Archived: Trafford General Hospital

Updated 13 June 2016

Trafford Hospital is part of Central Manchester Foundation Trust. Trafford Hospital is situated in the borough of Trafford. The hospital serves a population of approximately 226,600 residing in the surrounding area of Trafford, Altrincham and greater Manchester In total, the hospital has 229 beds and employs approximately 841 members of staff.

In 2014/15 the total number of admissions for 14/15, including day cases, in-patients and non-elective was 102,964, 433,069 outpatient attendances and 124,682 urgent care attendances.

During this inspection, the team inspected the following core services:

• Urgent Care services
• Medical care services (including older people’s care)
• Surgery services
• Children and young people's services
• End of life care

• Outpatients and diagnostic imaging services

Updated 13 June 2016

Trafford Hospital is part of Central Manchester Foundation Trust and provides a range of hospital services, including an urgent care facility, general and specialist medicine, general and specialist surgery a paediatric hospital service for children and young people and a range of outpatient and diagnostic services for adults and children.

Trafford Hospital is situated in Trafford and serves a population of approximately 226,600 people residing in the surrounding area of Trafford, Altrincham and Greater Manchester., the hospital has approximately 230 inpatient beds.

We carried out this inspection as part of our scheduled program of announced inspections

We visited the hospital on 4 and 5 November 2015. During this inspection, the team inspected the following core services:

• Urgent Care services
• Medical care services (including older people’s care)
• Surgery
• Children and young people's services
• End of life care
• Outpatients and diagnostic services

Overall, we rated Trafford Hospital as ‘good’. However Medical care services were judged as requiring improvement in the responsive domain and services provided to people at the end of life required improvement in all areas apart from caring which was judged as good.

Our key findings were as follows:

Leadership and management

• The hospital was led and managed by a cohesive and visible senior team. The team were very well known to staff and were regular and frequent visitors to the wards and departments.
• The Head of Nursing was well regarded by all departments who felt supported and valued.
• Staff were engaged and were committed to Trafford hospital providing a high quality service for patients and their friends and families.
• There was a positive culture throughout the hospital. Staff were open and honest and were very proud of the work they did and proud of the services they provided.
• Although there was additional work to be done to support staff in feeling part of the wider trust. Overall staff morale was good with the exception of some medical staff who were concerned regarding the number and complexity of services being delivered at the hospital.

