Tameside Hospital NHS Foundation Trust
Review into the Quality of Care and Treatment provided by
14 Hospital Trusts in England
RAPID RESPONSIVE REVIEW REPORT FOR RISK SUMMIT
July 2013
Contents
1.
Introduction
3
2.
Background to the Trust
7
3.
Key Lines of Enquiry
11
4.
Review findings
12
5.
Governance and leadership
16
Clinical and operational effectiveness
25
Patient experience
31
Workforce and safety
39
Conclusions and support required
Appendices
44
46
Appendix I: SHMI and HSMR definitions
47
Appendix II: Panel composition
49
Appendix III: Interviews held on announced visit
50
Appendix IV: Observations undertaken
51
Appendix V: Focus groups held
52
Appendix VI: Information made available to the panel by the Trust 53
Appendix VII: Unannounced site visit
55
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1. Introduction
Overview of review process
On 6 February 2013 the Prime Minister asked Professor Sir Bruce Keogh, NHS England Medical Director, to review the quality of the care and treatment being provided by
those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 NHS trusts which fall within the scope of this review were selected on the
basis that they have been outliers for the last two consecutive years on either the Summary Hospital level Mortality Indicator (SHMI) or the Hospital Standardised Mortality
Ratio (HSMR). Definitions of SHMI and HSMR are included at Appendix I.
These two measures are intended to be used in the context of this review as a ‘smoke alarm’ for identifying potential problems affecting the quality of patient care and
treatment at the trusts which warrant further review. It was intended that these measures should not be reviewed in isolation and no judgements were made at the start of the
review about the actual quality of care being provided to patients at the trusts.
Key principles of the review
The review process applied to all 14 NHS trusts was designed to embed the following principles:
1) Patient and public participation – public representatives played a key role and worked in partnership with clinicians on the reviewing panel. The panel sought the views
of the patients in each of the hospitals and also considered independent feedback from stakeholders, related to the Trust, which had been received through the Keogh
review website. These themes have been reflected in the reports.
2) Listening to the views of staff – staff were supported to provide frank and honest opinions about the quality of care provided to hospital patients.
3) Openness and transparency – all possible information and intelligence relating to the review and individual investigations will be publicly available.
4) Cooperation between organisations – each review was built around strong cooperation between different organisations that make up the health system, placing the
interests of patients first at all times.
Terms of reference of the review
The review process was designed by a team of clinicians and other key stakeholders identified by NHS England, based on the NHS National Quality Board guidance on rapid
responsive reviews and risk summits. The process was designed to:


Determine whether there are any sustained failings in the quality of care and treatment being provided to patients at these Trusts.
Identify:
i.
Whether existing action by these Trusts to improve quality is adequate and whether any additional steps should be taken.
ii.
Any additional external support that should be made available to these Trusts to help them improve.
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iii.
Any areas that may require regulatory action in order to protect patients.
The review follows a three stage process:

Stage 1 – Information gathering and analysis
This stage used information and data held across the NHS and other public bodies to prepare analysis in relation to clinical quality and outcomes as well as patient and staff
views and feedback. The indicators for each trust were compared to appropriate benchmarks to identify any outliers for further investigation in the rapid responsive review
stage as Key Lines of Enquiry (KLOEs). The data pack for each trust reviewed is published at http://www.nhs.uk/NHSEngland/bruce-keogh-review/Documents/trust-datapacks/tamside-data-packs-PUBLISH.pdf.

Stage 2 – Rapid Responsive Review (RRR)
A team of experienced clinicians, patients, managers and regulators (see Appendix II for panel composition), following training, visited each of the 14 hospitals and observed
the hospital in action. This involved walking the wards and departments, interviewing patients, trainees, staff and members of the Board. The report from this stage was
considered at the risk summit.

Stage 3 – Risk Summit
This brought together a separate group of experts from across health organisations, including the regulatory bodies. They considered the report from the RRR, alongside
other hard and soft intelligence, in order to make judgements about the quality of care being provided and agree any necessary actions, including offers of support to the
hospitals concerned. A report following each risk summit has been made publicly available.
Methods of investigation
The two day announced RRR visit took place at the Trust’s main hospital, Tameside Hospital on Thursday 23 and Friday 24 May 2013. A variety of review methods were
used to investigate the KLOEs and this enabled the panel to consider evidence from multiple sources in making their judgements.
The visit included the following methods of investigation:

Interviews
Nineteen interviews took place with members of the Board and selected members of staff based on the key lines of enquiry during the announced visit. See Appendix III for
details of the interviews undertaken.
An interview was also held with the Trust’s Governors attended by three members of the Council of Governors.
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
Observations
Ward observations enabled the panel to see the Trust undergo its day to day operations. They allowed the panel to talk to current patients, and their families where
observations took placed during visiting hours. They allowed the panel to speak with a range of staff and observe the quality of care and treatment being provided to patients.
The panel was able to observe the action by the Trust to improve quality in practice and consider whether any additional steps should be taken.
Observations took place in eleven areas of Tameside hospital. See Appendix IV for details of the observations undertaken.

Focus groups
Focus groups provided an opportunity to talk to staff groups individually to ask each area of staff what they feel is good about patient care in the Trust and what needs
improving. They enabled staff to speak up if they feel there is a barrier that is preventing them from providing good quality care to patients and what actions the Trust might
need to consider improving, including addressing areas with higher than expected mortality indicators.
Focus groups were held with four staff groups during the announced site visit. See Appendix V for details of the focus groups held.
The panel would like to thank all those attending the focus groups who were open with the sharing of their experiences and balanced in their perceptions of the quality of care
and treatment at the Trust.

Listening event
Public listening events give the public an opportunity to share their personal experiences with the hospital, and to voice their opinion on what they feel works well or needs
improving at the Trust in relation to the quality of patient care and treatment. A listening event for the public and patients was held on the evening of 23 May 2013 at
Dukinfield Town Hall. This was an open event, publicised locally, and attended by more than 200 members of the public and patients.
The panel would like to thank all those attending the listening event who were open in sharing of their experiences and balanced in their perceptions of the quality of care and
treatment at the Trust.

Review of documentation
A number of documents were provided to the panellists through a copy being available in the panel’s ‘base location’ at the Trust during the site visit. Whilst not all the
documents were reviewed in detail, they were available to the panellists to validate findings as considered appropriate by the panellists. See Appendix VI for details of the
documents available to the panel.

Unannounced visit
The unannounced out-of-hours visit took place at Tameside Hospital on the evening of Sunday 2 June and morning of Monday 3 June 2013. This focused observations in
areas identified from the announced site visit, see Appendix VII. Follow-up discussions were held with a few members of staff already interviewed during the announced visit.
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Next steps
This report has been produced by Gill Harris, Panel Chair, with the full support and input of panel members. It has been shared with the Trust for a factual accuracy check.
This report was issued to attendees at the risk summit, which focussed on supporting Tameside Hospital NHS Foundation Trust (“the Trust”) in addressing the actions
identified to improve the quality of care and treatment.
Following the risk summit the agreed action plan will be published alongside this report on the Keogh review website. A report summarising the findings and actions arising
from the 14 investigations will also be published.
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2. Background to the Trust
This section of the report provides relevant background information for the Trust and highlights the areas identified from the data pack for further investigation.
Context
Tameside Hospital NHS Foundation Trust is the principal provider of acute hospital services for the residents of Tameside in Greater Manchester and the town of Glossop in
Derbyshire. The Trust operates from the Tameside General Hospital site which is situated in Ashton-under-Lyne, and serves a population of approximately 250,000 people
residing in Tameside and surrounding areas. It has a total of 502 beds and is a small Trust for both inpatient and outpatient activity relative to the rest of England. Tameside
became a Foundation Trust on 1 February 2008.
The hospital has four divisions: Emergency Services and Critical Care, Elective Services, Diagnostic and Therapeutic, and the Women and Children’s Division. General
Medicine and General Surgery are the largest inpatient specialties, while Trauma and Orthopaedics and General Medicine are the largest for outpatients.
Tameside falls within the most deprived quartile of counties in England. Teenage pregnancy and alcohol-related hospital stays for under-18 year olds are particularly
common in this region, and violent crime and long-term unemployment are relatively more common than in England as a whole. The age distribution in Tameside is fairly
similar to the national age distribution. Tameside’s health profile outlines that there are a number of aspects for which children’s and young people’s and adults’ health is
significantly lower than the national average. The profile also shows that in Tameside life expectancy for both men and women is significantly lower than the national
average.
Key messages from the Trust data pack
Mortality indicators
The Trust was selected for this review as a result of its SHMI for 2011 and 2012 which were above the expected level. The Trust also reported an HSMR of 107 over the
period January to December 2012, meaning that the number of actual deaths is higher than the expected level, but this was statistically still within the expected range.
The Trust had an overall SHMI of 116 for the period between December 2011 to November 2012, meaning that the number of actual deaths is above the expected range. For
both the SHMI and HSMR, the Trust’s non elective admissions were the main contributing factors for higher than expected mortality. Elective admissions were also above
the expected range for SHMI, with a value of 166.
The main diagnoses contributing to the SHMI and HSMR indicators were noted in general medicine (in particular, pneumonia, acute myocardial infarction (heart attack) and
acute cerebrovascular disease (stroke)), so these were a focus identified for the review. The RRR visit included observations of the general medicine wards, specifically
those caring for patients with these conditions, and interviews with patients and staff within these areas.
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Governance and leadership
The Trust Board has three main subcommittees, including the Quality and Clinical Governance Committee, which is chaired by a Non-Executive Director and provides
assurance to the Board on quality. The Clinical Audit, Patient Safety and Effectiveness Committee is a subgroup of the Quality and Clinical Governance Committee and
considers mortality each month. Board responsibility for clinical governance and quality is split between the Medical Director and Director of Nursing.
Key risks identified by the Trust in the corporate risk register and other Board papers include ensuring that authorisation and registration requirements are maintained for key
regulatory bodies; ensuring that factors impacting on mortality are understood, addressed and managed; capacity issues and their impact on patients; horizontal and vertical
strategic partnership implementation in order to ensure critical mass of clinical services and 24/7 consultant cover to support non-elective emergency pathways.
The Trust currently has a ‘red’ Monitor governance risk rating as it has been in significant breach of two of its terms of authorisation since 2011. The two areas of concern
were; an unplanned financial risk rating of 2 and concerns raised in relation to safety and quality by a Care Quality Commission (CQC) review in 2011. The latest rating
against CQC Outcomes is ‘green’ which represents “No concerns”.
A high level review of the effectiveness of the Trust’s quality governance arrangements was a standard key line of enquiry for the review.
Clinical and operating effectiveness
In 2012, the Trust’s accident and emergency department (A&E) assessed and then treated, admitted or discharged as appropriate 95.8% of its patients within 4 hours, which
is above the 95% national standard level.
The Trust’s referral to treatment (RTT) within 18 weeks for admitted patients is 90.1% in the year to February 2013 which is higher than the national standard level. The data
showed that the Trust has been performing above the target level throughout the last 12 months, although this has dropped in recent months.
The Trust’s crude readmission rate, which is the percentage of patients that were discharged and then re-admitted within 30 days, is high when compared with trusts
nationally at 13.10%. However, the standardised readmission rate, which accounts for the Trust’s case mix, shows that it is within the expected range. The average length of
stay is 4.77 days which is shorter than the national mean average of 5.2 days.
The only red flag for clinical and operational effectiveness is that relating to hip fracture mortality. In the National Hip Fracture Database, a key measure of effectiveness is
the percentage of patients undergoing surgery within 36 hours of admission. On this measure, the Trust is an outlier, being some way outside the lower controls limits.
The data in this area did not highlight any further Trust-specific key lines of enquiry.
Patient experience
Of the nine measures reviewed within Patient Experience and Complaints there are two which are rated ‘red’:

