Archived: The Pennine Acute Hospitals NHS Trust

The Pennine Acute Hospitals NHS Trust serves the communities of North Manchester, Bury, Rochdale and Oldham, in the North-East sector of Greater Manchester and has a population of around 820,000.

It is a large Trust with a total operating budget of over half a billion pounds. Its main commissioners are NHS Bury, NHS Heywood, Middleton and Rochdale, NHS Oldham and NHS Manchester.

The Trust provides a range of elective emergency, district general services, some specialist services and operates from four main sites:

• North Manchester General Hospital has a full accident and emergency department, which includes a separate paediatric A&E unit. It also provides a range of general and acute surgical services. The site is also the Trust's main headquarters.

• The Royal Oldham Hospital has a full accident and emergency department and offers a comprehensive range of acute and general surgical services, including vascular surgery. The site also offers more specialist services including clinical haematology and gynaecological services.

• Rochdale Infirmary provides a range of hospital services including a 24/7 Urgent Care Centre (UCC), a short stay inpatient Clinical Assessment Unit, the Oasis Unit for acute medical patients with dementia, day surgery, in addition the hospital provides , antenatal services, early pregnancy unit, outpatient clinics, and a specialist Eye Unit.

• Fairfield General Hospital, in Bury is one of three primary stroke units in Greater Manchester. It is also the main site for elective surgery in the North Manchester area.

The trust also provides a range of community services in North Manchester, Bury, Rochdale and Oldham,

Community Services Adults

• The trust had five community inpatient units for adults, including The Floyd Unit, Wolstenholme Unit, J5 (enhanced immediate care), Henesey House and Tudor Court. The inpatient units were part of the trusts community services directorate.
• The trust also provided community-based health services for adults. Services included district nursing, continence, podiatry and orthotics, phlebotomy, physiotherapy, dietetics, tissue viability, occupational therapy and specialist muscular skeletal therapies.

• The community based Out of Hours (OOHs) service provided professional nursing assessment and advice, management and nursing treatment for patients with palliative care needs and those patients who were in the terminal phase of their illness. This service also aimed to reduce hospital admissions out of hours and also provided the following services, Assistance with the provision of emergency loans and equipment. Psychological support and advice. Administration of drugs in the out of hour’s periods.

Community Services for Children and Young People

• The trusts community children and young people services delivered a limited range of allied health professional (AHP) led specialist services for children and young people across four specialties; audiology, dietetics, orthoptics and orthotics. Other children’s community services, such as universal child health services, were provided by other healthcare providers.

• The number of patients referred to the services was relatively small and reflected the limited number of services provided by the trust.

• We carried out an announced inspection of The Pennine Acute NHS Hospitals Trust between the 23 February and March 3 2016 as part of our comprehensive inspection programme.

Community Services for people at the End of Life.

• The trust provided 24-hour end of life care services in the community for adults over the age of 18 years and children less than 18 years, including patients with individual and complex nursing need.

• End of life care is provided in a variety of organisational settings by a range of health care professionals. The range of services includes facilitation of discharge from the acute hospital and co-ordination of care provision in the community. District nurses provided end of life care with specialist and additional support provided by the Specialist Palliative Care Team.

We carried out our inspection as part of our planned inspection programme 23 February - 3 March 2016

And we inspected all 4 hospitals and all 4 community based services.

Below are our individual ratings for each location/service.

• We rated North Manchester General Hospital as Inadequate overall

• We rated Royal Oldham Hospital as Inadequate overall

• We rated Fairfield General Hospital as Requires improvement overall

• We rated Rochdale Infirmary as Good overall

• We rated Community Services as ’Good’ overall with ‘Outstanding’ for the Caring domain in the Community End of Life service.

Following a comprehensive inspection we have rated Pennine Acute Hospitals NHS Trust inadequate in both safety and well-led domains. In line with CQC policy we have considered recommending the trust go into special measures, such is the level of concern we have around quality and safety.

Special measures would involve the appointment of an improvement director and supporting infrastructure which would assure CQC that the trust had the capacity to improve at pace. Immediately following our inspection, Salford Royal NHS Foundation Trust was asked to assume leadership of the trust. Salford’s leadership team, rated outstanding in by CQC in its most recent comprehensive inspection of the trust, has put in place a comprehensive plan for further investigation into the challenges faced by Pennine Acute, with action plans to deliver improvement. Through regular engagement with the Salford team we are assured that the support being provided to the trust is commensurate with that of special measures package of support. As such, the Chief Inspector of Hospitals will not be recommending the trust be placed in special measures at this time.

