Archived: Central Manchester University Hospitals NHS Foundation Trust

Central Manchester and Manchester Children's University Hospitals Trust was given Foundation status on the 1st January 2009 and became - Central Manchester University Hospitals NHS Foundation Trust (CMFT).

There are 6 main hospitals within the trust, four of which are registered collectively as Manchester Royal Infirmary these include: Manchester Royal Infirmary and three specialist hospitals, Manchester Royal Eye Hospital, Saint Mary’s Hospital and the Royal Manchester Children’s Hospital. Trafford General Hospital and Altrincham Hospital are registered as separate locations but are known collectively as the Trafford Hospitals. In addition the trust provides an extensive range of community services.

There is also the University Dental Hospital of Manchester which was not inspected as part of this inspection.

• Manchester Royal Infirmary - is a large teaching hospital that provides a full range of general and specialist services including emergency care, critical care, general medicine including elderly care, surgery and outpatient services. The Manchester Royal Infirmary is a specialist regional centre for kidney and pancreas transplants, vascular services, haematology and sickle cell disease. The Manchester Heart Centre is a major provider of cardiac services in the region, specialising in cardiothoracic surgery and cardiology. Located on the same site as the Manchester Royal Infirmary were the following specialist hospitals:
• Manchester Royal Eye Hospital (MREH) – is a large, specialist ophthalmic teaching hospital.
• St Mary’s Hospital – is a specialist teaching hospital for women, babies and families. Genomics clinics are also provided in the Manchester centre for genomic medicine.
• Royal Manchester Children’s Hospital (RMCH) – is a specialist children’s hospital and provides regional and supra-regional specialist healthcare services for children and young people and secondary services for central Manchester.

Each of the above specialist hospitals are based on the Trust’s main site on the Oxford Road campus alongside the Manchester Royal Infirmary (MRI) each with a separate, purpose-built building with its own entrance.

• Trafford Hospital provides a range of general hospital services, including an urgent care facility, general and specialist medicine, general and specialist surgery, a paediatric day case and outpatient services for children and young people and a range of outpatient and diagnostic services for adults and children.
• Altrincham hospital provides hospital services including a minor injuries facility, renal dialysis and outpatient’s services to both adults and children.

We carried out this inspection as part of our comprehensive inspection programme on 3 - 6 November 2015. In addition an unannounced inspection was carried out between 3pm and 8pm on 23 November 2015 at Manchester Royal Infirmary, St Mary’s Hospital and Royal Manchester Children’s Hospital.

The community services provided by the trust included a wide range of community based services including supporting health and wellbeing promotion, minor ailments and serious or long-term conditions. The services provided included: district nursing, podiatry, nutrition service, active case managers, home care pathway, sickle cell and thalassaemia service, complex discharge service, continence service, physiotherapy services, home support team, falls team and occupational therapy.

The services were newly integrated into four locality hubs to promote integrated care provision. Services were provided across Manchester in people’s homes, residential and nursing homes, clinics and in community venues.

We inspected community services on 11, 12 and 13 November 2015 in several different locations across Greater Manchester.

We rated Manchester Royal Infirmary as ‘Good overall’. We have judged the service as ‘Good’ for safe, caring, effective and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs. In addition:

We rated Trafford Hospital as ‘Good’ overall.

We rated Altrincham Hospital as ‘Good’ overall.

We rated community end of life care services as ‘Requires Improvement’ overall.

We rated children and young people’s community services as ‘Requires Improvement’ overall.

We rated community inpatient services as ‘Good’ overall.

We rated community services for adults as ‘Good’ overall.

We rated the community dental service as ‘Good’ overall.

We rated Child and Adolescent Mental Health Services, Community and Inpatient Services as ‘Outstanding’.

We rated the Trust as ‘Good’ overall with ‘Requires Improvement’ in the responsive domain.

Our key findings were as follows:

Leadership and Culture

The trust was led and managed by a stable and visible executive team. The team were well known to staff and were regular visitors to most services. The trust had a vision and strategy with clear aims and objectives. The vision was underpinned by the trust core values: Pride, Dignity, Respect, Empathy, Consideration and Compassion. The trust’s vision, values and priorities were understood by staff who were aware of their role in achieving them.

There was, in the, main, a positive culture throughout the trust. Staff felt supported, able to raise concerns, suggest improvements and develop professionally. Staff were proud of their services and proud of the trust.

There were positive levels of staff engagement. Staff were well motivated and committed to providing high quality services and experiences for patients.