The Inpatient survey: There were several areas of concern across the national inpatient survey 2012 results, including delays in being admitted to a ward, weaknesses in
information given to patients on discharge, lack of patient involvement in decisions and being treated with respect and dignity.
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
Comments collected through CQC’s patient voice system: Whilst the majority of the comments recorded were positive, the negative comments included noteworthy
allegations including those of ignoring formal whistle-blowing from a senior doctor, lack of healthcare worker professionalism, poor or disrespectful communication to
patients and patients being bullied or shouted at.
The Trust is A-rated by the Ombudsman which indicates a low risk of non-compliance with its recommendations. The Ombudsman investigates complaints escalated to it by
complainants who are not satisfied with the Trust's response. It rates Trusts on whether they have implemented the recommendations made at the end of an investigation in
a satisfactorily and timely manner, helping to ensure that Trusts learn from mistakes. The Ombudsman rates each Trust’s compliance with recommendations and focuses on
monitoring organisations whose compliance history indicates that they present a risk of non-compliance.
Keogh review patient voice comments
The patient voice comments received directly via the contact details on the Keogh review website (at the time of writing this report) identified the following positive and
negative themes from 57 e-mails and letters. Roughly 45% of comments were positive and 55% negative.
Positive
Negative
Positive experience of hospital stay
Poor quality of care
Professional, caring and helpful staff
Poor communication from staff
Good treatment received; bed changed daily
Misdiagnosis and follow-up treatment slow
Caring nurses
Poor standard of surgery
Good care received in Cardiology
Perception of negative impact of Chief Executive
Lack of care for elderly – spoken to in unprofessional manner
Poor cleanliness and hygiene of staff
Poor level of patient safety as an inpatient
Inadequate staffing
Poor administration of outpatient appointments
Key lines of enquiry were followed in the review based on what patients say about the quality of care and treatment and what the Trust is doing in response to
this feedback.
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Workforce and safety
The Trust is ‘red rated’ in the following safety indicators:
th

For MRSA, the Trust has the 7 highest rate of infection of 141 trusts nationally over the three years from 2010 to 2012. For Clostridium difficile, the Trust had the second
highest infection rates in the country over the same period. This highlighted infection prevention and control as a potential area for review.

The Trust has the 35 highest percentage of patients harmed for the four safety thermometer indicators out of 141 non-specialist trusts. It experienced a harm rate of
10%, compared with the national average of 8.9%. However, it must be noted that due to potential differences in case mix and data collection practices at different
organisations, definitive conclusions about differences in the burden of harm between organisations cannot be made.

The Trust’s clinical negligence payments have significantly exceeded contributions to the ‘risk sharing scheme’ over the last three years, by a total of £21m over this
period. This highlighted incident reporting and learning from incidents as an area for review.

A review of the Coroner’s rule 43 reports highlighted a number of areas for potential review, including arrangements for transfer of patients between hospitals,
communication procedures between staff, senior house officer and house officer staffing levels, staffing levels within A&E and the medical admissions unit (MAU), written
procedures for handling incident reports, arrangements for nurses to summon help if required and record-keeping.
th
A review of the workforce data flagged five ‘red rated’ indicators:

The Trust had a high agency spend over 2011/12 (9.4% of total staff costs) compared to the region median (3.5%).

The data also shows that the three month vacancy rate for medical staff is over 50% higher than the national average rate and that the sickness absence rate for medical
staff is nearly twice the national average.

Whole Time Equivalent (WTE) nurses per bed day were 1.31 which was low compared with a national average of 1.96.

Fifteen doctors in training commented on patient safety concerns in the National Training Scheme (NTS) survey 2012, representing 13.99% of respondents. This was
nearly three times the national average of 4.7% and included concerns over supervision at the weekend, bed shortages and locum cover.
Key lines of enquiry were included in the review focusing on how the Trust plans its workforce and its arrangements for patient safety.
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3. Key Lines of Enquiry
The Key Lines of Enquiry (KLOEs) were drafted using the following key inputs:

The Trust data pack produced during the first stage and made publicly available.

Documentation submitted by the Trust.

Insights from the Trust’s lead Clinical Commissioning Group (CCG).

Review of the patient voice feedback received specific to the Trust prior to the site visit.
The KLOEs were agreed by the panellists during the panel briefing session held prior to the RRR site visit. The KLOEs identified for the Trust were the following:
Theme
Key Line of Enquiry
Governance and leadership
1. Can the Trust clearly articulate its governance process for assuring the quality of treatment and care?
2. How does the Trust use information locally?
Clinical and operational effectiveness
3. What governance arrangements does the Trust have to monitor and address clinical and operational performance data
at a senior level?
Patient experience
4. How does the Trust engage with stakeholders?
5. How is the Trust assured that its mission statement and values are achieved within its clinical pathways?
Workforce and safety
6. In the context of this review, can the Trust describe its workforce strategy?
7. How is the Board assured that it has the necessary workforce deployed to deliver its quality objectives?
8. What assurance does the Board have that the organisation is safe?
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4. Review findings
Introduction
This section provides a detailed analysis of the panel’s findings based on the evidence gathered from the Trust data pack, interviews, observations, staff focus groups and
patient and public listening events.
Overview of findings
The panel found committed staff at the Trust and examples of good practice, but there were a number of areas of concern identified. The Trust should focus on urgently
addressing these issues to improve the quality of care, patient safety and experience.
1. The clinical safety and experience of care for medical and elderly patients admitted via Accident and Emergency needs further review and urgent action to
address operational issues
The panel considered that external review recommendations to review and improve the acute medical pathway had not been sufficiently progressed by management. This
has led to a number of systematic issues identified by the panel to be impacting on quality and patient safety. The most urgent requiring action are:

Inadequate consultant supervision of junior doctors and patients, particularly at night

Inadequate patient handover

Inappropriate use of escalation areas and medical assessment unit beds to resolve capacity challenges

Insufficient access to critical care beds for patients who may require them

Insufficient nurse staffing levels and the use of nurses in escalation wards who are not regular staff on the wards

Poor infection control practice for patients admitted with Clostridium difficile.
Insufficient senior clinical cover, particularly out of hours, is leading to a lack of timely investigations and poor management of deteriorating patients in some areas, particularly
the Medical Assessment Unit and Women’s Health Unit. The Trust urgently needs to ensure all acute patients receive a daily ward round review by senior medical staff. The
Trust also needs to review its staffing levels and skill mix to improve medical cover arrangements and reduce the use of bank and agency, and locum cover.
2. The Board is not effectively leading the Trust in delivering quality care and the governance and leadership has not delivered the improvements in quality of
care required
The Board needs to improve its focus on quality improvement in the organisation as the panel considered that it has undertaken insufficient scrutiny and challenge of the
executive team to establish how well the Trust is delivering in this area. It was recognised that the Board has received limited performance information to enable it to obtain
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assurance on quality of care and treatment, but it has also not sought to effectively use all available information in the Trust to do so. This includes limited evidence of taking
on board fully the views of its patients and staff. The Chairman was not able to confirm that he was fully assured of the quality of services provided in the hospital – during his
interview he described being 60% assured and 40% reassured. Furthermore there appeared to be gaps in communication between the Chairman and Senior Independent
Director. The Senior Independent Director could not describe what was on the Chairman’s worry list.
From interviews, the panel considered that the Chief Executive’s approach to leading the organisation was overly operational and that the Chairman had not fully considered
the impact of this leadership style on the executive team’s ability to fulfil their functions. In interviews with the Non-Executive Directors, it appeared that not all felt they could
always effectively challenge at Board meetings because of a perception that the Chief Executive’s response would be unpredictable.
As a consequence of these issues the strategic approach to improving care is not adequate and the panel was not convinced that the Board has the capability currently to
fully address the cultural change required in the Trust. The Chairman should consider how the Board can address its overall leadership style urgently to drive quality
improvement within the organisation.
3. The Quality Strategy and performance management information needs significant improvement
Board members were not able to share a consistent view of what the Trust’s quality and safety priorities are because there is no single, cohesive quality strategy. Staff were
equally unable to state what their priorities for improvement were or the progress that was being made in achieving these. The Trust has a number of action plans relating to
quality and patient safety that must urgently be brought together into a quality strategy which can be effectively monitored at Board level. The recommendations of the Quality
Governance Follow Up Review 2012 and other high priority action plans need to be implemented and the role of the Clinical Audit and Patient Safety Committee and Mortality
Working Group clarified as part of the quality strategy.
The Board does not receive on a monthly basis a comprehensive quality dashboard including performance information relating to CQUIN and quality account objectives. This
would limit opportunities for the Board to address deviations in performance. Although the Trust has quality impact assessments of CIPs, these do not include selection of
quality indicators for monitoring improvement or deterioration in care quality. The Board is also not receiving adequate information on mortality, for example on SHMI or
escalated information from the Quality and Clinical Governance Committee, and therefore has insufficient focus on improving care in the relevant specialties.
The Board must urgently agree a management information dashboard to underpin the quality strategy, to provide a mechanism for the Board to hold directorates to account
for implementing improvements and to enable the Non Executive Directors to challenge the Board. Accountability for delivering patient quality needs to be embedded at
every level of the organisation and individuals need to be held to account for delivering improvements. This will require ward level dissemination of quality priorities and
monitoring arrangements so that all staff are clear on their role in delivery.
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4. There is a need to develop the organisational culture to remove tolerance of sub-optimal care and engage more effectively with staff at all levels to improve
quality and patient experience
The Trust needs to review how it can improve its organisational culture to focus more on quality and patient experience. The panel did consider that the staff that were
interviewed and observed were committed and loyal to the Trust and genuinely believed that they were providing good care, though they could not easily describe what good
looked like or how they knew that care compared well to other providers. The frequent external reviews of the Trust and what was seen as constant criticism from the media
is affecting the morale of staff. The Board should consider how it can listen more effectively to its staff to engage them further in its vision and improve the clinical leadership
from both nurses and medical staff to further enable this.
The panel observed acceptance of sub optimal standards of care across the organisation which the Trust needs to review and address, including:

The response to patient complaints has been slow, brief, lacking in compassion, candour and accountability and learning from the complaints appears limited.

Care bundle compliance was around 50% and although the Patient Safety Strategy includes an aspirational target of 75% (which the panel still considers to be
low), no evidence of urgent action to increase compliance was provided. Low compliance undermines the purpose of care bundles to improve consistency of
treatment and care.

There was evidence of an acceptance of bed moves for non-clinical reasons (for example, a patient will undergo four bed moves before an incident is reported
and investigated), poor discharge planning and other operational drivers overriding the ability of staff to provide good patient experience.

Poor quality mortality reviews and clinical audits with limited evidence of lessons learnt from when things went wrong.
5. There is a need to improve patient and public engagement
The Panel did not see clear evidence that the Board is listening to patients and families to improve the quality of patients’ experience. This is essential to set a cultural tone
for staff that is in line with the stated objectives of initiatives, such as Everyone Matters, and provide development to ensure staff are sensitive to patients needs and learn
from complaints. Immediate focus is needed on the following issues:

Improve timeliness of responding to complaints and articulate how complaints inform improvement.