Access and Flow

• Data showed that 99% of patients presenting to the urgent care centre were seen within four hours.
• All patients we spoke with told us they were seen quickly and expressed no concerns about waiting times.
• Staff told us that availability of beds for patients who required admission to the hospital was good and that they did not experience delays in transferring patients to wards. However delays were experienced in transferring patients over to the acute hospitals in particular Manchester Royal Infirmary.
• There was a divisional and departmental escalation policy in place. This policy guided staff on steps to take if patients were in the centre for longer than expected or were waiting excessive times for an inpatient bed.
• A winter pressures plan was in place for the Trafford Division
• The medical service was experiencing significant challenges with access and flow. Ten ambulatory care areas in the Medical Assessment Unit were regularly being used as inpatient beds increasing the pressures on staffing on the unit. There were delayed discharges across the service due to a lack of intermediate care and re-ablement beds and waiting for packages of care to be put in place. Some discharge delays were caused on Ward 3 by the wait for specialist community care funding and on Ward 2 by the lack of funding provision for overseas patients. The service was working to address these issues but at the time of our inspection timely discharge remained a challenge.
• Discharge arrangements were initiated upon admission. Discharge summaries were sent to the patients’ general practitioner (GP) and there were procedures to enlist support from social services and district nurses if necessary. Staff completed a ‘nurse led’ discharge form that included information about medication and copy of the discharge letter for the family to inform about the care during the hospital stay.
• Theatre utilisation was 70.4% between August and October 2015, this was based on high cancellation rates and inefficient organisation of theatre lists. Whilst the local management were keen to increase utilisation and had made some improvements (up from 62% for the previous 3 months), This had been recognised by the Trust and an external consultant had been commissioned to work with staff to develop options for expanding the service and increase the utilisation of the surgical services for Children and young people at the hospital.
• The average referral to treatment time was 13 weeks and for some specialties such as Gynaecology, was as low as 5 weeks.
• Trust data showed that a total of 1149 operations were carried out, in Trafford, on children and young people (18 years and under) between October 2014 and September 2015.
• The trust recorded incidents when patient records were not available prior to surgery, resulting in cancellations of procedures, or have arrived later than planned from RMCH.
• Patients at the end of their life were not always seen within 24 hours of referral to the Specialist Palliative Care Team particularly if they were referred at the weekend. Data provided by the trust showed that in the three months at the beginning of 2015 75% of patients were seen within 24 hours of being referred to the SPCT. However the data provided did not give information about how long the 25% not seen in 24hours waited to be seen by the team.
• From August to October 2015 there were 3912 outpatients clinics held at the hospital, an average of 1304 per month.
• Patients use the “Choose and Book” system, which gives them choice when booking and outpatient appointment.
• In February 2015, the Endoscopy Unit was able to offer 61% of patients a choice of appointment times on the day of their procedure.When we inspected, this figure had dropped to 20% and this was because patients referred from Manchester Royal Infirmary were filling up clinics. This is increasing patient flow at the Trafford site.
• In the period April 2015-September 2015, 93.6% of patients at Trafford had started outpatient treatment within 18 weeks of referral (referral to treatment (RTT)).
• The percentage of people waiting over six weeks for a diagnostic test at Trafford General Hospital was 0.8%. This was better than the England average.
• On the days that we inspected the services, we saw that patients were seen promptly and well inside the 30 minutes recommended in national guidelines. When we spoke to patients, they reported that they had never had a long wait in the clinic before their appointment.
• The percentage of patients who did not attend their appointment (DNA rate) between April and September was an average of 8.0%.This is better than the England average for the same period of 8.8%.

Cleanliness and Infection control

• Patients were cared for in a visibly clean and hygienic environment.
• Staff followed the trust 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. The hospital had employed infection control link nurses. Their role was to provide training and to liaise with staff so patients that acquired infections could be identified and treated promptly.

Nurse staffing

• Nurse staffing levels were determined using an evidence based tool.
• The expected and actual staffing levels were displayed on a 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.
• However, nurse staffing levels, although improved, remained a challenge in some areas. This was particularly the case in medical care services. Staffing levels were maintained by staff regularly working overtime and with the use of bank or agency staff. Where possible, regular agency and bank staff were used which meant they were familiar with policies and procedures. Any new agency staff received an induction prior to working on the wards.
• The trust had implemented a number of initiatives to address shortages in nurse staffing including: actively recruiting nursing staff from overseas and linking with local universities.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• The medical staffing skill mix was sufficient in the urgent care department when compared with the England average. Consultants made up 22% of the medical workforce across the urgent care division which was 1% lower than the England average of 23%. However, there were more registrar group doctors who made up 64% of the medical workforce compared with the England average of 39%. 15% of the medical workforce were made up of junior doctors which was lower than the England average of 24%.
• There were three consultants working within the urgent care centre. They worked on a rota basis to provide cover between 8am and 8pm. Consultant cover after 8pm was available on an on call basis.
• There was no resident paediatric doctor based in Children’s Resource Centre, however; doctors told us that there were medical staff in attendance for out – patient clinics each day.
• Doctors told us that, if a child or young person needed to be reviewed by a doctor, post – operatively, there were doctors, with the necessary competencies and skills available on – site, at Trafford, either in out – patient areas or the theatre suites.
• There were three consultants in post and two consultant radiologist vacancies at Trafford and Altrincham. There was a plan in place to mitigate for these shortages by recruiting an additional consultant and introducing a consultant rota across the trust.
• The reporting turnaround times in the Radiology Directorate are adversely affected because of staff vacancies. There are plans, in the interim, to increase the outsourcing of plain imaging and increase the use of outsourcing companies for CT and MR imaging to reduce reporting times.
• The Diabetes Centre has a Consultant vacancy and the Consultant currently employed also works in Endocrinology. Consultants on short-term contracts, locums and GPs with a special interest in diabetes have covered the staffing gap.