There was a range of reward and recognition schemes that were valued by all staff. Staff were encouraged to be proud of their service and achievements. Successes were acknowledged and celebrated

However at Manchester Royal Infirmary and Royal Manchester Children’s Hospital we found that the culture in the surgical medical workforce required improvement. We raised this issue with the trust and were provided with assurances in respect of actions taken in response.

Equality and diversity

The senior team and other staff groups reported that the trust had made good progress in this important aspect of the organisational culture, work was on-going to embed and sustain an inclusive and supportive environment throughout the trust.

The trust had made a number of key appointments at both non-executive director and executive level. The (relatively) new appointees were leading a range of work streams to raise awareness and support the comprehensive inclusion of staff from a BME background and other staff groups with protected characteristics.

The programmes were being supported by a three year Equality and Diversity strategy. This approach was seen positively by staff.

As part of the trust’s Equality & Diversity week there were over 40 scheduled events including an Equality and Diversity Conference. The events were well attended and supported by staff at all grades. The events were aimed at raising awareness, encouraging and embracing diversity and promoting an inclusive work environment.

In addition, a new equality advocate initiative had been launched recently and over 110 people both from BME and other backgrounds had signed up to be advocates for diversity.

Governance and risk management

The trust had an embedded approach to governance and risk management that had developed over time. Governance was managed and board assurance sought (through both acute and community based services) through a divisional structure supported by Corporate Services and a Research Division. There was a strong committee structure in place that supported challenge and scrutiny of performance, risk and quality.

An established ward accreditation scheme had been in place since 2010 and regular care quality assessments were carried out across all wards. These included assessments on the environment, clinical care and leadership. Each ward was assessed and awarded either a gold, silver or bronze standard. On-going improvement was underpinned by action plans following each assessment to improve standards focusing on the specific needs of the patient group.

In addition, the trust had introduced an annual quality peer review programme known as Quality Reviews using the domains of safe, caring, effective, responsive and well led. There was evidence of service and quality improvement plans across the trust, for example the emergency department at MRI had undertaken a quality improvement project in sepsis recognition and treatment.

Mortality rates

The trust’s mortality rates compared with the England average. The trust had the lowest crude mortality rates in the North West of England. The trust was active in reviewing and assessing mortality. There was good medical and board oversight. It was evident deaths were reviewed and learning opportunities shared and applied to improve patient outcomes and reduce incidents of avoidable death.

Nurse Staffing

Nurse staffing levels were determined using a recognised tool and were regularly reviewed. However nurse staffing levels, although improved, remained a challenge. There were still nursing vacancies across a number of services. The trust was actively recruiting nursing staff, including nurses from abroad to address the shortfalls. In the interim, staffing levels were maintained by staff working additional shifts and the use of bank and agency staff. However, there were occasions when the staffing levels in some services and departments were below the required level.

Midwifery Staffing

There were concerns regarding staffing in the midwifery service.

The service was under significant pressure from increased demand and although there were an agreed number of midwives required in each area, there was a system of assessing the demands on the service throughout a 24-hour period. In response to emerging pressures, the midwife responsible for the service would move midwives and support workers between areas to provide cover based on need and patient complexity. This redeployment of staff (often to the delivery unit) could then lead to staffing shortages in other areas within the service. The trust had increased the establishment of midwives and was actively recruiting additional staff to address the identified shortfalls. The trust was in discussion with the commissioners of maternity services regarding the rising demand for maternity services.

Community staffing

There was a shortfall in staffing levels across adult community services. This was particularly evident in district nursing and the out of hours’ service. District nursing actual staffing was 9% below establishment. Bank staff were utilised regularly to maintain staffing levels within the service and recruitment was underway.

Staffing in the Child and Adolescent Mental Health Service (CAMHS)

At the time of our inspection senior management were conducting a review of staffing skills mix across tier 3 services. The aim was to identify where more practitioners, skilled in treating particular disorders, may be required to meet the changing needs of the local population.

Medical Staffing

There were sufficient numbers of consultants and medical staff to provide patients with appropriate care and treatment. There had been an increase of consultant cover in maternity services to support the increase in demand.

Locum doctors were used to cover existing vacancies and for staff during leave. Where locum doctors were used, they were subject to recruitment checks and induction training to ensure they understood the hospital’s policies and procedures.

The trust had less foundation doctors than other trusts and therefore had increased the number of trust doctors in the junior grades to maintain rotas.

Palliative care consultant cover was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland and the National Council for Palliative Care guidance.

Safeguarding

Staff in all service areas were able to identify and escalate issues of abuse and neglect. Practice was supported by regular and ongoing staff training. Staff had 24 hour access to advice and guidance so that safeguarding issues were escalated and managed appropriately and promptly. In children’s services there was a multi- agency approach with links to local authority Child Protection Teams.