Develop a patient and public engagement strategy in collaboration with stakeholders, including patients and staff.
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The following definitions are used for the rating of recommendations in this review:
Rating
Definition
Urgent
The Trust should take immediate action to respond to these recommendations and
ensure improvement in the quality of care
High
The Trust should develop a response and action plan for these recommendations to
ensure improvement in the quality of care
Medium
The Trust should implement these recommendations to ensure ongoing improvement
in the quality of care
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Governance and leadership
Overview
The two KLOEs in the area of governance and leadership were focused on the governance processes for assuring the quality of treatment and care. The panel sought to
address the effectiveness of governance and leadership through reviewing documentation supporting key governance processes and interviews with Board members and
senior staff, including Non-Executive Directors and Governors. We also spoke to staff in different settings and observed conditions in clinical areas to understand whether
there was effective Board to ward level communication on quality assurance.
Detailed findings
KLOE 1: Can the Trust clearly articulate its governance process for assuring the quality of treatment and care?
Good practice identified
A new Director of Nursing was appointed in October 2012, and two new deputies were recruited following his appointment. The Chairman, other directors and many clinical staff in multiple
areas recognise the positive impact which has been made by the Director of Nursing and his two deputies, including improved visibility in the organisation. At the focus group, nurses told
us that they are feeling more empowered and more able to challenge than they did in the past, for example on staffing levels. They feel that nursing now has a higher profile and is much
stronger in the organisation. Our interviews with the nurse leaders revealed a commitment to raising standards in the hospital.
The PATHway initiative (intentional rounding) was identified as good practice, introduced in May 2013, to ensure nurses on all wards are regularly assessing patients for pressure ulcer risk
and falls risk (performed hourly from 8am until 8pm, and then two-hourly overnight). All forms observed had been completed, but it was noted that staff interviewed were not fully aware of
its main aims, with a view that it is just another piece of paper to fill in. Other good practice examples were identified including improvements with patient flow management, patient and
public involvement, and improved safeguarding arrangements and care for dementia patients.
The Trust sought external support to review and improve its approach to Quality Governance in September 2011. A number of recommendations were made and developed into an action
plan by the Trust which was led by the Medical Director and Director of Nursing.
A further review in November 2012 identified that the Trust has made progress in a number of important areas for ensuring more effective monitoring and assurance of quality, particularly at
Divisional level. The report identified that the new Director of Nursing had provided fresh insight into where further refinements can be made, for example, in relation to Care Quality
Commission (CQC) compliance assurance.
The improvements were still in the process of being embedded and when compared to best practice there remained scope to deliver further improvements particularly in relation to reporting
and use of quality performance information for monitoring. The report further noted that the Quality and Clinical Governance Committee (QCGC) received information from the specialties
only after the three month red escalation rule had been triggered. The report made recommendations that will allow committee members to identify earlier deterioration in performance and
obtain assurance over specialty level performance on behalf of the Board.
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Good practice identified
There were examples of areas which seemed to be benefiting from good medical leadership. In particular, the Women’s Health Unit and trauma and orthopedics.
The Trust Board, including Executive and Non Executive Directors could describe the clinical governance committee structures and reporting to the Trust Board. A Non-Executive Director
confirmed that the Board had debated vacancy rates, healthcare associated infections, staff sickness, the GMC trainee survey responses and mortality figures. Board members were aware
that there was a Joint Health Economy mortality action plan.
The Trust Risk Register dated April 2013 identified five corporate risks rated as red, which the panel considered demonstrated appropriate focus on quality risks:

Failure to meet authorisation and requirements for CQC or Monitor

Failure to meet financial and contractual /demand targets including Cost Improvement Plan (CIP) delivery

SHMI being higher than expected

Failure to reduce healthcare-associated infections (HCAI)

Clinical Services become unsustainable due to operational pressures/staffing
The Trust informed us that they were submitting their annual statement of compliance with Monitor’s Quality Governance Framework.
Non-Executive Directors undertake ward-walkarounds and those interviewed could describe checking if handwash gels are full, checks observations charts and that the patients have had
their drugs, and asks patients if the nurses are attentive to their needs. Concerns had been raised with the Executive team following these including use of an escalation ward for day case
and in-patients and doctors doing ward rounds without nurses. The NEDs followed up to ensure appropriate action was taken to address this.
The Medical Director confirmed that he and the Director of Nursing were required to sign off a quality impact assessment of each CIP. There was also evidence of Board challenge of CIP
delivery at meetings.
Outstanding concerns including evidence
Priority – urgent,
high or medium
Planned improvements
Recommended action
Quality Governance Review
Report 2012 recommendations
The Board should review how it
can introduce more challenge to
the “assurance process” including
seeking independent corroboration
of statements on outcomes and
processes which are reported to
them.
Urgent
The Trust should continue to
High
Board assurance processes
Interviews with Board members identified that they did not appear to be obtaining the
necessary levels of assurance on quality. In an interview, the Chair acknowledged that he
was not fully assured. He described being only 60% assured and 40% reassured.
Furthermore there appeared to be gaps in communication between the Chairman and
Senior Independent Director. The Senior Independent Director could not describe what
was on the Chairman’s worry list. The panel was told that the Board has gained
assurance through numerous external reviews commissioned. However, it was not clear
how these had provided assurance and there is evidence of inadequate learning from
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Outstanding concerns including evidence
Planned improvements
these reviews (more detail on this is provided in the section on evidence of gaps in
learning from recommendations below). The Board also appears to also have received
limited performance information to enable it to do to effectively challenge on quality of
services (more detail on this is provided in clinical and operational effectiveness section).
Recommended action
Priority – urgent,
high or medium
implement the recommendations in
the Quality Governance Follow Up
Review Report 2012.
Review the development support
required for the Governors so they
can perform their assurance role
effectively.
In interviews with the Non Executive Directors it was revealed that not all felt that
challenge at Board could take place effectively as the response from the Chief Executive
to challenge was viewed as not always being positive or responsive. The Board also
appears to also have received limited performance information to enable it to effectively
challenge on quality of services (more detail on this is provided in clinical and operational
effectiveness section).
High
Governors who the panel spoke to appeared to be disengaged and have only limited
information about the Trust’s quality and safety priorities. One reported not receiving
training that had been requested a year earlier. Some Governors were unable to articulate
the Trust’s position in relation to adjusted mortality. This raised the question about how
informed they were about the major issues facing the Trust. Governors described that
they were not yet able to hold the Non-Executive Directors to account.
Quality strategy and priorities
Although the Trust has a quality strategy, it is lacking detail of the specific areas for
improvement and metrics to measure progress. The Trust submitted a Patient Safety
strategy. However, this was more in the form of an action plan, rather than a strategy, and
targets were not specific.
The Trust has a number of action plans in place. However, they do not appear to be
linked to an overarching quality strategy and the Board does not have a single, coherent
overview of the current quality of care in the Trust.
During interviews, not all Board members and senior managers could articulate the
organisation’s key quality and safety priorities in a consistent manner. Whilst they could
articulate the main challenges, including poor community care, capacity and bed
management issues, Board members did not always share a common understanding of
how clinical pathways operated within the Trust and consequently did not have an
accurate appreciation of the quality of care that patients receive. For example, they could
not describe the Trust’s approach to medical supervision of patients and junior medical
The Nursing Director indicated that
he had written a draft of a quality
strategy for nursing which was
fairly comprehensive, but as yet
unpublished.
The panel noted that the Trust had
refreshed a document called the
“Quality Governance Modus
Operandi” in 2013. It included an
action plan, clinical governance
reporting framework and a number
of key improvements.
Develop an updated, single,
High
cohesive quality strategy that takes
account of external reports,
mortality concerns, feedback from
patients and staff, clinical audit
recommendations, current
identified risks and current Trust
performance. As part of this, agree
quantifiable and measurable
improvements
Develop a single improvement plan High
relating to quality and outcomes as
set out in the quality strategy. Be
clear how any actions link to a
reduction in mortality and
improvement in quality.
18
Outstanding concerns including evidence
Priority – urgent,
high or medium
Planned improvements
Recommended action
None identified by the panel.
Review the Board's leadership
style and optimise the
effectiveness of this on
organisational culture and quality
improvement. This should include
enhancing the visibility and impact
of all Directors.
Refer to planned improvements
described under the findings for
KLOE 5: How is the Trust assured
that its mission statement and
values are achieved within its
clinical pathways
The Trust needs to review its out of Urgent
hours clinical cover to ensure there
is appropriate clinical leadership
and supervision. Input from the
Deanery should be sought where
necessary.
The Trust has an action plan in
response to the Deanery report.
The Trust needs to create a culture
of enhanced clinical leadership
amongst consultants.
High
Review the Deanery Action Plan
and ensure an effective monitoring
programme is put in place.
High
Review the approach to improving
Infection Control to address
effective medical engagement and
establish effective monitoring
mechanisms.
High
staffing and supervision at the week-ends.
Impact of Board leadership style on organisational culture
The panel observed that the Chief Executive was seen by staff and Board members
interviewed as being heavily involved in the day to day operations of the Trust, which was
seen to impact adversely on the ability of other Executive Directors to deliver their
functions. The panel considered that the Chairman had not fully considered the impact of
the Chief Executive’s leadership style on the executive team’s ability to fulfill their
functions.
Urgent
Feedback from the Governors was mixed. Staff interviewed highlighted limited visibility of
the Executive Board members. The Board needs to consider visibility in the organisation
to improve the overall leadership culture.
Evidence of a lack of impactful leadership from medical staff, especially out of
hours
On the unannounced visit, the panel was told that out of hours the wards on the Ladysmith
site rely on nurse practitioners to provide medical cover. The panel was shown lists of
jobs that had been referred to the medical teams and had not been completed. The list
included prescribing duties such as for warfarin, referring patients to the Liverpool Care
Pathway and assessing a patient for potential aspiration. This was also evidenced in the
nursing notes where entries had been made requesting a medical review and there had
been no corresponding entry in the medical notes to suggest that the review had been
made. Similarly, medical outliers on the trauma ward had not been reviewed on a daily
basis and requests for medical review had either taken too long to be performed or not
been done at all.
The most senior surgical doctor in the hospital was a Foundation Year 2 doctor. This
doctor described that the registrar was on-call at home. When asked about supervision,
the doctor described being supervised during the day, but not at night.
The Deanery recommended in their August 2012 report after their visit in May that
“handovers should be supervised by a Consultant”. The Trust response action plan
however recommends that MAU handovers in the morning require senior medical
presence (either a consultant or a middle grade) and in the evening handovers require a
19
Outstanding concerns including evidence
Planned improvements
Recommended action
Priority – urgent,
high or medium
senior nurse and a middle grade. It was not clear to the panel why the recommendations
had not been implemented.
Commitment of all clinicians to the Infection Prevention Committee was not evident. In the
Clinical Governance Accountability Committee minutes from 7/12/12 (page 5 item
320/2012) on the matter of the Infection Prevention Committee, it states “It was agreed
that medical membership needs to be reviewed. [Medical Director] to request clinical
attendance”.
Evidence of limited connectivity from the Board to ward level staff
The review panel identified clear gaps in Board to ward communication including
assurance of quality and safety. Evidence of this included:

Staff members interviewed at ward level could not provide a comprehensive
explanation of what the Trust’s quality and safety priorities are.

Several qualified staff at all grades on both the announced and unannounced visits
discussed the “6 C’s” and about providing good, safe care, but were not more specific.

Staff were unaware of common themes of incidents, for example the top three harms /
incidents reported at ward / division / Trust level.

Senior nursing staff interviewed could not articulate the Trust’s nursing strategy and
targets, for example, pressure ulcer reduction targets.

Staff could not describe the key performance indicators relevant to their areas of the
hospital, e.g. hand washing audit rates, stroke performance data, pressure ulcers and
infection rates at ward level.

It was noted that ward performance data on key indicators such as pressure ulcers
and falls was seen at the entrance to some wards but nursing and medical staff
interviewed on the wards were still unable to describe their performance.

Staff found it difficult to identify improvements following complaints or incident reports.