Nutrition and hydration

• Wards had access to a dietician if required.
• The nutritional needs of patients were assessed and recorded in their notes and are highlighted on large noticeboard so they can be assessed ‘at a glance’.
• There was a red tray system in place which meant that patients who needed extra support at mealtimes were easily identifiable.
• Patients needing assistance were also identified on a board in the ward kitchen.
• Patients were satisfied with the standard of food provided at the hospital.

We saw several areas of outstanding practise Including

• Multidisciplinary work with other agencies to manage frequently attending patients.
• Collaborative working with AGE UK, Stroke Association and Trafford Carers Association.
• Patient tracker system and ‘tell us today’ initiatives to improve patient experience feedback.
• Staff approach to patient care and commitment to providing outstanding, compassionate care to patients.

However, there were areas of practice that required improvement. Importantly, the trust MUST:

• Ensure that it fully implements the national recommendations following the removal of the Liverpool Care Pathway

Action the hospital SHOULD take to improve

In urgent care services:

• All records within the urgent care centre should be kept in a secure location.

In medical care services:

• Ensure that all medical staff receive the correct level of mandatory training within the required timescales to ensure they have the right level of skills and competencies to safely fulfil their roles.
• Nurse staffing levels should be increased to meet the minimum day time requirement of 1:8 nurse patient ratio recommended by NICE (Safe staffing for nursing in adult inpatient wards in acute hospitals).

In surgery:

• Consider improving the inpatient environment for people living with Dementia as it is could be made more ‘dementia friendly’.
• Improve the theatre utilisation and theatre list compilation efficiency.
• Investigate the high rates of patients not attending for scheduled procedures with a view to reducing the rates of non-attendance.

In Children and young people’s services

• Monitor the integration of the services with RMCH, including development of Standard Operating Procedures (SOP’s) and audits of care to demonstrate effective care.
• Develop the service and be able to evidence safe care e.g. risk assessments and training data.
• Ensure facilities are suitable and responsive for children and young people of all ages in the local community.

In End of life care services

• The trust should have in place a vison and strategy for end of life care services for Trafford Hospital.
• The trust should ensure that it has sufficient specialist staff to support the demand for end of life care in the trust.
• The trust should review its access to specialist palliative care over 24 hours (seven days) in line with national guidance for end of life care.
• The trust should review the leadership for palliative care at Trafford Hospital to reflect the needs of people at end of life and their loved ones.
• The trust should ensure that robust audit of end of life care is in place particularly the use of the DNACPR process and documentation.

In outpatients and diagnostic imaging services:

• Consider what actions can be taken to reduce the reporting turnaround times for urodynamics.
• Consider how privacy can be improved at reception areas in radiology and orthopaedic outpatients.
• Consider improving facilities for patients to comment on their care and treatment (Patient Tracker pedestals and Friends and Family forms).

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 13 June 2016

We rated as medical care services as 'good' overall. However, we found further improvements were needed in how the service provided care that was responsive to patient needs.

Patients received compassionate care and their privacy and dignity were maintained. Patients were positive about the service, felt involved in their care, and were provided with appropriate emotional support.

There were effective systems in place for incident reporting and investigations led to changes in practice where necessary, and lessons being learned. There were systems in place to keep people safe and staff were aware of how to ensure patients’ were safeguarded from abuse. The hospital was visibly clean and staff followed good hygiene practices.

Staff attended mandatory training courses but compliance rates for medical staff were below the trust target. There were good systems in place to ensure patient safety was monitored and maintained. Staffing level challenges were being addressed, with plans in place for further recruitment of both nursing and medical staff.

Care was provided in line with national best practice guidelines and medical services participated in clinical audits. Actions, recommendations and plans to re-audit were in place where appropriate.

There was a monthly ‘hot topics’ training programme and a culture of encouraging professional development; however appraisal rates for staff did not meet the trust’s target. Staff had a good understanding and awareness of assessing people’s capacity to make decisions about their care and treatment and were able to contact the safeguarding matron for support if required.