Our key findings were as follows:

• Vision and Values

The trust vision was to be “a leading provider of joined up healthcare that will support every person who needs our services, whether in or out of hospital to achieve their fullest health potential.' The mission statement was “to provide the very best care, for each patient, on every occasion”.

The underpinning values were ‘Quality Driven, Responsible, and Compassionate’.

The trust had overarching strategic goals and had produced a ‘trust transformation map’, This was displayed around the trust and was well known to staff, although at the time of our inspection this work had not yet resulted in clearly defined quality priorities and objectives for all of the divisions and consequently there was variance in both progress and understanding of its implementation and requirements.

Leadership

Following the appointment of the CEO in April 2014 there had been significant changes to the Executive team with the team only completed just prior to the inspection when the recently appointed Medical Director took up post. The Chief Nurse had been in post 10 months. In addition, the secondment of the CEO to manage another trust was announced during the inspection and the Chair’s tenure also came to an end at the time of the inspection.

From 1 April 2016, the Chair and Chief Executive of Salford Royal NHS Foundation Trust were appointed as Interim Chair and Chief Executive at to provide leadership and support to the Trust.

Staff were very positive about the visibility and responsiveness of the former Chief Executive (recently seconded) and the Chief Nurse. Staff felt that they both listened to concerns and took action to address them where possible; staff stated that historically this had not always been the case and that in the past the raising of concerns was not encouraged. However, staff did not feel that the Non-Executive Directors were accessible and were not visible throughout the organisation.

We found poor leadership and oversight in a number of services, notably maternity services, urgent care (particularly at North Manchester Hospital) the HDU at Royal Oldham hospital and in services for children and young people.

In all of these services leaders had not led and managed required service improvements robustly or effectively. In addition service leads had tolerated high levels of risks to quality and safety without taking appropriate and timely action to address them.

Culture within the trust

Staff told us that historically the culture in the trust had been quite closed and the raising of concerns and ideas was not supported or encouraged. Staff felt that the culture had (until recently) focused on financial matters and operational delivery rather than service quality.

Since 2014 the trust had been working on developing and encouraging a more open and inclusive culture where staff raise issues and concerns without blame.

In many services including community services we found that there was a positive culture emerging where staff felt well supported by their managers and colleagues and were positive about service changes and improvements. Staff reported being better heard and valued by the organisation and were positive about the new ways of staff engagement.

However, in a number of services and in particular maternity services we found low morale. In maternity services we also found a poor culture with deeply entrenched attitudes where some staff accepted sub optimal care as the norm and patients individual and specific needs were not appropriately considered or met.

Governance, risk management and quality measurement

The trust had recently made changes to the divisional and corporate structures to support an improved system of governance, performance management and clinical leadership. The Division of Medicine and the Division of Anaesthetics & Surgery were now managed by a triumvirate of 3 senior staff that included a clinical, nursing and managerial lead. The Division of Women & Children had 4 leaders (including Divisional Nurse Director for Midwifery and Nurse Director for Children), Integrated and Community Services by 2 leaders and Support services 2 leaders. There was one vacancy still to be filled in both Integrated and Community Services and support services.

However, at the time of our inspection the new structures had not yet been fully embedded and were not well understood, many of the new divisional management triumvirates were new in post and there was degree of misunderstanding as to how the processes should work in relation to the management and reporting of both performance and risks.

Consequently, the trust did not have a robust understanding of its key risks at departmental, divisional or board level. In a number of services such as urgent care, critical care ,maternity and services for children and young people key risks were not understood , recorded , escalate or mitigated effectively.

Performance reporting was not consistent we saw a number of performance reports prepared in various formats that contained no commonality. This had been acknowledged by the trust and work was underway to address this, however, this was work was still in its early stages at the time of our inspection.

We also had concerns in respect of the quality of data provided to support performance reporting and underpinning metrics. We did not see any evidence of testing data quality in respect of performance monitoring and management as part of our inspection.

Incident reporting and learning from investigations

The trust had an on line incident reporting system that staff were aware of and able to use. The application of the incident reporting process was inconsistently applied. In some services incident reporting was well established and staff reported appropriately, feedback and learning was applied and helped to improve practice.

However, we found that there was not a strong culture of reporting and learning from incidents across the trust as a whole. This was evident by the practices we found in emergency care, medicine, maternity and gynaecology and children and young people services where staff stated that they did not enter all reportable incidents on to the system as there was often no managerial response or feedback.