In the community services a child protection clinic was held daily by community paediatricians who would see any child where a professional had raised safeguarding concerns. The vulnerable babies’ team had specialist care planners who chaired strategic partnership meetings and led on safeguarding cases. If neglect was suspected by the health visitor, the team would facilitate support and intervention. In the CAMHS service staff demonstrated a thorough understanding of safeguarding and their responsibilities in relation to identifying and reporting allegations of abuse. The care records we reviewed identified that staff were following the trust’s safeguarding policy and sharing information with other agencies appropriately and in a timely manner.

However, there were opportunities for strengthening the trust’s approach to alerting staff to children who may be at increased risk of abuse or neglect, particularly in the trust’s emergency departments.

Access and Flow

As a result of the increased number of emergency admissions and increased demand for services there was continual pressure on the availability of beds across the hospitals, particularly the Manchester Royal Infirmary (MRI) and Royal Manchester Children’s Hospital (RMCH). Consequently, the management of patient access and flow remained a significant challenge for managers.

The trust provided a number of services for patients to be seen urgently and performance across the range of urgent care services exceeded the national 95% target between March and May 2015. However, the adult emergency department at MRI regularly failed to meet national targets for time to treatment, time to discharge and ambulance handovers.

The trust had a transformation plan in place to address the impact of increased demand on its urgent care services and had work in progress to support improved access and flow. It is envisaged that the planned improvements will increase service capacity and improve patient experiences in terms of waiting times and access to a suitable clinical placement in a timely way.

The surgical services achieved the 18 week referral to treatment standards across all specialties for adults. Referral to treatment (percentage within 18 weeks) for non-admitted was better than the standard and similar to the England average from September 2013 to October 2014. From November 2014 to July 2015 the trust’s performance was lower than the England average and expected standard.

The outpatient service at the RMCH did not meet national targets for referral to treatment times between April 2015 and September 2015. Waiting times for non-urgent magnetic resonance imaging (MRI) scanning, fluroscopy and computerised tomography (CT) scanning exceeded the six week waiting time target between February 2015 and July 2015. There were also long waiting times for elective surgical treatment at RMCH with a number of specialities failing to meet the 18 week referral to treatment target.

For Incomplete pathways the trust performed in line with or better than the standard and lower than the England average from September 2013 to July 2015. All three cancer wait measures (patients seen within 2 weeks, 31 day wait and 62 day wait) were generally better than or similar to the England average from 2013/14 to 2014/15.

Although there was a strong and clear focus on discharge planning there were a number of patients who were experiencing delayed discharge and remained in hospital longer than they needed to be. This was sometimes due to the delayed provision of care packages in the community.

Bed occupancy rates in maternity services were 25% higher than the England average throughout April, May and June 2015. This meant there was insufficient capacity for the numbers of patients attending the maternity unit. A policy to divert patients to other units in the area was in place however, the threshold for the use of this policy was not clearly defined and there was no risk assessment to support the process. The lack of capacity and staffing challenges led to patients waiting to be seen in unsuitable areas, waiting for available beds and having treatment delayed.

In Trafford Hospital, theatre utilisation was 66% on average across all nine theatres between May 2015 and October 2015; this was based on high cancellation rates and the organisation of theatre lists and was similar across all specialities. This had been recognised by the trust and an external consultant had been commissioned to work with staff to develop options for expanding the service and increase the utilisation of the theatres and increase the number of surgical services for children and young people at the hospital.

Hydration and nutrition

Patient records included assessments of their nutritional requirements. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.

The food and drink provision had been reviewed since the last inspection in 2013; As a result, actions had been taken to improve the range of food available in all services so that it met a diverse group of patient needs. The standard of food was an identified risk on the trust’s risk register and a programme of work was underway to improve both the quality and choice of food available.

Cleanliness and Hygiene

There was a good standard of cleanliness throughout the trust. Staff were aware of current infection prevention and control guidelines and were supported by staff training and the adequate provision of facilities and equipment to manage infection risks in all services.

There were regular audits of cleanliness and infection control standards with high levels of compliance across the trust. Where audits identified shortfalls in practice, action plans were developed and implemented to secure improvement. Infection rates were within the England average.

The trust had also invested in the identification and control of an antibiotic resistant organism Carbapenemase Producing Enterobacteriaceae (CPE). In addition the trust was working with Public Health England to help generate the evidence base for national and international guidelines for controlling CPE and other antibiotic resistant organisms.

Medicines Management

Arrangements were in place to ensure that medicines incidents were reported, recorded and investigated. The trust is the highest reporter of incidents in England and we found there was an open culture around the reporting of medicine errors.