The service was experiencing significant challenges with access and flow. Ten ambulatory care areas in the AMU were regularly being used as inpatient beds which was reducing the capacity for ambulatory care and increasing the pressures on staffing on the unit. There were delayed discharges across the service due to a lack of intermediate care and re-ablement beds and waiting for packages of care to be put in place. Some discharge delays were caused on Ward 3 by the wait for specialist community care funding and on Ward 2 by the lack of funding provision for overseas patients. The service was working to address these issues but at the time of our inspection they were ongoing.

There were a number of schemes in place to help meet people’s individual needs. People were supported to raise a concern or a complaint and lessons were learned from these. Medical services captured views of people who used the services with changes made following feedback. A survey showed that people would recommend the hospital to friends or a relative.

Staff told us they felt valued and proud of their work. There was good staff engagement and staff were involved in making improvements for services.  Staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

Updated 13 June 2016

We rated services for children and young people as 'good' overall because;

Families, including children and young people, were positive about the care and treatment provided. They felt supported and reassured as staff actively engaged with them in an age – appropriate manner whilst providing kind and compassionate care.

Staff followed strict criteria for admission of children and young people to access day case surgery at TGH. Any surgery for a child or young person that is not eligible was carried out at the Royal Manchester Children’s Hospital (RMCH).

Systems were in place for reporting incidents including safeguarding. Staff were aware of and followed current infection prevention and control guidelines. Equipment was available, clean and well maintained. Medicines were stored securely in locked cupboards in a key pad entry room. Records of administration of any medication were clear and complete. Patient care records were safely stored, structured and clearly documented on the trusts electronic patient record system (EPR).

Staff attended mandatory training and staffing levels were sufficient to meet the needs of the children and young people.

Staff followed National Institute for Health and Care Excellence (NICE) and evidenced based practice in delivering care and treatment to patients. Post-surgery pain relief and nutritional needs were well managed. Staff were competent and well supported.

The CRC had been designed in collaboration with local schools and the local youth parliament, with a music theme. It included a playroom, DVD’s, games consoles, free television in the bays and a parents room including drinks & food facilities and leaflets.

Staff allocated the side room for children and young people with an individual need such as Autistic Spectrum Disorder (ASD). Staff positioned older adolescent patients in a bay being aware of the proximity and gender of other children.

Managers were developing the service including plans to increase the numbers of day attenders. This included children and young people who require investigations or treatment in an environment that could be monitored over several hours. Other development plans included increasing the numbers of outpatients seen at TGH for regional referrals and increasing the utilisation of the surgical services.

Updated 13 June 2016

We rated end of life care services as 'requires improvement' overall because;

Staff delivered end of life care that was caring, compassionate and supportive of patients and their families. However, there were significant areas for concern.

The advanced care plan document developed to replace the Liverpool Care Pathway in July 2014 was not being used in any of the ward areas at Trafford Hospital and some staff, including those in the Specialist Palliative Care Team, were unsure how the advance care was to be implemented.

Improvements were required to ensure that the services were safe and responsive to patients needs. The hospital did not provide seven day access to specialist palliative care other than an advice line provided by the local hospice.

Consultant staffing levels relating to palliative /end of life care across the trust were below the recommended national level.

There was a need to identify and formalise a clear strategy for end of life care throughout adult services to provide an impetus to develop end of life care.

The trust had identified a senior manager to lead end of life care for the trust three months prior to our inspection who was to coordinate the implementation of the strategy once ratified .

Updated 13 June 2016

We rated outpatients and diagnostic imaging services as 'good' overall because;

Staff were confident about raising incidents and encouraged to do so. Staffing levels were appropriate to meet patient needs although increased demand on the radiology services meant that a high proportion of reporting on diagnostic imaging was outsourced to meet reporting targets.

There were appropriate protocols for safeguarding vulnerable adults and children and staff were aware of their roles and responsibilities in regard to safeguarding. Staff were up to date with mandatory training, including level 2 safeguarding.

The departments inspected were visibly clean and staff followed good practice guidance in relation to the control and prevention of infection. Medicines were stored and checked appropriately.

Most departments were of an appropriate size and well set out, although the physiotherapy unit lacked space in the gym facility. Equipment was clean and in good working order. An excellent electronic patient record system allowed the filtering out of relevant information and facilitated information being available to different teams very quickly. As a result, instances of patient notes not being available at a clinic were minimal.