Although improvements in relation to incident reporting and investigation were underway (led by the Director of Clinical Governance and Head of Patient Safety) that included the introduction of standard operating procedures, clarity of role and responsibility and staff training, the historical poor governance systems for the management of incidents had led to backlogs and significant delays in investigations.

There were a number of historical look back exercises conducted in 2015/16 (3 year look back at maternity incidents to inform, the maternity improvement plan and 5 year look back at diagnostic incidents to inform the diagnostic improvement plan).

This, along with improved reporting accounted for an increase in Serious Incidents that contributed  to a  significant delay in completing investigations due to capacity issues.

The backlogs were challenging managers in terms of their capability and capacity to address them. As a result, opportunities for identifying causal factors and trends were limited, and opportunities for learning and improved lost or delayed as a consequence.

The previous CEO had recognised that the reporting and management of SIs was of concern when they were appointed in 2014 and subsequently commissioned an external review by HASCAS (Health & Social Care Advisory Service). This report, published in April 15 was presented to all senior managers within the Trust and commissioners from all CCGs as part of a workshop. The review identified 14 key concerns around the management, culture and SI investigation processes. The trust felt that as a result of the scale of the concerns raised at the time of the reports publication that the required improvements would take at least a year to implement and embed changes.

Additionally, as part of the HASCAS -SI review it was identified that the quality of investigations both in terms of analysis, identifying root causes and producing recommendations was poor. We were informed that there had been no root cause analysis training had been delivered for the previous 3 years.

As a result in May 2015 the Director of Clinical Governance commissioned an external provider to deliver a 2 day programme of RCA training over 2015/16. As part of this programme 103 senior managers and clinicians have been trained.

However, it was evident that the trust still had much to do as despite the investment in improving incident reporting and investigations, we found incident reports and investigations with no recommendations or learning points identified or recorded, staff, including senior managers, were unaware of the outcomes of serious incident investigations and the process for quality checking of reports was not properly understood by those completing investigations.

Mortality and Morbidity

The Trust mortality indicators such as the Hospital Standardised Mortality Ratio (HSMR) and the Summary Hospital-level Indicator (SHMI) did not highlight any elevated risks at the time of our inspection.

The key mortality indices were included within the Trust Integrated Performance report that was submitted monthly to the Board.

The Trust had reviewed its mortality review process to ensure that mortality alerts are reviewed at the Trust’s Safety Committee, reporting to the Trust Quality and Performance Committee as well as the Board to support the investigation of mortality outliers and appropriate action taken to secure improvement.

In some services we found that there was evidence of shared learning and improvements in practice as a result of mortality and morbidity reviews.

However in other services there was limited evidence of the sharing of learning and opportunities for improvement. We also noted that in some specialty’s poor attendance at mortality and morbidity related meetings and poor recording and ownership of improvement actions.

However, since our inspection the trust has confirmed that the process for ensuring implementation of actions in respect of findings from reviews has been identified as a key clinical effectiveness priority for 2016-17, and in order to develop this further, the trust was aiming to improve the sampling for mortality reviews to focus on areas of risk in line with new Department of Health guidance: The Good Governance Guide for Mortality. (Issued in December 2015).

Safeguarding

Staff in all service areas were able to identify and escalate issues of abuse and neglect.

There were safeguarding policies and procedures in place that covered a range of issues regarding abuse and neglect.

Staff had 9am -5pm Monday to Friday access to and support from the safeguarding team. Outside of these hours staff could seek support and guidance to escalate issues of abuse and neglect from managers on call, a paediatrician on call and the Social Care Emergency Duty Team.

Safeguarding practice was supported by mandatory training Compliance for level 2 safeguarding training indicated that 94% of staff have completed Level 2 training against a target of 80%.

The trust had set a target that 80% of staff working with children and young people had to have level three safeguarding training. In the children and young people’s service at North Manchester General Hospital the trust provided information that supported 72% of staff in paediatrics had completed this training and 30% of neonatal staff had completed this training.

In addition, there were low levels of level 3 safeguarding children’s safeguarding in the urgent care services

It was of concern that the trust’s target for training staff at level 3 was not met.

Nurse Staffing

Nurse staffing establishments in adult services were determined using a recognised tool and were reviewed every six months. Never the less there were significant shortages in medical, midwifery and nurse staffing establishments. Although a substantial amount of work had been undertaken by the Chief Nurse to address staffing shortfalls, wards and departments were not always adequately staffed to meet the needs of patients in terms of numbers or skills. In addition, in 2015 the Chief Nurse had introduced an escalation process that supported staff in raising issues so that managers could make an appropriate response in managing staffing related risks.