Despite management describing use of the 15 steps, awareness of staff at the
unannounced visit was poor.
Management mentioned
Accelerate the ward level and
improvements to address concerns senior leadership development,
with ward-level nursing leadership. including nurses and consultants.
Develop a clinical effectiveness
programme to improve the staff
knowledge of evidence based care
including infection control, clinical
audit, leading and managing
quality improvement change.
High
High
Enhance staff communication,
High
including ward performance and
audit results and incident reporting.
This maybe more effective through
better use of directorate and ward
level meetings and direct email
newsletters
The night staff in particular seem disconnected from the day-time hospital and it is
important that they are included in any strategy to improve communication.
Board visibility and engagement
Director and Non-Executive Director walk-arounds take place monthly, but Non-Executive
None identified by the panel.
Undertake a Safety Culture Audit
to inform a refreshed quality
strategy and improvement
High
20
Outstanding concerns including evidence
Planned improvements
Directors perform ward rounds on their own in an unstructured manner. Some staff
interviewed did know of the Board walkabouts and were aware of the Board, but generally
the panel noted limited awareness amongst staff on the wards of the incumbent directors
and the ward walk-arounds.
Staff in different settings referred to a monthly briefing session led by the Chief Executive,
but they did not feel they could ask questions in the sessions. The panel was also told
about apprehension amongst many other staff around speaking out and not really feeling
listened to. For example, recent Francis listening events were described as staff having to
do the listening, rather than their views being invited.
The panel considered that the Trust was reliant on external reviews, but does not have a
history of delivering improvements based on them.
Priority – urgent,
high or medium
programme.
Although staff described good visibility of the Director of Nursing and his deputies, there
appears to be less exposure of other executive directors. Front-line staff described being
unaware of what happened following ward walk-arounds as they did not receive feedback.
Evidence of gaps in learning from recommendations
Recommended action
The ECIST report had been
discussed with all A&E and
medical consultants.
The Invited Services Review of the Royal College of Physicians performed in 2008
includes recommendations which do not appear to have been implemented. “Medical staff
need to complete a short discharge proforma before any patient leaves the hospital” and
discharge summaries “at present are not being sent to the primary care teams with
sufficient urgency”. However, the discharge summaries are still being flagged as red on
the performance dashboard.
In an interview with the Director of
Nursing and a Non-Executive
Director, panel members were told
that the Board had been made
aware of the concerns of trainees,
these having been highlighted in
recent Deanery reports to the
Trust.
The Royal College of Physicians Invited Services Review in 2008 also produced
recommendations that “more senior time will need to be apportioned to the MAU and acute
care which should become less dependent on trainees”. A mortality review was
undertaken by Dr M Mohammed and Professor R J Lilford, Birmingham University, June
2012 that made recommendations regarding the monitoring of mortality related data e.g.
example run charts. Issues have been flagged in the Urgent & Emergency Care Intensive
Support Team (ECIST) review in April 2013, ”the acute physicians were not managing
acute medicine patients” and “we identified only one ward where a consultant-led ward
round was undertaken every day Monday to Friday.”
The Medial Director told the panel
members that an action plan had
previously been sent to the
Deanery to address their concerns.
It was not clear how this statement
fitted with the Deanery’s recent
letter of concern to the Trust.
Establish a systematic programme
for Board safety walkabouts, in line
with best practice.
High
As part of an effective approach to
staff engagement, agree a
programme of development and
listening events, such that there
can be effective cultural change
where staff, including trainees, feel
heard, valued and cared for.
High
The Trust should review how it is
responding to recommendations
from external reviews, ensuring
these are aligned with its overall
quality strategy and action plan.
High
Improvements in receiving and
acting on trainee feedback should
be implemented and its
effectiveness measured by the
Trust.
High
Management stated that the Trust
21
Outstanding concerns including evidence
Planned improvements
The panel was told that the Trust now puts on staff listening events and the Board believed
they are identifying feedback themes. However, in a letter sent to the Trust in April 2013
by the Dean of Postgraduate Medical Studies, it is clear that the Deanery outlined
concerns regarding the Trust not having adequate systems to address issues raised by
trainees. The letter states: “The Trust still does not hear about everything that is
concerning trainees. Further reflection on why this continues to be the case is a priority for
the Trust”. The panel therefore did not gain assurance that trainee concerns were being
captured.
has been working to improve the
timely delivery of discharge letters,
but acknowledge that 20% are still
not going out on time.
Outstanding concerns over the Quality Impact Assessments (QIA) for the latest
Cost Improvement Plan (CIP)
The panel noted that the Trust had sought an external review of its QIA process for CIPs.
The PwC Report “Review of FY 13/14 CIPs and scaling of further opportunities”, dated 22
April 2013, cites that 25% of CIPs had yet to have a QIA completed. Of these, 44% were
partially completed and were populated with insufficient detail. In an interview with the
panel to follow up on this, the Director of Finance described further progress that had been
made since the drafting of the report. In total 37 QIAs were provided for our review –
these had been signed off between 16 May and 31 May. Two separate QIA templates
were used, with one not requiring the Medical Director’s signature. In total, 21 had not
been signed by the Medical Director and two were missing signatures from both the
Medical Director and the Director of Nursing. A number were poorly populated and did not
contain indicators for monitoring quality.
Recommended action
Priority – urgent,
high or medium
All CIPs should have a quality
High
impact assessment which follows
the Trust’s process consistently but
also identifies key indicators to
allow ongoing monitoring post
implementation
The Trust should review its
arrangements to monitor CIPs post
implementation and provide
assurance to the Board on the
ongoing quality impact
High
Interviews with the Board indicated that there was not a shared understanding of how the
QIAs would provide assurance to the Board. The panel had some concerns that the
quality governance system may be insufficiently sensitive and agile to detect deterioration
in care quality particularly in relation to CIPs, as it is unclear how the QIA indicators are
being selected and monitored.
The quality impact assessments did not contain quality indicators for monitoring of either
an improvement or deterioration in care quality. A template exists to record a post-CIP
implementation quality review, though it is not clear from the policy if the business as usual
quality governance systems will be used to monitor the impact of the CIP or whether
reliance is being placed on the Finance Recovery Programme Governance.
22
Outstanding concerns including evidence
Clarity of responsibility and accountability for clinical outcomes
The panel noted that clinical governance responsibility at Board was a shared
responsibility between the Medical Director and Director of Nursing. However, it was
unclear who was accountable for the delivery of specific actions. An example of where
ambiguity was documented is in the Quality and Clinical Governance Committee minutes
of February 2013, where four agenda items had action points with the action lead being
named as both the Medical Director and the Director of Nursing. The panel could not see
who would be held accountable for delivery in this scenario. The Medical Director had
been identified as the lead for mortality and it was unclear to the panel why the mortality
reports and the mortality case review process were submitted to the CAPSEC committee,
which is chaired by the Director of Nursing, rather than a Board scrutiny committee chaired
by a Non Executive Director.
Planned improvements
Recommended action
Board level accountability for
specific aspects of quality and
clinical governance should
reviewed and made more explicit
Priority – urgent,
high or medium
Medium
KLOE 2: How does the Trust use information locally?
Good practice identified
The Medical Director described work being done to engage hospital consultants, local GPs and the Clinical Commissioning Group (CCG) to address key areas of risk for the Trust. The
Trust is engaging the local health economy to ensure that patients are in the right place, first time.
Senior nurse managers described working in partnership with care homes to try to reduce hospital admission of elderly and dying patients, but highlighted that training could be offered to
facilitate this. An integrated transfer team was set up October 2012 with Social Services. Management stated that communication with Social Services had improved, but staff had been
TUPE (Transfer of Undertakings (Protection of Employment))transferred and it was “not quite working” yet.
The Trust is also working with GPs to promote end of life care in the community as opposed to in hospital and the CCG is being engaged to find alternatives.
23
Priority – urgent,
high or medium
Outstanding concerns including evidence
Planned improvements
Recommended action
Impact of imbalances in the local health economy
Noted improvements in good practice
above.
It is important that the Trust performs and
Medium
communicates the results of robust analysis to
identify true external factors before attributing to
the “Shipman effect”.
From numerous interviews and discussions, there appears to be a commonly
held belief in Trust management that responsibility for excess mortality lies
with the wider health economy, in particular:

The “Shipman effect”, caused by a reluctance to allow very ill patients to
stay in the community