Outpatient and diagnostic services were delivered by caring, committed and compassionate staff who treated people with dignity and respect. Care was planned and delivered in a way that took patients’ wishes into account. Their confidentiality and privacy were respected whenever possible. We saw instances of service planning and delivery to meet the needs of local people.

We saw good examples of assessing and responding to patient risk. The hospital was performing at better than the England average for “did not attend” rates and patients waiting more than six weeks for a diagnostic test. They were slightly worse than the England average on referral to treatment times.

Departmental managers were knowledgeable and supportive and had vision to expand and improve their services. There was a trust wide out-patient transformation programme group. The aim of this was to develop and implement service standards for OPD clinic. The group also led on improving patient experience across all the trust sites. The standards would deliver a consistent, reliable and quality clinic experience to patients and their families.

Staff in outpatients and diagnostic services enjoyed working at the hospital, demonstrated good team working (including multidisciplinary working) and were competent and well trained. They felt respected and valued. However, there was little feeling of inclusion in the trust as a whole and rather an affiliation to the Trafford Hospitals (Trafford General Hospital and Altrincham Hospital).

Updated 13 June 2016

We rated surgery services as 'good' overall because; 

Staff were experienced and had good levels of training and competency to carry out their role. The department was good at identifying and reporting safety issues and worked hard to learn from past experience. They actively sought to improve quality and safety in a supportive and non-judgemental environment. We found satisfactory provision for identification and care of the deteriorating patient. The environment was clean, hygienic with low levels of healthcare associated infections.

Medicines, including controlled drugs, and records were stored appropriately. Staff compliance with mandatory training was 96% and staffing levels were sufficient to meet the needs of patients. The organisation assessed and responded to potential risks in an organised and proactive manner.

Care was planned and delivered in line with evidence based guidance and practice. There was good multidisciplinary team working with good access to a range of specialties. The surgical team treated patients with dignity and respect and patients told us staff were caring and compassionate; patients said they were kept informed and involved in the treatment they received.

The hospital met the national referral to treatment (RTT) target of 18 weeks between referral and surgery. Staff showed a genuine desire to cater to individual patient needs. Reasonable adjustments were made to accommodate individual patient needs.

Theatre utilisation was inefficient; this was contributed to by poor co-ordination of services off-site by Manchester Royal Infirmary (MRI), Royal Manchester Children’s Hospital (RMCH) and Salford Royal Hospital, which were largely out of the control of local managers. Whilst locally there was awareness of the issues and attempts to remedy such failings, it was felt that this issue needed to be addressed at trust management level. There were also issues with problems obtaining patients records, most notably those for MRI patients, this caused delays and further affected efficiency in theatre utilisation.

Surgical services were well-led on a local level, but there were concerns about Central Manchester University Hospitals NHS Foundation Trust (CMFT) senior management being visible at the Trafford Hospital site.

Updated 13 June 2016

We rated urgent and emergency services as 'good' overall because;

Incident reporting was good with very low rates of avoidable harm including infections and pressure ulcers. Staff completed patient’s records fully and in legible handwriting. Risk assessments were completed fully and measures implemented to minimise risk to patients. The uptake of mandatory training was high in the urgent care centre, where all staff apart from two had undertaken the relevant mandatory training.

Medicines were managed well and staff undertook appropriate checks when administering medication. Medical staffing and skill mix of staff was adequate to ensure safe patient care. The facilities and equipment across the service were well maintained.

Care and treatment were provided in line with national and best practice guidance. Regular auditing of care and treatment was undertaken. Some patients did not receive timely pain relief and the service told us how they were working to improve this issue. Patients were treated with kindness, dignity and compassion and patients and their relatives were involved in their care and treatment.

The urgent care service was responsive to patients needs and provided timely access to care and treatment with minimal delays. The service managed complaints well and responded to them in a timely manner.

The urgent care centre was well led and staff were clear on the divisional vision. Managers and leaders were visible and staff felt able to able approach them. There were areas of innovation including examples of collaborative working with national and local organisations to seek patient’s views