Nevertheless the nurse staffing in critical care services failed to meet the standard set by the Intensive Care Society for supernumerary shift co-ordinators at band 6/7. This issue was well known to the trust and was highlighted as a concern in the May 2015 review by the Greater Manchester Critical Care Network.

Nurse staffing levels and skills mix in paediatrics did not reflect Royal College of Nursing (RCN) guidance (August 2013). There were no advanced paediatric life support (APLS) or European paediatric life support (EPLS) trained nursing staff. Only 23.7% of nursing staff were up to date with paediatric immediate life support training.

We reviewed neonatal staffing in line with BAPM (British Association of Perinatal Medicine) guidance over the course of a month. In 25.8% of shifts, nurse staffing did not comply with BAPM guidance for the nurse: patient ratio. On average in each of these shifts the unit was understaffed by at least one registered nurse. When we reviewed the planned vs actual staffing information, this showed in 83.3% of shifts the unit was understaffed by on average 2.2 nurses.

Midwifery Staffing

Maternity staffing did not meet the national benchmark set out in the Royal College of Obstetricians and Gynaecologists (RCOG/RCM) guidance RCOG recommendation of 1:28 births. In addition the labour ward frequently had lower than the planned number of midwives on duty; consequently Midwives were not always able to provide one to one care for women in labour in accordance with good practice.

At the time of our inspection we found that the maternity service triage facility was not staffed appropriately and women were left unsupervised. We raised this at the time and the trust took action to address this matter immediately.

An escalation processes in relation to midwifery staffing had been introduced that included mitigating actions that should be taken when midwifery staffing levels fell below establishment. There was also a divert policy in place and an ongoing recruitment programme. However, maintaining the required staffing levels in maternity services was a daily managerial challenge and midwifery staffing shortages were a frequent occurrence.

Community Nurse Staffing

Community nursing services were suitably staffed and there were minimal staffing shortages.

Medical staffing

North Manchester General Hospital

There were a number of departments in the hospital where there were concerns regarding medical staffing. This was particularly significant within the Urgent and Emergency Care, medicine, maternity and gynaecology and children’s and young people’s services (CYP)

Within the Urgent and Emergency (U&E) care department an establishment of nine consultants had been commissioned. Only one consultant was employed substantively at the time of our inspection. However, consultants from other areas of the trust worked in the department on a rotational basis to provide senior support.

The A&E department was established for seven middle grade positions and 13 junior doctor positions. However, only three middle grade doctors and five junior doctors were employed substantively at the time of the inspection. As a result, the department relied heavily on locum doctors of all grades. There was a local induction process for locum staff, however on our unannounced visit to U&E care we noted that one locum doctor had not been subject to a local induction and was reliant on nursing staff to assist in locating key items and equipment.

There was limited assurance that the performance of locum doctors with U&E was being reviewed on a regular basis. This was important as locum doctors formed a large percentage of the medical workforce within the department.

There was no consistent consultant presence on the paediatric wards during peak times in accordance with ‘Facing the Future Standards’. The trust advised that consideration had been given to new rotas as part of the paediatric improvement plan. However, no implementation date had been set at the time of our inspection.

The ‘Facing the Future’ Standards also recommend that every child who presents with an acute medical problem is seen by a consultant, or equivalent, within 24 hours. In one paediatric serious incident investigation we reviewed this had not occurred and was deemed a causal factor in the delay of diagnosis.

The trust did not monitor this standard at the time of our inspection.

Royal Oldham Hospital

There were a number of departments in the hospital where there were concerns regarding suitable and appropriate medical staffing. This was particularly significant within the critical care, maternity and gynaecology and children and young people’s services.

There were medical staffing vacancies in medical services and this had been identified as a risk. There were actions identified to mitigate this risk such as an ongoing recruitment programme.

At the time of our inspection there was no dedicated medical cover for the High Dependency Unit (HDU). The unit was ‘open’ unit with potential referral and admissions from any speciality within the hospital. Consequently this meant that on the HDU many of the standards for critical care as set out in the “Core Standards for Intensive Care “(Nov 2013) the Draft D16 Service Specification for Adult Critical Care and the Guidelines for the Provision of Intensive Care Services (GPICS) Standards. (2015) were not being met. Of particular concern was that the inappropriate medical cover for the HDU had been known to the trust in 2013 and it was only during our inspection that arrangements were made to provide adequate medical cover in this area.