Poor community care

Deprivation and high prevalence of multiple co-morbidities
Compared to surrounding areas, Tameside has the lowest community death
rates. The community death rates are lower than those in the Stockport area
which would be the other Trust potentially affected by the “Shipman effect”.
This provides some support to the theory that more patients come into
hospital to die in Tameside. As mentioned above, work is underway to
engage GP’s and care homes to reduce end of life care in the hospital.
However, there is a risk that the emphasis on the “Shipman effect” and other
external factors could reduce focus on improvements within the Trust that may
also reduce excess mortality.
There is also local GP involvement in
the mortality review panel and the
CCG has commissioned at a level
sufficient to enable the Trust to invest
in additional nursing and medical staff.
There is regular engagement with the
Medical Director, so it is hoped that
care in the community can be
addressed.
A whole health economy approach to
performance improvement is to be continued
and emphasised, but should include all
stakeholders, including community and social
services provision.
The Trust should work with local GPs and the
CCGs to ensure good practice is followed when
referring patients to hospital. Similarly,
adequate facilities need to exist to support early
discharge into the community with adequate
medical follow up to prevent unplanned
admissions.
24
Clinical and operational effectiveness
Overview
The panel explored one Key Line of Enquiry for clinical and operational effectiveness, covering the processes the Trust uses to monitor and address clinical and operational
performance data. As for our review of other aspects of governance and leadership, we used a combination of documentation and data review, interviews and observations to
review the effectiveness of these arrangements.
Detailed findings
KLOE 3: What governance arrangements does the Trust have to monitor and address clinical and operational performance data at a senior level?
Good practice identified
Management told the panel that the Trust has used mortality data to focus improvements in care, for example care bundles have been introduced, staff cover increased in A&E
and MAU, nurse to bed ratios increased and work done to improve clinical documentation.
An example of a new care bundle being used was on the Trauma Unit, which is using a new fractured neck of femur care bundle/enhanced recovery pathway.
A&E staff told the panel that they had identified their optimum staffing levels of 13 qualified staff during a day shift and the new Director of Nursing had agreed this. They now
worked to this level, although not all staff were contracted. Some were regular bank staff and would be until ongoing recruitment was completed. The new e-rostering team (see
section on Workforce and safety) acknowledged the current staffing gaps in A&E and MAU, but stated that they were improving. The panel’s review of the Trust’s staffing and
medical cover is documented in Workforce and safety.
On the wards, we observed that a new integrated prescription chart has been introduced (Medicines Prescription and Administration Record), which appears to be well designed,
covering venous thromboembolism (VTE) prophylaxis, antibiotics, anticoagulant prophylaxis, IV fluids and oxygen. However, the panel noted that the observation charts are
poorly designed in that it is unclear which actions need to be taken based on the early warning score. There is also duplication within the charts.
25
Priority – urgent,
high or medium
Outstanding concerns including evidence
Planned improvements
Recommended action
Governance arrangements for monitoring mortality indicators
None identified by the panel.
Review the governance of mortality High
improvement to bring rigour and
pace to a comprehensive and
coherent programme of work
ensuring multi-professional
specialty input to the review of all
deaths and to take account of
previous review recommendations.
SHMI is not included in the Board performance dashboard and from a review of other
meeting minutes does not appear to be discussed at key performance meetings. According
to the Mortality Reduction Hospital Action Plan, no clinical lead has yet been assigned to
investigate SHMI.
Although it was noted that there is a health economy group looking at how to address the
SHMI, management acknowledged that the drivers of the SHMI are not well understood at
the Trust and are unclear what the best actions are to address it.
Ensure that there are clear lead
responsibilities in particular with
regard to any joint health economy
strategies and actions. As part of
this work the Trust needs to pay
greater attention to the SHMI and
ensure that it fully understands the
issues which are driving higher
than expected mortality.
The Medical Director explained that mortality is monitored in several ways, but principally
that there is a random choice of 8 – 10 patient deaths per week whose case notes are
reviewed by a pediatrician. The process therefore could miss about 6 deaths per week.
The pediatrician writes a report and where a case is identified with improvements required, it
is referred to a Mortality Review Panel. This process appears to rely on one individual’s
judgement and has no external scrutiny, as the panel considered that the summaries
provided to the CAPSEC did provide enough depth to provide a useful learning exercise and
enable scrutiny. For example, if a patient died from sepsis a reviewer would want to know
when blood cultures were taken, when antibiotics were administered, whether the correct
antibiotics were used, whether an arterial blood gas sample was taken and from this,
whether it was possible to identify any emergent themes from poor practice.
A number of senior clinicians set up their own Mortality Working Group, and wrote a
separate report outside of clinical governance committee processes, which is unusual. This
group supplied an undated narrative commentary to the Medical Director, who submitted the
comments to the Clinical Audit and Patient Safety Committee (CAPSEC) in April 2013. The
minutes show that the Medical Director is to ask the Mortality Working Group to consider
making a formal action plan. It is not clear how this will fit with the overall Trust strategy,
and to which action plan the clinicians would then be working. On balance, it was not clear
who was providing clinical leadership on this issue.
Evidence of inadequate progress in addressing mortality issues
The current joint health economy mortality action plan is non-specific and does not always
The action plan makes a number of
recommendations on issues which
we identified at ward level: targeting
Review the governance of mortality High
improvement to bring rigour and
pace to a comprehensive and
26
Outstanding concerns including evidence
Planned improvements
Recommended action
identify the impact of an action or the responsible lead. It does not include all possible
stakeholders and instead focuses on the Trust and CCGs. Accountability for delivery and
where this sits was not clear to the Panel.
senior cover to peak admission
times, patients needing to be seen
within 24 hours by a senior clinician
(but preferably within 4 hours) and a
medical-led service out of hours.
coherent programme of work such
that mortality reviews are of
adequate depth to produce
recommendations. Ensure that
there are clear lead responsibilities
in particular with regard to any joint
health economy strategies and
actions.
The Trust’s own hospital mortality action plan is clearer and seems to now be considering
the specifics around adjusted mortality risks. The hospital mortality action plan (“Mortality
Reduction Hospital Action Plan”) refers to nine care bundles which have recently been
introduced, but refers to compliance as being “better, but variable” which does not provide
assurance on compliance.
The Health Economy Action plan is
to be revised and updated for
2013/14.
See also recommendations above
in relation to whole health economy
working.
The plan seems to address issues such as lack of understanding of SHMI, but it is unclear
what progress is being made by the hospital.
According to the Mortality Review Group paper presented to the Clinical Audit and Patient
Safety Committee (CAPSEC) in April, Critical Care capacity has been reviewed, but action is
not being taken given uncertainty over the potential impact of moving emergency surgery to
partner hospitals.
Limitations in performance monitoring
The approach to quality and safety performance reporting is fragmented and could be better
integrated. Board papers recognise general themes, but lack SMART objectives on which to
judge performance. A Non-Executive Director interviewed could not articulate the measures
being used to monitor progress on the quality strategy.
Commissioning for Quality and Innovation (CQUIN) targets are being used to address four
sources of harm (pressure ulcers, VTE, falls and UTI), but these are not currently reported to
monthly Board meetings.
The North West Care (NWC) Indicators, which summarise audit information collected by
nurses at ward level, showed unexpectedly high performance (all rated “green”) in February
in the paper presented to the Board in March. The indicators cover areas such as infection
control, but the panel were made aware of poor performance in March and April, with high
numbers of Clostridium difficile cases being experienced. By the time the panel were on-site
for the unannounced visit at the beginning of June, 10 cases had been experienced in the
Priority – urgent,
high or medium
The Trust needs to satisfy itself
that measurable progress is being
made with effective, transparent
monitoring which affords
accountability to the public.
None noted by the panel.
Review performance management
reporting to the Board to make it
more responsive and
comprehensive to achieve best
practice standards.
High
Assess performance against the
upper quartile of national care.
High
Address the recommendations of
the Quality Governance report as
previously stated.
High
27
Outstanding concerns including evidence
Priority – urgent,
high or medium
Planned improvements
Recommended action
None noted by the panel.
High
The Trust should review its
approach to mortality reviews to
ensure they are appropriately
robust. In addition, the Trust
should consider external scrutiny to
care audits and mortality reviews.
year-to-date (vs. a target of no more than 31 for the year).
Observations during ward visits which included random notes audits showed other areas
that were inconsistent with the currently reported “green” rating on NWC indicators. This
included gaps in patient assessments, observation completion, actions taken and responses
to treatment. Other gaps were in relation to infection prevention and control care and
management. This raised questions over the relevance and usefulness of the information.
At the unannounced visit, 8 out of 14 sets of notes viewed did not have the basic patient
details on each chart. 5 out of 10 did not record appropriate monitoring of fluid input and
output, even in a patient who had undergone transfusion. There were also gaps with regard
to nutritional assessments and plans, weighing of patients and monitoring of stools.
However, all patients had received their twice daily observations and appropriate escalation
had taken place in the case of elevated scores. Apart from a DNAR form that appeared to
be missing, the panel noted generally good practice on ward 45 (the stroke unit).
CAPSEC receives “verbal reports” from specialty governance reports. There was no clear
process demonstrated as to how quality issues identified at the Board and sub-committee
levels are transmitted to and owned by the Specialty Governance Groups to make them
responsible and thereby accountable. The Quality Governance Follow-up Review Report
November 2012 identified a number of these issues. “The QCGC receives minutes from the
CGAC which are verbally presented by the Medical Director. In addition, three members of
the CGAC (the Medical Director, Director of Nursing and the Chief Pharmacist) sit on the
QCGC. However, as a subcommittee to the Board, it is essential that the Non Executive
members of the QCGC can obtain assurance over Specialty level quality governance from
the CGAC. Currently, based on the verbal report given it would be difficult for the subcommittee members to challenge under-performance in a specific Division.”
Poor quality of mortality reviews
Mortality reviews and clinical audits reviewed by the panel were weak. Audits submitted to
CAPSEC, produced by clinicians in response to alerts about high mortality rates in acute
myocardial infarction and acute cerebrovascular disease, are of poor quality. The audits are
of insufficient detail and too superficial to identify the causative factors and produce
recommendations that would reduce the unexpectedly high death rates in these patient
groups.
The Board should satisfy itself that
the approach to clinical audit and
Medium
28
Outstanding concerns including evidence
Planned improvements
Recommended action
Priority – urgent,
high or medium
effectiveness meets an acceptable
standard of practice.
The stroke audit performed following the Dr. Foster mortality alert for stroke patients
between February 2011 and January 2012 identified poor compliance with national
monitoring guidelines with some standards only being achieved in 40% of patients. These
low rates were accepted as being adequate when reported to the relevant committee.
Specifically, it identified significant deficiencies in monitoring and nutrition, but concluded
that “no substandard care that would have made a difference to the outcome was identified
on medical review.”
The cases selected for review by CAPSEC were studied in insufficient detail to provide a
useful learning exercise and promote discussion. For example, in cases of sepsis little
consideration had been given to the application of the care bundle and the
recommendations of the surviving sepsis campaign.
Acceptance of substandard or variable practice, and a paucity of high aspirations for
excellence
The panel identified evidence that substandard or variable practice is frequently accepted in
the Trust. The culture appeared to be one of managing to targets rather than ensuring
overall quality and patient experience.
The Mortality Reduction Hospital Action Plan for May 2013 includes the implementation of
nine key care bundles expected to reduce death rates. An update on progress described
“better but variable compliance, particularly in MAU” and when asked, the Medical Director
estimated compliance with care bundles only at around 50%, but 60% in A&E based on spot
checks. The Panel noted meeting minutes stating that care bundle compliance would be
measured only once compliance had improved. The Patient Safety Strategy includes an
aspirational target of 75% which the panel still considers to be low and there are no clear
timeframes or milestones.
The aspiration for managing the right patient, right bed policy is set at a target of only 75%–
80%, and there is an allowance of four bed moves for non-clinical reasons before an
incident and root cause analysis (RCA) is triggered. It was not considered to be unusual
practice to ensure that the four-hour target was met for surgical patients to be transferred to
MAU even though this added an unnecessary non clinical move to their journey. This
None noted
The Board should satisfy
themselves that there are effective
mitigation plans in place to ensure
a safe and dignified patient
experience.
Urgent
In order to regain the confidence of High
the local community, and so that all
internal and external stakeholders
believe in the “Everyone Matters”
campaign the Board needs to
revise its approach to creating a
culture of excellence. There needs
to be a clear alignment between
the Boards strategy and its
operational practice for example
the Panel would expect to see:

Compliance rate targets for
the application of clinical care
29
Outstanding concerns including evidence
practice was highlighted in the Deanery, May 2012, which stated that "all trainees said that
there were surgical patients being admitted to MAU to avoid the 4 hour wait target" and that
they were "not always informed that patients had been transferred to MAU".
Staffing levels in acute medical wards were found to be at 1 registered nurse to 10 beds
during the day and 1 registered nurse to 15 beds at night. This is potentially resulting in a
poor experience of care for patients as the staff had to create work arounds to prevent falls.
This included patients being cared for at the central nurses station or remain in their bed
side chairs until there is sufficient nursing time available to assist them to bed. It was noted
that it is common practice for the nursing charts, including the intentional rounding charts, to
be gathered at the central nurses’ station overnight. This would not meet CQC’s standards
and increases the risk of suboptimal care being delivered. Staff shared that they could not
always provide basic care at all times because of capacity issues.
Planned improvements
Recommended action


