monitored their progress and ensured planned care, were relevant.

Patients reported they felt safe and confident in the skills of staff.

However:

Medicine administration was not always a protected activity and staff could get distracted which posed a risk of medication errors.

There was a lack of storage areas at Wellington House which presented a risk of tripping or falling to patients. Substances hazardous to health were found unattended on a cleaner’s trolley in an unlocked toilet.

There was a dressing trolley left in a corridor which contained creams, elastic bandages and scissors which could be accessed by patients. There were damaged dining room chairs at Buccleuch Lodge which carried a risk of cross infection, substances hazardous to health accessible to patients, a lack of PAT testing of equipment and at Buccleuch Lodge there was a fire door in a bedroom which was poorly fitting.

The overall rating for adult community services was ‘requires improvement’ with some areas good.

The adult community services had no robust systems in place to monitor safety performance. There was a lack of fully completed risk assessments in patient records and we were not assured that patients were receiving harm free care.

The trust had an electronic system to record incidents and all staff we spoke with knew how to access the system. When serious incidents were reported, the trust performed a route cause analysis to determine if incidents were avoidable. We found, where incidents were found to be avoidable, learning and actions were not completed and we were not assured that the trust was learning from incidents. We found not all incidents were reported.

There had been recent changes following a consultation with staff that had resulted in the integration of community nursing services. This had resulted in a reduction in senior roles and experienced staff leaving the service. We were not assured that staff that had been redeployed into new roles had the competencies to fulfil their role and at the time of our inspection the trust had not performed a training needs analysis to understand the gaps: however, they informed us at the time of our inspection that they were planning to complete one.

There were high nursing vacancies at the time of our inspection and although there was a recruitment plan in place high vacancy levels were experienced prior to June 2015. This was having a negative impact on staff morale and the trust was not achieving the contracted contacts for the service.

Care and treatment did not always reflect current evidence-based guidance. Care assessments we reviewed were not fully completed and so did not consider the full range of people’s needs. Outcomes of peoples care and treatment was not monitored regularly within the nursing services: however, there was a monitoring process in place in therapy services. There was a lack of consent to treatment documented in nursing records. We found clinical policies were not being adhered to and some were out of date.

There was a lack of robust systems in place in relation to lone working to keep staff safe in the integrated community nursing teams. We accessed the lone worker policy on the trust intranet which was out of date. Staff in therapy services knew where staff were and had a timely system to respond if staff were late arriving at their destination.

There was a governance structure in place within the community services which fed into the trust risk management committee. Risk issues and poor performance were not always dealt with in a timely manner. Risk registers were in place but we found that some risks identified by staff were not on the risk register.

Premises we visited at the time of our inspection were appropriate for the services being delivered. Cleanliness and hygiene was of a high standard throughout the clinics we visited and staff followed good practice guidance in relation to the control and prevention of infection.

There was timely access to services and people with the most urgent needs were prioritised. Improvements in service delivery had resulted in a significant reduction in waiting times for therapy services. There was a process for patients to make a complaint: however, staff informed us that most complaints were dealt with informally and resolved at service level. There was no process in place to monitor or record these informal complaints to enable learning from complaints.

The adult community service was delivered by caring, committed, and compassionate staff that treated people with dignity and respect. Staff actively involved patients and their carers in all aspects of their care.

Services were responsive to people in vulnerable situations and interpreting services were available as required.