In the hospitals services for children and young people ‘Facing the Future’ Standards recommend there should be consultant presence on the ward at self-defined peak times. Staff informed us that their peak times were between 4pm and 9pm. The hospital had consultants scheduled to be on site up until 5pm. The trust confirmed that consultant presence during peak times was not in place. The trust advised us that consideration had been given to new rotas as part of the paediatric improvement plan. However, no implementation date had been set at the time of our inspection.

More positively, the emergency department had sufficient numbers of medical staff with an appropriate skill mix to ensure that patients received the right level of care.

Fairfield hospital

There were medical staffing vacancies in medical services and this was on the trust risk register. There were actions identified to mitigate this risk such as a recruitment programme. Existing vacancies and shortfalls in surgery were covered by locum, bank or agency staff when required, such staff were provided with local inductions to ensure they understood the hospital’s policies and procedures. The information we reviewed at the time of our inspection indicated medical staffing was appropriate at the time of the inspection.

Rochdale Infirmary

Medical staffing levels and skill mix in surgical services was recognised as being appropriate to meet patient need and reflected current guidance. Operating theatres were established against the ‘Association for Perioperative Practice (AfPP) staffing recommendations.

Medical cover was provided 24 hours a day and senior advice was available from Fairfield General Hospital if required.

Assessing and responding to risk.

In the U&E departments there were a high number of patients experiencing unacceptable waits for ambulance handover, triage and initial treatment. Performance against the Royal College of Emergency Medicine (CEM) standard of patients being triaged within 15 minutes of arrival was poor in all 3 departments.

The trust had a deteriorating patient programme as part of its safety improvement plan and Sign Up to Safety initiative that included a review of the EWS policy, review of critical care outreach, development and review of educational programmes as well as the development of a business case for IT solution of e-observations. However at the time of our inspection  these improvements were not yet implemented or embedded and although we found that the Early Warning Systems in place to promptly identify deteriorations in patient’s condition, we found that these were not consistently recorded and escalated in a number of services including urgent care, medical services, maternity services and in services for children and young people. This meant that risks to patients were not always identified and medical intervention provided in a timely way.

Staff on the Medical Emergency Unit (MEU) at North Manchester Hospital had not received training to use the continuous cardiac monitoring in place and there was no monitoring system in place at the nurse’s station.

Royal College of Nursing (RCN) standards (August 2013) recommends that in children’s services a member of the nursing staff should have Advanced life Support (APLS) training at all time throughout the 24 hr period. The trust did not have any APLS trained nursing staff members in paediatrics. Only 13/46 (28.3%) nurses had current paediatric life support (PILS) certification on paediatrics. We raised this with the trust at the time of our inspection and immediate action was taken to mitigate and manage this risk.

Neonatal records showed that only 23.9% of nursing staff had current NLS training at the time of our inspection.

However, in surgical services we found good use of systems to ensure that risks to elective and emergency patient groups were identified pre-operatively, venothromboembolism (VTE) assessment was completed for all hospitalised patients within 24 hours of admission. In Rochdale surgical services Audit data for 2015 against the trust target of 95% confirmed completion of VTE assessments as 97%.

Similarly there was good use of the 5 steps to safer surgery checklist in most surgical settings. Compliance rates were consistently above 90% across the trust.

The trust had undertaken improvements in Sepsis, as part of its Safety Programme and Sign Up to Safety work, including development of algorithms, development of training tools and auditing practice via the Advancing Quality programme. However, in A&E we found that patients with symptoms of sepsis were not always identified and treated in a timely way.

In community services we found that systems and processes to maintain patient safety were appropriately applied, reviewed and monitored.

Staff were clear and consistent in maintaining steps to protect patients from avoidable harm.

Evidence based care and treatment

Care and treatment was based on evidence-based guidance and the policies and procedures, assessment tools and pathways followed recognisable and approved guidelines such as the National Institute for Health and Care Excellence (NICE).

There was use of clinical audit to monitor and improve performance. However, where audits highlighted areas for improvement we did not find always find evidence of implemented and monitored action plans to secure improvement.

Patient outcomes in medical services particularly for patients with heart failure, diabetes and children’s diabetes required improvement.

Competent staff

The trust had a system in place for staff to receive an annual appraisal. However compliance rates across the hospitals and services varied considerably, in some services such as community services and outpatients departments 100% of staff had received an appraisal, yet in medical services at North Manchester General Hospital compliance rates were as low as 23%.

This meant that there were significant numbers of staff that had not had the opportunity to meet with their managers to discuss their performance and continued professional development.