Priority – urgent,
high or medium
bundles should be set at 90%
to encourage excellence.
There needs to be a lower
tolerance for moving patients
and for medical outliers.
Out of hours clinical cover
needs to be led by senior
doctors rather than by nurse
practitioners.
The panel also talked to staff on wards who understood targets for infection control but did
not seem to relate them to the effect on patients, accepting that a few cases were allowable.
Other findings
It was noted from the data pack that the percentage of deaths with a palliative care coding increased significantly over the past financial year. The Trust provided an audit
report from an external party which did not raise any concerns regarding the depth of coding or the accuracy of coding per the national PbR and local clinical coding audit
standards, but coding was not investigated further by the panel.
30
Patient experience
Overview
The panel focused on how the Trust responds to patient and family feedback and reviewed the effectiveness of the Trust in delivering an appropriate patient experience
through its clinical pathways. According to its website, “the Trust's mission statement is to gain and retain the status of Hospital of Choice for local people. Dignity, Respect,
Trust and Partnership are the themes which underpin our mission and values.” The panel sought to understand whether the values are being achieved through discussions
with patients and staff on wards and at the focus groups and listening events.
Detailed findings
KLOE 4: How does the Trust engage with stakeholders?
Good practice identified
The panel heard from several patients who were very satisfied with the level of care at the Trust. Patient satisfaction with the care provided in the surgical wards in the new
building was one theme that emerged. Staff from a surgical ward that we spoke to said that they would not mind their family or friends being treated at the Trust. A staff nurse on
a medical ward also said she would have her family and friends treated on that ward.
Through observations, the panel noted instances of high patient satisfaction on some wards, including on ward 45 (in relation to nursing staff, physiotherapy and food) and ward 5
(in relation to nursing care, and the answering of the buzzer very quickly). Patients interviewed on wards 5, 40, 43 and 45 described nursing staff as hard-working.
Staff the panel met were very kind, approachable, hard-working and open and described wanting to do what is best for patients and their local hospital.
In interviews, including with the Chairman, a Non-Executive Director, the Medical Director, and Deputy Director of Quality and Governance, it was acknowledged that
improvements are needed to the Trust’s complaints process. The Medical Director reported that the 25 days response to complaints has already improved from 40% to 75%.
31
Outstanding concerns including evidence
Responding to concerns and complaints
The public event was well attended and a consistent theme from patient stories was communication
following incidents and the complaints process, including slow, cold, brief responses and a lack of
candour and accountability. The public attending felt that their complaints are not dealt with seriously
or that there is no appreciation of how much patients and their relatives have been affected by poor
quality care. The public considered that the Trust responses lacked compassion and often down
played the seriousness and personal impact of the incident which has made it difficult for families to
gain closure. Whilst some of the stories were some years old, the themes remained contemporary
and a Non-Executive Director confirmed that the complaints process “could be improved”, “possibly
not all responses are transparent” and “responses can seem standard”.
Planned
improvements
The new Deputy Director
of Nursing responsible for
complaints had only been
in post for around seven
weeks, but highlighted
improvements he plans to
make to the complaints
process and to evidence
greater learning and
improvement.
The public also told the Panel of feedback on nursing staff who they considered were brusque when
complaints were made about important issues relating to their treatment. On the ward visits the Panel
learnt that the ward managers were seen to ‘deal’ with complaints and staff were not able to describe
any learning or changes to practice that had occurred as a result.
Recommended action
Priority – urgent,
high or lower
Review the complaints management Urgent
process so that the ethos to reflect
the Everyone Matters espoused
principles so that public expectations
and the required duty of candour and
standards are met.
The impact of changes to the
complaints process will need to be
evidenced so that the Trust Board
can be assured that full and proper
learning takes place.
Respond to more complaints face to
face.
The Panel did not see clear evidence despites the programme of work that the Board is “hearing the
voices of patients and families” to improve the quality of patients experience and setting a strategy to
improve the cultural tone in line with the stated objectives of initiatives such as Everyone Matters.
Staff will require development support to enable them to engage with patients on their treatment and
care needs effectively.
Communication with patients and families
The panel heard numerous stories from the public highlighting instances where staff have not
responded to immediate family or patient concerns or provided inadequate information. A number of
recent examples were shared with the Panel including not being listened to, even where they held
critical technical information directly relevant to their care or being kept informed of progress. Care
was not always felt to be safe for example where a patient had been given penicillin, despite telling
staff that they were allergic to this drug or caring for example being left with inadequate bed clothes
and family members having to provide essential hygiene following episode of faecal incontinence.
None noted.
The Trust needs to provide further
development for its staff on
responding to patients’ and carers’
concerns.
High
Review and improve the
administration of outpatient
appointments ensure patient
involvement in the redesign.
High
Patients and members of the public spoke about the distress particularly for the older members of the
public about the erratic issuing of outpatient appointments and of receiving a Did Not Attend letter
before receiving an appointment letter.
32
Outstanding concerns including evidence
Planned
improvements
Recommended action
Priority – urgent,
high or lower
The Trust has recently introduced the ‘Friends and Family Test’ in April 2013. It was widely
advertised on each ward visited, but no meaningful feedback has yet been received as it is too
recent.
KLOE 5: How is the Trust assured that its mission statement and values are achieved within its clinical pathways?
Good practice identified
Generally, good practice was found to be implemented in the surgical pathways, which seems to be achieving good outcomes. This was evidenced through observations and interviews
with patients both on the wards and at the public listening event. We heard at the listening event that the “surgical wards are good, but the medical wards are struggling”.
Areas of good practice observed include (on the elective orthopedics and elective surgery wards): use of enhanced recovery, meticulously clean wards, strict antibiotic prescribing and
venous thromboembolism (VTE) prophylaxis for all patients. On the elective orthopedics ward, the panel also observed a dedicated consultant-led trauma list, well-managed orthopedic
pathway (the pre-op, post-op, intermediate care and rehabilitation pathways were clear), pro-active bed management, a fully populated ward board (all patients had VTE prophylaxis and
antibiotics recorded) and good rapport with allied specialties (physiotherapy and occupational therapy). The consultant-led trauma service has had a positive impact on the elective service.
A member of theatre staff confirmed the use of the World Health Organisation (WHO) surgical check-list protocol in theatres, as well as timeout before and after surgical procedures. There
is also a daily emergency surgery list. Surgical mortality is discussed at CEPOD meetings.
There was some evidence of good practice for stroke pathway patients. Multiple therapists review patients within the 24 and 72 hour time frames and note keeping made by the therapists
and nursing staff was of a high standard. It was clear to panel members that on the two visits made to ward 45, the nursing staff were highly dedicated, caring and professional. On stroke
ward 5, other points of good practice noted include close working with the stroke association which provides information packs and discharge plans, having outreach from the community
stroke team and use of the MOOD screen which is done on all patients.
The panel was given the impression that chronic obstructive pulmonary disease (COPD) (in particular asbestos-related lung disease) is common in Tameside, with a large pool of patients
having repeated admissions because of it. The respiratory department has introduced non-invasive ventilator support for such patients.
Despite the Trust’s challenges with capacity and bed management, the Deputy Director of Nursing and Patient Experience described some good practice and recent improvements in bed
management. There are three bed meetings per day (the panel attended one of these meetings, which was well-attended and well-managed), fit for transfer meetings now receive greater
challenge and scrutiny, patient movements are documented and reported to the executive group and there is a monthly Strategy Group. Bed managers are more aware and patient
experience is a priority for the executive group. The panel observed good predictor tools for assessing bed availability.
In general, the hospital estate was in reasonable condition and the wards and A&E department were tidy, clean and organised.
33
Good practice identified
At the unannounced visit, staff explained that there was easy access to CT scanning at night. If an urgent MRI was needed, it could be obtained at Salford.
Priority – urgent,
high or medium
Outstanding concerns including evidence
Planned improvements
Recommended action
Failure to deliver a high quality patient experience through the emergency
and acute medical pathway
The Trust accepts that its surgical footprint is not
large enough to support complex and emergency
surgery. Management described an option being
investigated to transfer emergency and complex
elective surgeries to partner hospitals, to ensure
on-going safe and effective clinical services.
The Board should assure itself that
no patients are at immediate risk of
unsafe in the acute medical
pathway care including ensuring
appropriate clinical cover and
improving the management of
escalation areas and bed
management protocols
immediately.
Urgent
Agree a plan of action for
improving the acute medical
pathway in line with the
recommendations from the reports
already commissioned by the
Board.
High
The Trust appears to be struggling to cope with a rising non-elective demand,
which is contributing significantly to the clinical risks facing the Trust. Patients
also told the Panel of long waits in waiting rooms and on trolleys, a lack of
attentiveness, lack of monitoring and observations whilst on trolleys and of
some staff not showing basic compassion and that “consultants talk down to
you”.
This is subject to regulatory review and no
formal agreement has been signed with
competing local Trusts for the distribution of
Patients are potentially subject to a high numbers of patient transfers between
elective day case work. There are no guarantees
wards, frequent escalation into sub-optimal areas such as the Women’s Health that the Trust will receive this extra work – it is
Unit, Gynaecology Day Unit and Endoscopy Unit, as well as non-specialty areas dependent on patient choice, GP referrals and
such as Trauma. Staff told the panel that patients are frequently held on
responses from other Trusts. The timeframe for
trolleys in the Endoscopy Unit and the Gynecology Day Unit when escalation is reconfiguration was suggested by the Finance
required as a result of an overload of admissions. At a visit to the MAU it was
Director as October 2014.
confirmed that moving patients to the ward is often delayed and patients are
often moved to an inappropriate specialty or to escalation beds, for example the The Trust is looking at swapping wards 39 and
Endoscopy Unit. This was reported as often taking place after 10pm.
31 – trauma and cardiology –so as to free up
beds and so that cardiology will be next to the
The Endoscopy Unit offers a poor patient experience as it is not designed as a
critical care unit (CCU). The panel was told by
medical ward in terms of privacy, washing and toilet facilities. Patients due to
staff that a paper has been written on this
have elective endoscopic procedures are at risk of having their treatment
proposal.
delayed or postponed because of the medical outliers blocking beds. Whilst the
Endoscopy Unit is actually a recovery area with high levels of monitoring
Following the panel’s announced visit,
management indicated that the Standard
equipment, the panel were told this would not be used to monitor the medical
Operating Procedure had been strengthened in
outliers and the nursing staff who looked after the escalation beds were
response to feedback from the panel regarding
unfamiliar with the endoscopy environment and would bring in equipment and
staffing of the endoscopy area and that the
documentation packs from other areas of the hospital for these patients.
34
Outstanding concerns including evidence
The Panel observed that patients who are moved into the Women’s Health Unit
(WHU) are not subject to the same escalation risk assessment, the Panel noted
that one patient in the WHU had been there for her fourth night over the weekend. The Panel also noted that the WHU was being managed by a nurse who
described herself as an agency nurse. The panel’s understanding was that this
was violation of the Trust’s policy. In the panel’s view, this would lead to
inadequate staff familiarity of the escalation area.
Planned improvements
Recommended action
requirement for risk assessment of patients had
been reinforced.
Priority – urgent,
high or medium
A risk assessment needs to be
done for all patients who are not in
The Trust is considering trying to create a Clinical the appropriate specialty, including
Decision Unit to improve patient flow in A&E.
in all escalation areas, and
appropriate monitoring
arrangements need to be in place.
Urgent
The Board should assure itself that
no patients are at immediate risk of
unsafe care and improve the
management of deteriorating
patient protocols and practice
immediately.
Urgent
The number of critical care beds
required should be benchmarked
against population (currently
~3.5/100,000 average UK) and
used to inform a mid to long term
plan.
High
There was insufficient or locum-based medical cover out of hours and
weekends and poor documentation of handover between teams. A junior doctor
raised concerns with the panel that bed managers are not always complying
with the written policy to require appropriate medical sign-off of moves which
puts patients at risk. Concerns were also raised over compliance with the
discharge policy.
The current approach to managing the emergency and acute medical pathway
is placing patients at risk the Panel observed that a patient had been admitted
to a six-bedded bay in MAU with suspected Clostridium difficile, which was a
breach of the Trust’s own policy and placed the remaining five patients at risk.
Management of deteriorating patients and adequacy of critical care
facilities
The Panel observed during their unannounced visit that the management of the
deteriorating patient is sub optimal due to the out of hours medical management
is mostly delegated to junior medical staff and a critical care outreach nurse.
Patients are transferred back to MAU when escalation of care is required as
there may not be sufficient critical care beds in the Trust to cater for the demand
which would mean that seriously ill patients could be managed on the ward
inappropriately. This is contrary to a recommendation made in an Invited
Service Review by the Royal College of Physicians. It was not clear whether the
inadequacy of critical care beds alters decision-making regarding escalation of
care for some patients, but the perception that this could happen is real. The
Panel were provided with data that stated that 19 patients were transferred out
because of capacity issues (not for clinical reasons) to other Trusts and 32
patients were cared for in recovery as a result of a lack of critical care beds
The Trust stated that there had been a review,
but does not believe that any action is required.
35
Outstanding concerns including evidence
Planned improvements
Recommended action

There needs to be an urgent
process and pathway design
session with all consultants
involved with the acute medical
pathway. The solutions may need
changes in the organisational
model of departments /
directorates.
Priority – urgent,
high or medium
between April 2012 and April 2013, with an average length of stay of 6 hours 45
minutes.
Concerns have also been raised by the consultant body that there are not
enough High Dependency Unit beds for general surgical patients but no
improvements had been made.
Inadequate medical supervision and junior medical staff supervision and
cover, and other instances of poor management of the emergency
pathway
The need to address supervision of junior medical staff is a longstanding issue
and is well known to the executive team. There has been a long standing
vacancy for additional medical consultant cover. The Royal College of
Physicians 2008 review stated that on MAU “two consultant ward rounds must
take place every day including weekends”. However, the ECIST report stated
that “over the weekends we understand that the on-call consultant sees new
patients only”. A junior doctor and middle grade in general medicine both
described the A&E and MAU as being overworked and this affected the middle
grade doctor’s ability to manage on-call. A consultant physician described the
medical supervision of patients in the MAU as independent of specialty.