There was an induction and a preceptorship plan in place for new staff. This included agreed supernumerary periods so that staff could develop their competency and skills with supervision and support. However we found that due to staffing pressures the plans and support for new staff were not always adhered to and staff formed part of the staffing establishment sooner than anticipated. This was a particular issue in urgent and emergency care.

Compassionate care

Care and treatment was delivered by caring, committed, and compassionate staff.

In community end of Life services we found outstanding care and excellent examples of staff displaying an individualised person centred and compassionate approach to patient’s needs and preferences. There was a compassionate approach for patients whose condition or circumstances made them vulnerable. However, there were examples when due to staffing pressures, care had become task focused and we observed little positive interaction with patients other than at those times. There were times when care delivery was functional and impersonal.

Access and Flow

In the 3  A&E departments the proportion of all patients that attended the emergency department and were treated within four hours was consistently and significantly below the national target. Patients were subject to delays in triage, initial assessment and waited for unacceptable lengths of time for transfer from the A&E departments.

A review of patient records indicated that there had been a high number of patients waiting for over 12 hours in the U&E departments. As a result of the trust’s decision to admit policy these were not always recorded appropriately, potentially providing an inaccurate picture of performance and limiting the ability to improve the service. The trust acknowledged the need to review the Decision To Admit Policy to ensure clinical leaders and senior staff were fully appraised about the time patients spend in A&E. This trust has confirmed that a new policy was fully implemented in early March 2016.

In addition there were times due to bed capacity and availability; patients were placed in areas not best suited to their needs. (Known as outliers) Patients also experienced frequent moves between wards and departments often during the night without there being a clinical need for the transfer to take place.

Despite a focused approach to discharge planning, people remained in hospital longer than they needed to be and there were examples of delays in patient discharges particularly in medical services.

However, performance at the urgent care centre at Rochdale Infirmary consistently met national expectations. 

The trust had an urgent care improvement plan in place , however, this had not yet secured significant improvement at the time of the inspection.

In terms of referral to treatment times the information available to us indicated that the trust met internal and national referral to treatment targets in all specialties. and that national cancer treatment targets were met. However, since our inspection we have been made aware of a number of concerns in relation to the quality and accuracy of the data provided by the trust in respect of referral to treatment times. This matter is under review by the new Executive Team and we will be monitoring the trusts response and actions in respect of this matter through our ongoing regulatory activity.

Meeting individual needs

There were positive examples of initiatives to meet the needs of patients whose circumstances or illness made them vulnerable including patients who were living with dementia or who had a learning disability.

The trust also used a leaf symbol to indicate that a patient was frail and a butterfly symbol to indicate that a patient was at the end of life. These discreet symbols alerted staff to so that assessments and care plans considered any reasonable adjustments required to meet the patient’s needs.

Interpreters were available on demand for patients whose first language was not English. British Sign Language interpreters were also available for patients who were deaf.

Learning from complaints

We found that overall the management of complaints was poor. The previous two full calendar years; 01.01.2014 – 31.12.2015, the Trust received 1455 complaints. The two full calendar years prior to the date of inspection; 21.02.2014 – 21.02.2016, the Trust received 1414 complaints. At the time the inspection commenced 22.02.2016, the Trust had 227 open complaints, and over 80 had remained open for over 100 days.

In addition, we found limited oversight and review of action planning in response to complaints and recurring themes in respect of causal factors. We found that learning from incidents and complaints was not systematically implemented and monitored and as a result opportunities for improving services, patient experiences and confidence were lost.

Importantly the trust must

Urgent and Emergency Services

• Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff deployed in the Urgent and Emergency department to assess and meet patients needs

• Ensure that there are sufficient numbers of staff with the appropriate skills available at all times. This includes ensuring that there are sufficient numbers of staff available to resuscitate adults and children.

• Ensure that patient risk is monitored and documented appropriately through the use of the early warning scores (EWS) and the Manchester early warning score (MANCHEWS) for children.

• Ensure that daily checks and relevant documentation of controlled drugs are completed correctly and accurately in line with legislation and trust policy.

• Ensure that patients attending the department are assessed and treated in a timely manner.

• Ensure that the effectiveness and timeliness of treatment is measured on a regular basis so that there is the opportunity to improve services where required.

Medical services

• Ensure that there are sufficient nursing staff on duty to meet patients needs at all times.

• Ensure that patients staying overnight at the Manchester treatment centre have facilities to wash and store personal belongings.

• Ensure that records are completed in line with best practice guidance and are maintained and stored securely.

• Ensure that incidents are investigated promptly and learning is shared through formal, established channels.

• Ensure that plans are in place for wards sharing facilities and staff in the case of an outbreak of infection.

• Ensure that staff receive training on and understand how to apply the Mental Capacity Act and deprivation of liberty safeguards.

• Ensure that staff follow the agreed standards for adult patient observation practice.

• Ensure that assessments of patient’s nutrition and hydration needs are fully completed and patients receive appropriate support where necessary.

• Ensure that the discharge lounge and ambulatory care unit is fit for purpose.

Surgical Services

• Ensure that there are sufficient nursing staff on duty to meet patients needs at all times.

• Ensure that DNACPRs are reviewed regularly particularly when a patient’s condition has changed.

• Ensure that staff understand and act in line with the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards.

• Ensure all nursing and medical staff have annual appraisals completed.

• Ensure that staff complete training in ‘Sepsis six’ so staff are aware of the process to follow when a patient is put on a ‘Sepsis six’ treatment pathway.

• Ensure that critical care beds are available for surgical patients who require their initial post-operative care to take place in a designated critical care unit so that they receive treatment and care from staff who have the skills and training in this area.

• Ensure that patients who are outliers on wards have the appropriate care, review and support to ensure a positive outcome results from their treatment.

Critical care

• Take action to ensure that level 2 patients on the high dependency unit at the Royal Oldham Hospital are managed in accordance with the national guidance and standards for critical care.

• Take action to provide suitable medical cover for the High dependency unit at Royal Oldham Hospital.

• Take action to reduce the numbers of delayed and out of hours discharges from both level 2 and level 3 critical care facilities.

Maternity and Gynaecology Services

• Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed in the maternity services. This includes sufficient consultant resident cover in the labour ward.

• Ensure that the risks to the health and safety of patients of receiving the care or treatment are assessed, escalated and met.

• Investigate incidents within agreed timescales and take action to prevent recurrence.

Children and Young People

• Ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced Nursing and Medical staff deployed in the paediatric and neonatal services to meet patients needs at all times.

• Assess the risks to the health and safety of patients of receiving the care or treatment and escalate and managed appropriately.

• Investigate incidents robustly within agreed timescales and take action to prevent recurrence

• Ensure that electrical equipment is appropriately maintained and fit for purpose.

End of life services

• Take action to ensure that any DNACPR decision is supported by the consent of the patient. Take action to ensure that where a patient appears to lack capacity to consent to a DNACPR decision, a mental capacity assessment must take place prior to the decision being made.

• Take action to ensure where a patient has been assessed as lacking capacity to make the DNACPR decision a documented discussion with patient’s family takes place prior to the decision being taken.

Professor Sir Mike Richards

​Chief Inspector of Hospitals

Overall rating for this core service Good O

We rated the community children and young people services at the Pennine Acute Hospitals NHS trust as ‘Good’.

This was because: -

• The level of incidents reported showed low risk of harm and safe systems for care and treatment of patients. Staff understood how to report incidents.

• There were enough suitable skilled, competent staff with the right mix of skills to meet patients’ needs. Patients were treated in clean and suitably maintained premises. Patient records were complete and accurate.

• Care and treatment was based on national clinical guidelines and staff used care pathways effectively. The services participated in clinical audits to look for improvements to the service. Audit records showed most patients experienced positive outcomes following their care and treatment and appropriate actions were taken to improve compliance with best practice standards. Some staff experienced difficulties in accessing trust-wide IT systems. This was being addressed by providing staff with additional computers enabled with access to trust-wide systems.

• Services were planned and delivered to meet the needs of local people. There were systems in place to support vulnerable patients. Most patients received care and treatment in a timely manner. However, a significant number of patients did not attend (DNA) their scheduled appointments in the community orthoptics and audiology services. Staff followed up patients that did not attend by sending letters to them and to other health professionals involved in their care, such as their general practitioners (GP’s).

• Patients and their relatives spoke positively about the care and treatment they received. They were treated with dignity and compassion. They were kept involved in their care and they were supported with their emotional needs.

• The service delivery was based on the trust values and core objectives and staff had a clear understanding of what these involved. There was clearly visible leadership in place through local team leaders and staff were positive about the culture and support available.

Overall rating for this core service: Good

We rated this service as good because:

Staff were aware of the trust’s safeguarding policies and procedures. Safeguarding training formed part of the trust’s mandatory training programme and 100% of staff working in community inpatients had completed level two and three safeguarding adults training.