An Incident Investigation Report dated February 2013 highlights inadequate and
infrequent consultant review of patients, inadequate cover for consultants on
leave, inadequate registrar cover, junior medical staff caring for patients
unsupported by senior colleague review for many days, and dysfunctional ward 
rounds with junior doctors rounding without nursing staff.
From the panel’s observations, there appears to have been little progress with
acting on previous reports findings. Consultant cover appears to be poorly
managed including on two separate medical wards (a general medicine and a
respiratory ward) where the panel noted three consultant ward rounds on the
same three days, and no full ward rounds on other days. There is a significant
reduction of medical cover over the weekend. A consultant ward round on a
Saturday and Sunday has been introduced, but is not part of the formal job
plan.
The Medical Director recognised the need to
improve the interface between MAU and
A&E and to improve pathways between
surgical, orthopaedics and A&E, including
recruiting more MAU physicians, defining
responsibilities of consultants, establishing
roles and leadership, pathways, quality and
governance. He indicated that this was
agreed by the Board.
He referred to actions resulting from the
ECIST report, and four meetings that have
already taken place between A&E and
medicine, which has improved working
together with nurses. Some nursing staff told
the panel that better engagement with
medical staff is being driven by the Medical
Director, but this message was not heard
consistently.
The Medical Director acknowledged that
consultants need to do ward rounds on a
daily basis, and is working on job plans to
increase 3 and 4 ward rounds up to 5 in a
week and also to make training mandatory
per job rotas. He explained that the Trust
needed to recruit two more physicians in
MAU (1 replacement currently filled by a
locum and 1 newly created post), two in A&E
(both of which are established posts
currently filled by locums) and two in elderly
medicine, reflecting the conversion of current
Urgent
High
The leadership responsibilities of
consultants on MAU need to be
clearer.
High
All acute patients need to receive
daily ward round review by senior
medical staff.
High
The Trust needs to create a culture
of enhanced clinical leadership
amongst consultants.
36
Outstanding concerns including evidence
Planned improvements
Management informed the panel that board rounds are performed by
consultants on the remaining weekdays. However, the panel considered that
full ward rounds should take place daily.

It was noted from comments made to the panel that “there is lack of acute
medical leadership at this hospital” and that the structure is “disjointed”,
specifically, that there are three consultants covering the MAU, but each has
another specialty in which they are based. Consultant cover being located in
A&E could help prevent inappropriate admissions to MAU.

Other feedback from junior doctors on senior support was mixed. Ease of
access to consultants and registrars even out of hours was reported to be good
(excluding in medicine), others considered that support whilst on call is poor,
that the middle grade is too busy and that junior trainees have to take decisions.
It was reported that the consultant (who does a ward round everyday) is
available for help all the time and “very dedicated”.
At the unannounced visit, the most senior surgical doctor in the hospital was a
Foundation Year 2 doctor. This doctor described that her registrar was on-call
at home. When asked about supervision, this doctor described being
supervised during the day but not at night.
Recommended action
Priority – urgent,
high or medium
enhanced payments into new posts.
The Trust confirmed that they are in the
process of recruiting two additional
substantive acute physicians to the MAU.
One position will be a Director of Urgent
Care, who will address interface issues
between the Emergency Department and
MAU in addition to formulating enhanced
pathways of care.
When questioned around the difference
between mortality on weekdays and at
week-ends, the Medical Director stated that
he is in the process of writing a paper to
address middle grade out of hours service
(there is a plan to increase the rota from 10
to 12). He stated that there is an additional
consultant in adult medicine at the weekends who supervises discharges with midgrades or SHOs and that pharmacy hours
have been extended.
A Respiratory physician job plan showed only 2PAs out of 12.5PAs devoted to
ward rounds. A consultant physician described to the panel his likelihood of
attendance out of hours as low yet the job plan has 2PAs for this activity.
It is hospital policy not to directly admit patients from A&E to the surgical wards
without prior surgical review. There is no resident surgical SpR out of hours so
the FY2 is responsible for reviewing patients. The FY2 on site out of hours had
to assess a patient on MAU (who had already waited for nearly four hours in
A&E) before the patient was transferred to a surgical ward. The panel noted
other examples of where this policy was affecting admission and discharge
processes for the patients observed on the unannounced visit.
Sign-off of “Do Not Resuscitate” (DNAR) forms
On ward 45 and the MAU, the panel saw DNAR forms which did not contain the
None noted
The Board needs to assure its self Medium
that patient’s choice and dignity is
respected at the end of life and that
37
Outstanding concerns including evidence
consultant’s name or sign-off. The Trust’s policy, as described by a staff
member, is that the DNAR decision has to be made by a consultant or his/her
representative at the hospital when the consultant is not present. That
representative cannot be below the rank of “SHO”, but juniors can complete the
form. During the unannounced visit, one of the forms examined was signed off
by an FY2, one by a CT1 and one by SpR. None of them had a consultant
signature.
Planned improvements
Recommended action
Priority – urgent,
high or medium
vulnerable people are
safeguarded.
The panel would see that this
action goes beyond a simple audit,
and the plan to improve DNAR
documentation needs to reflect
creating an ethos that places
listening to patients at the centre of
care.
38
Workforce and safety
Overview
The three KLOEs on workforce and safety focused on:

The Trust’s workforce strategy

Assurance that the Board has the necessary workforce deployed to deliver its quality objectives

Assurance that the organisation is safe
Detailed findings
KLOEs 6 and 7: In the context of this review, can the Trust describe its workforce strategy? How is the Board assured that it has the necessary workforce deployed to deliver
its quality objectives?
Good practice identified
A new electronic system for rostering (e-rostering) has recently been introduced – only the theatres had yet to be put on the system. The e-rostering team explained that it allows fairer
allocation to rotas, each ward can tailor the skill mix needed and it ensures that there is always one senior and one junior nurse on duty. Mandatory training is built in automatically. Staff can
see their own rota and when training is planned. It helps flag gaps in staffing, thereby aiding recruitment. Twelve hour shifts have also recently been implemented.
Surgery staff commented positively on the implementation of e-rostering and 12 hour shifts, saying that it is better for patients as it provides better continuity of care. However, medical staff
argued that one size does not fit all and that the subject needs further thinking through. Some staff were concerned that the change has been purely finance-driven.
From what staff have told us, there appears to be a good induction programme, supported by the Director of Nursing. A nurse on ward 45 described good mandatory training / induction, good
professional development and funding and good communication with medical staff.
In response to negative comments from the Deanery report for junior doctors, the Medical Director stated that action plans had been developed and that the Deanery will conduct an interim
review against action plans. The Medical Director described one example of where feedback from the Deanery had resulted in positive changes in Endoscopy, ensuring that there is now
consultant support for each trainee.
The Medical Director explained that more medical staff now receive appraisals and it is his intention to link this with pay progression. The Director of Human Resources said appraisal was at
84% for medical staff.
39
Good practice identified
A quarterly Board report on workforce is given to the Board which covers recruitment, pay expenditure, sickness absence and mandatory training. During interview, a Non-Executive Director
stated that Board gets “a comprehensive HR report”.
During separate interviews, both the Medical Director and Director of Human Resources identified that the strategy was to enhance permanent staffing and to reduce locum spend.
Nurses at a focus group described how the Trust had won the Midwife of the Year Award.
Priority – urgent,
high or medium
Outstanding concerns including evidence
Planned improvements
Recommended action
Staffing levels and quality of training experience
As described above, the strategy
is to enhance permanent staffing
and to reduce locum spend.
The Board needs to assure its self that staffing skill Urgent
mix and levels does not present any immediate risk
to patient care or staff welfare.
The Board had agreed to
establish additional nursing posts
using expenditure connected with
bank costs to fund them, pending
the CCG’s agreement to
recurrently fund contracted
activity in 2013/14. A CCG
funding increase followed in
2013/14.
Develop a workforce strategy to support the clinical High
strategy and as part of this undertake a nurse
staffing review to ensure safe standards of care
and dignified patient experience is achieved.
Focus on reducing locum spend, vacancy rates
and staff moves. Ensure that the e roster templates
reflect staffing standards guidance and effective
deployment practice.
The Panel identified a number of concerns on staffing including:

An increase in nurse bank spend in the last year linked to staffing
escalation wards.

The Trust is failing to meet its 10% target for nursing understaffing
levels which is reported to the Board. The April Board paper showed
that the target had been breached from November to March 2013, with
14.8% of nursing shifts having less staff than planned in March.

Long-term sickness was highlighted as an issue by Directors and the
biggest challenges seem to be faced by nursing staff for whom the
sickness rate is as high as 6.5%.