Admission procedures included appropriate risk assessments of key areas of health and personal care needs, including: tissue viability, nutrition screening, moving and handling, infection, continence and risk assessments for falls. We saw that the risk assessments were regularly reviewed according to the level of risk and appropriate action was taken in response to the risks identified.

There was effective teamwork and clearly visible leadership within the services. Staff were positive about the culture within the community inpatient services and the level of support they received from their managers. The management team understood the key risks and challenges to the service and how to resolve these.

The consultants at the Floyd Unit were part of Greater Manchester neurology rehabilitation network where there was MDT representation. This ensured consistency across Greater Manchester and allowed for benchmarking best practice.

Patients and their relatives spoke positively about the care and treatment provided. They told us they were treated with dignity, empathy and compassion. Staff ensured patients or their relatives were involved in their care and supported them with their emotional and spiritual needs.

However, there were a number of areas where improvements could be made:

Cleaning staff were present on a daily basis, with a list of cleaning duties; however, they did not keep records to show what cleaning had taken place. This meant there was no way of establishing whether all cleaning duties were being regularly completed.

Staff could access information such as policies and procedures from the trust’s intranet. However staff at Tudor Court and Wolstenholme did not have access to IT systems. This was due to server problems at Tudor Court following the transition from the local authority and staff not being issued with login details at Wolstenholme. Plans were in place to address this.

Within the records at each of the community inpatients units, there was no evidence of a formal mental capacity assessment completed by medical staff.

Incidents were reported using an electronic reporting system and staff were familiar with the policy around incident reporting. However, staff at Tudor Court and Wolstenholme were not able to report incidents on the electronic reporting system as they did not have access to the trust computer system. This was due to the transition over from local authority to the trust in September 2015. The trust was in the process of addressing this but there was no date of when this would be introduced. This was not identified as a risk on the departmental risk register.

Overall rating for this core service Good

We Community services for adults at The Pennine Acute Hospitals NHS Trust as good because:

• Staff delivered care that was caring, compassionate and supportive of patients and their families.
• The service worked effectively and engaged with other professionals to ensure patients received the required level of care and support.
• Staff appraisals were completed and staff had sufficient clinical supervision.
• Staff spoke positively about the support they were given by seniors and management.
• Staff worked effectively with hospitals, GPs and specialists to seek advice when needed.
• When we talked with patients and staff and observed care, we found that staff were passionate and committed to providing good end of life care.
• Staff were observed providing care to patients with kindness, compassion and dignity
• Safety was a high priority and there was measurement and monitoring of safety and performance within the service.
• Risks were appropriately managed and identified.
• We found that the care delivered to patients was evidence-based and in line with key documents such as National Institute of Clinical Effectiveness guidance.
• There was routine monitoring of patient outcomes of care and treatment, and patient feedback was actively sought on a regular basis.
• Patients could access the care and treatment they required in a timely way.
• There were strong areas of innovation and the service had won a number of awards for innovative practice.

However:

• Data from the NHS Friends and Family Test showed that the percentage of patients who would recommend the service to their friends and family was below the England average for the 2015/2016 period at 85%.

Overall rating for this core service: Good

We rated community end of life care services at The Pennine Acute Hospitals NHS Trust as good because:

• Staff delivered end of life care in the community setting that was caring, compassionate and supportive of patients and their families.
• The service had a comprehensive framework and strategy for end of life care.
• The advanced care plan document developed to replace the Liverpool Care Pathway in July 2014 was comprehensive and person-centred.
• The trust had appointed a board member with a specific lead role for end of life care and staff were aware of whom this executive lead was.
• Safety was a high priority and there was measurement and monitoring of safety and performance within the service.
• Risks were appropriately managed and identified.
• We found that the care delivered to patients was evidence-based and in line with key documents such as National Institute of Clinical Effectiveness guidance and priorities of the dying person, particularly personalised care.
• There was routine monitoring of patient outcomes of care and treatment, and patient feedback was actively sought on a regular basis.
• The training for staff involved with the delivery of end of life care was appropriate and provided on a regular basis.
• The end of life care team worked effectively and engaged with other professionals to ensure patients received the required level of care and support.
• Staff appraisals were completed and staff had sufficient clinical supervision.
• Staff spoke positively about the support they were given by seniors and management.
• A consultant with a responsibility for end of life and was co-located with the end of life care team provided good clinical leadership and support to the palliative care team.
• Staff worked with local hospices, hospitals, GPs and specialists to seek advice when needed.
• When we talked with patients and staff and observed care, we found that staff were passionate and committed to providing good end of life care.
• Staff were observed providing care to patients with kindness, compassion and dignity.