Elderly care wards, A&E and MAU staffing appeared the most
significant areas of concern.
In interview the Director of Human Resources stated that locum medical and
nursing spending is on the increase because of demand when there is bed
escalation.
Concerns were raised by both consultants and junior doctors that nursing levels
were in their view dangerously low with a high dependency on agency staff.
This was considered by staff to be affecting patient experience and care. The
40
Outstanding concerns including evidence
Planned improvements
Recommended action
Priority – urgent,
high or medium
quality of care is also being impacted when nurses are moved from as it
depletes the ward of staff with specialty expertise.
The panel heard of a number of concerns from nurses relating to both poor
staffing levels and skill mix, including, little opportunity to take entitled breaks in
12 hour shift, poor supervision of newly qualified staff and having to attend
mandatory training in their own time.
Staff interviewed on one ward described themselves as de-motivated, they
attended training in their own time because they cared about patients and their
own professionalism and accountability.
41
KLOE 8: What assurance does the Board have that the organisation is safe?
Good practice identified
The antibiotic prescribing policy is strict. No more than three days of antibiotics are prescribed at one time and the treatment chart has been designed in such a way that no one can prescribe
more than three days’ antibiotics at a time. The microbiologist was widely praised and it was stated that he engaged staff and regularly reviewed guidance. According to staff on a stroke
ward, intensive teaching of GPs about antibiotic prescribing led to a decrease in the incidence of Clostridium difficile and MRSA. Junior doctors at a focus group were all aware of the
antimicrobial policy. They explained that the Trust has been rolling out credit card-sized antibiotic prescribing guides to slide in behind ID badges.
The Medical Director described a new online system for incidence reports which has recently been established, as well as an incident reporting hotline, but explained that it would still take 6 –
8 weeks to be embedded. In a focus group, of the 6 to 8 of the doctors which had reported incidents, only 2 or 3 had had any feedback. However, these doctors noted that under the new
system they had been receiving feedback. Nurses on the wards also told us that they did not receive feedback on critical incidents from the forms they had submitted, but this may be
improved by the implementation of the new electronic recording system.
The screen saver message on Trust PC’s seen by the panel advises staff of the infection control targets and the achievement against the target.
Priority – urgent,
high or medium
Outstanding concerns including evidence
Planned improvements
Recommended action
It was not clear how the Trust was using serious incident reporting and
learning to improve care.
None noted.
As previously stated the Board should
undertake a Safety Culture Audit to inform a
refreshed quality strategy and improvement
programme.
High
The Trust should review its incident reporting
process and the wider safety culture to
ensure learning is disseminated effectively.
High
Whilst the Trust has roughly average levels of incident reporting, it has higher
than average levels of patient accident and clinical assessment-related incidents.
A report on serious incidents 01/04/2012 – 31/03/2013 describes a never event
(defined by the NHS as serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been implemented),
but it has not been classified as such. It also logs an incident which took place on
11/6/11, which is still awaiting a final investigation report in June 2013.
The ward and / or clinical teams do not appear to be closely involved with the
process of incident management based on the panel’s observations. There did
not appear to be team meetings or root cause analysis following serious incidents
in some areas and staff could not give examples of feedback they had received
on general themes or specific incidents.
Staff perception was that if there is a Clostridium difficile or MRSA episode, the
42
Outstanding concerns including evidence
Planned improvements
Recommended action
Priority – urgent,
high or medium
Infection Control Team takes over the management rather than supporting the
clinical teams to do so.
43
5. Conclusions and support required
Urgent and high priority actions for consideration at the risk summit
Problem identified
Recommended action for discussion
Support required by the Trust
Care risks associated with the
emergency and medical pathway,
including capacity and staff
planning, clinical cover and out of
hours clinical leadership.
The Board should assure itself immediately that no patients are at immediate risk of unsafe care
due to the issues raised in this report and improve key safety processes, including management of
deteriorating patients.
The Trust needs to work with the CCG and the
Deanery to address the whole system and
workforce challenges.
The Trust should review operational planning in the emergency and medical pathway to support
appropriate care, including improving clinical cover and leadership, particularly at night. The Trust
should agree a plan of action for improving the acute medical pathway including the management
of escalation areas and bed management protocols immediately.
The Trust should agree a plan of action for improving the acute medical pathway in line with the
recommendations from the reports already commissioned by the Board.
The Trust should develop a workforce strategy to support the clinical strategy and as part of this
undertake a medical and nurse staffing review to ensure safe standards of care and dignified
patient experience is achieved. The review should focus on reducing locum spend, vacancy rates
and staff moves and ensure that the e roster templates reflect staffing standards guidance and
effective deployment practice.
The Board is not effectively
leading quality improvement in
the Trust and the leadership and
governance arrangements need
urgent review to improve
assurance and accountability at
all levels.
Urgently review the Board's leadership style and optimise the effectiveness of this on organisational To be discussed with the Trust and included in the
culture and quality improvement, including enhancing the visibility of all of the Directors.
risk summit action plan.
The Board should consider how it can introduce more challenge to the “assurance process”
including seeking independent corroboration of statements on outcomes and processes which
are reported to them.
The Trust should accelerate the ward and senior leadership development programme and focus on
improving clinical leadership (both medical and nursing) in the organisation.
Enhance staff communication, including ward performance, audit results, incident reporting and
learning from reviews. This maybe more effective through better use of directorate and ward level
meetings and direct email newsletters.
44
Problem identified
Recommended action for discussion
Support required by the Trust
Absence of an updated and
effective quality strategy, a single
cohesive implementation plan
and supporting performance
information to focus on key risks
and drive improvement.
Develop an updated, single, cohesive quality strategy that takes account of external reports,
mortality concerns, feedback from patients and staff, clinical audit recommendations, current
identified risks and current Trust performance. As part of this, agree quantifiable and measurable
improvements
The Trust needs to work with the CCG to ensure
that whole system challenges are addressed
consistently.
Develop a single improvement plan relating to quality and outcomes as set out in the quality
strategy. Undertake a Safety Culture Audit to inform this and prioritise actions that link to a
reduction in mortality and improvement in quality and patient experience.
A whole health economy approach to performance
improvement is to be continued and emphasised,
but should include all stakeholders, including
community and social services provision.
Review reporting to the Board to ensure that performance against the quality strategy and action
plan can be monitored and challenged effectively. Reporting should be more responsive and
comprehensive, including improvements identified in Board level review of quality accounts,
mortality data and the ongoing quality impact of CIPs. Assess performance against the upper
quartile of national care.
Review the governance of mortality improvement to bring rigour and pace to a comprehensive and
coherent programme of work such that mortality reviews are of adequate depth to produce
recommendations.
Ensure that there are clear lead responsibilities in particular with regard to any joint health economy
strategies and actions. In addition, the Trust should consider external scrutiny to care audits and
mortality reviews.
The organisational culture
accepts sub-optimal care and
does not engage staff effectively
in improving quality and patient
experience.
Develop a clinical effectiveness programme to improve the staff knowledge of evidence based care
including infection control, clinical audit, leading and managing quality improvement change.
Lack of meaningful patient and
public engagement and
transparency.
Develop a programme to improve listening to patients including training staff to respond to
concerns in line with the Trust’s vision of “Everybody Counts” and "treat you and your family as
partners in care".
To be discussed with the Trust and included in the
risk summit action plan.
Agree a programme of development support such that there can be effective cultural change where
patients and staff, including trainees, feel heard, valued and cared for.
To be discussed with the Trust and included in the
risk summit action plan.
Review the complaints management ethos and process to ensure that public expectations and the
required duty of candour and standards are met.
The impact of changes to the complaints process will need to be evidenced so that the Trust Board
can be assured that full and proper learning takes place.
45
Appendices
46
Appendix I: SHMI and HSMR definitions
HSMR definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would
expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the
hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in-hospital deaths (multiplied by 100)
for 56 specific groups (CCS groups); in a specified patient group. The expected deaths are calculated from logistic regression models taking into account and adjusting for a
case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of
palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number; in order to identify if
variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when
these have been crossed is performance classed as higher or lower than expected.
SHMI definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI
follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for
potential deviations away from regular practice.
How does SHMI work?
1) Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
2) The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
3) The Indicator will utilise 5 factors to adjust mortality rates by
a.
b.
c.
d.
e.
The primary admitting diagnosis
The type of admission
A calculation of co-morbid complexity (Charlson Index of co-morbidities)
Age
Sex
47
4) All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted using a Random Effects funnel plot
Some key differences between SHMI and HSMR
Indicator
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
No, around 80% of in hospital deaths are included,
which varies significantly dependent upon the
services provided by each hospital
If a patient is transferred between hospitals within 2
days the death is counted multiple times
Does the use of the palliative care code reduce the
relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Is this applied to all health care providers?
Yes
Only considers in hospital deaths
SHMI
Yes all deaths are included
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
No
Considers in hospital deaths but also those up to 30
days post discharge anywhere too.
No, does not apply to specialist hospitals
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Appendix II: Panel composition
Panel role
Name
Panel Chair
Gill Harris
Senior Regional Support
Damien Riley
Lay representative (Patient/public representative)
Steve McNeice
Lay representative (Patient/public representative)
David Tompkins
Lay representative (Patient/public representative)
Margaret Hughes
Lay representative (Patient/public representative)
Jackie Wilkinson
Junior Doctor
Tom Foley
Doctor
Gulzar Mufti
Doctor
Gavin Nicol
Doctor
Roger Hall
Student Nurse
Sarah Weight
Senior Nurse
Helen Carter
Board Level Nurse
Mike Wright
CQC representative
Jeanette Berry
Senior Trust Manager
Chris Harrop
Local Area Team Observer
Trish Bennett
Clinical Commissioning Group Observer
Steve Allinson
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Appendix III: Interviews held on announced visit
Interviewees
Date held
Chief Executive (Christine Green)
23 May
Chair of Quality and Clinical Governance Committee (Tricia Kalloo), Director of Nursing (and DIPC) (John Goodenough) and Patient Safety Lead (R
Kitson)
23 May
Deputy Director of Nursing and Patient Experience (Beverley Tabernacle) and Senior Nurse Safeguarding Adults (Naz Khadim)
23 May
Director of Nursing (and DIPC) – John Goodenough
23 May
Medical Director – Tariq Mahmood
23 May
Director of Finance – Barbara Herring
23 May
Director of Clinical Services – Paul Williams
23 May
Director of Human Resources – David Wilkinson
24 May
Associate Director of Planning and Performance – Melissa Laskey
24 May
Deputy Director of Quality and Governance – Peter Weller
24 May
Individual interviews/calls with each Non-Executive Director
24 May
Staff and Patient Governors
24 May
Divisional Nurse Manager
24 May
Medical Staffing Officer
24 May
E-rostering Team
24 May
Trust Secretary – Tom Neve
24 May
Chairman – Paul Connellan
30 May (held offsite due to
availability)
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Appendix IV: Observations undertaken
Observation area
Date of observation
Ward 43 – General medicine
23 May
Ward 41 – General medicine/Diabetes
23 May
Ward 30 – General Medicine
23 May
Surgical Unit
23 May
Ward 40 – Respiratory
23 May
Ward 42 – Gastroenterology
23 May
Accident and Emergency
23 May
Medical Assessment Unit
23 May
Ward 31 – Cardiology
23 May
Ward 5 – Acute Stroke
23 May
Ward 45 – Acute Stroke
23 May
Ward 44 – Dementia
23 May
Ward 27 – Maternity
23 May
DSEC Unit – Endoscopy
24 May
Trauma and Orthopaedics
24 May
Renal Unit
24 May
Women’s Health Unit
24 May
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Appendix V: Focus groups held
Focus group invitees
Focus group attendees
Date held
Band 5 and 6 nurses
12 nurses
23 May
Doctors below registrar
16 doctors
23 May
Senior nurses (band 7 and above)
17 nurses
24 May
Consultants
12 doctors
24 May
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Appendix VI: Information made available to the panel by the Trust
Urgent & Emergency Care Intensive Support Team (ECIST) report, April 2013
SEPSIS bundle
AQuA report, April 2013
Payment By Results Assurance Framework
Letter from Chief Executive to Jacky Hayden from NHS, April 2013
Tameside PATHway Accreditation Strategy
Board Quality Strategy
Adult Safeguarding Internal Self Assessment
Board Assurance Framework and Trust Risk Register
Tameside Journey – Our Experience
Clinical Audit plans for 2013/14 and latest Clinical Audit Annual Report
Reflect and Review Case Studies
Cost Improvement Programmes for 2012/13 and 2013/14 and details of the
process for assessing the quality impact of these
Mortality rates on a daily basis
Most recent self assessment or external assessment of quality governance
(against Monitor’s Quality Governance Framework or equivalent)
Graphs for improved survival for pneumonia, stroke and cardiac
Organisation structure and CVs of executive team
18 Week RTT performance
Governance and committee structures and terms of reference for assuring quality
including mortality governance structure chart
Waiting list payments report
Trust Board (private and public) papers and minutes for the most recent four
months (excluding minutes for May)
BREACH analysis
Board sub-committee with delegated responsibility for assuring quality and safety.
Papers and minutes for last two months (public and private)
Metrics for bed movements
Mortality review group papers and minutes for the last two months (CAPSEC
papers and minutes were provided for the four months)
Maintenance log for Equipment in Surgical, Medical, MAU, A&E
Summary of key performance measures for 2012/13 including finance,
performance, quality and patient experience
Clinical Coding Audit
Annual plan submission to Monitor or equivalent for NTDA for 2013/14
ITU Flow – OCC rate for Level 1 & 2
CQC mortality alert action plan and implementation
Paper on the surgical collaboration with Stockport and USM
Various independent reviews and self-assessments of quality performed within the
last year
Respiratory and General Medicine Consultant Job Plans
53
Background Information regarding supporting services and service specification
Junior medical staff rota for the medical wards for w/c 20th May
SUIs (never events and serious harm) – report on serious harm over last year
Junior and senior medical rota for ICU for w/c 20th May
Board Annual Report
Mortality strategy
Risk Plans at BU level
Escalation policy
Deanery reports (May 2012, October 2012, April 2013)
Completed Quality Impact Assessments (QIA)’s
Antibiotic policy
Birmingham report
Whistle-blowing policy, intranet screen shots
Director of Infection Prevention and Control (DIPC) report
Minutes from Patient’s Group and Minutes from Everyone Matters
2012/13 Tameside Hospital Contractual Performance Measures
Nursing Strategy
Quality Accounts
Council of Governors – minutes of meetings
54
Appendix VII: Unannounced site visit
Agenda item
Panel pre-meeting
Entry into Accident and Emergency and announced arrival to site manager
Observations undertaken of the following:
 Accident and Emergency
 Medical Assessment Unit
 Medical wards
 Stroke wards
 Women’s Health Unit
 Trauma ward
Discussions held with senior nursing staff to understand current staffing and patient levels, as well as details of outliers
Follow up meeting with Director of Clinical Services
Follow up meeting with Director of Nursing
Follow up meeting with Medical Director
55