The medicines safety officer had oversight of incidents across the trust and we saw examples of learning from frequent errors being shared across the trust, for example involving insulin. Serious medication errors were reviewed by the Medication Safety Steering Group, and the minutes of these meetings demonstrated appropriate actions when improvements in practice were needed.

The trust demonstrated a deep commitment to research, innovative and active development of its services We found many examples of innovative and outstanding practice across a range of services. Some examples are detailed below and there is a comprehensive list included in all of the services reports.

Outstanding Practice

• Staff monitored patients by using an electronic early warning score system that automatically notified medical staff and some non-medical staff (such as the surgical lead pharmacist) if there was deterioration in a patient’s medical condition. This process was fully embedded across the main site and all the staff we spoke with were positive about using this system.
• The diagnostic imaging department used innovative new technology for assessing coronary artery disease which was available in only two centres in the UK. This meant that patients only required a single one hour visit rather than two visits and three hour appointments. It also meant lower radiation doses were administered to both staff and patient when compared with conventional technology.
• The neonatal unit used video technology to support women who were not well enough to visit their baby, and a bleep system for parents so that they were involved when decisions were being made by medical teams.
• The gynaecology emergency unit was locally unique in that it allowed patients to refer themselves to a specific unit for assessment and treatment of gynaecological emergencies and problems in early pregnancy.
• The development of a nationally unique service relating to developmental sexual dysfunction. This specialist clinic met the very specific needs of patients suffering a variety of sexual development issues. Patients who attended this clinic had the opportunity to be seen by consultant gynaecologists, endrocinologists and phycologists. Counselling services specific to the patients who attended the clinic was also available.
• Staff at St Mary’s hospital participated in an extensive programme of local, national and internationally recognised research. In areas such as female genital mutilation (FGM), senior staff within St Marys were participating in the development and implementation of national guidelines.
• The adult rheumatology ward had really thought about the feelings of young people transitioning into their department. They considered how young people would feel sitting in waiting rooms predominately designed for older patients and had developed a separate young person clinic, which was due to start in January 2016. They had involved young people in the re-design of the waiting room, using a mural of photographs of the young patients. The ward had set up a youth group who communicated via social media, which the staff monitored. They had developed their own education sessions for young people, in particular a session called ‘Sex, drugs, rock and roll’, to inform the young people of their condition and the impact of their life style choices.
• The baby hip clinic was the first example of a one stop assessment and treatment service for children with developmental dysplasia of the hip to be a collaboration between all consultants, rotating through the clinic, with agreed protocols and pathways, allowing standardisation of care and facilitating audit and research. This innovation placed the clinical needs of children and ease of accessing assessment and treatment for parents at the forefront of service redesign.
• Trained nurses were able to undertake eye screening for retinopathy of prematurity (ROP) using a web cam for babies in the neo-natal unit and were able to get immediate clinical review by ophthalmology consultants. The service had been evaluated as successful and was provided in other units as a result.
• The MREH was identified as a NICE exemplar (best practice) service for the management of glaucoma.
• The Divisional Director of the CAMHS service successfully placed a bid to become one of 9 CAMHS teams nationally to gain a place on the i-Thrive accelerator programme. I-Thrive is a needs based model that enables care to be provided specifically for a population that is determined by its needs.Emphasis is placed on prevention and promotion of health.Patients are involved in decisions about their care through shared decision-making.In gaining a place on the national programme, the service will have access to national experts to further their vision in meeting the needs of the local population.
• The trust had invested in the identification and control of an antibiotic resistant organism Carbapenemase Producing Enterobacteriaceae (CPE). In addition the trust was working with Public Health England to help generate the evidence base for national and international guidelines for controlling CPE and other antibiotic resistant organisms.

However, there were also areas where the trust needed to make improvements.

Importantly, the trust must:

• Ensure that sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed in all services, particularly urgent and emergency services, medical care, surgery services and end of life care. This also includes midwives in all areas of the maternity services and sufficient doctors to provide timely review of patients when requested.
• Improve patient flow through the Manchester Royal Infirmary, St Mary’s Hospital and Royal Manchester Children’s Hospital, particularly in maternity services, medical care, surgery services and A&E.
• Ensure that it fully implements the national recommendations following the removal of the Liverpool Care Pathway

We also identified a number of areas were the trust should make improvements. These are detailed in the individual reports for the hospitals and services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated child and adolescent mental health wards as outstanding because:

• The service had developed their approach to working successfully with complex patient groups. Care pathways for patients with PAWS and eating disorders were part of the monitoring contract with NHS England.
• Rating scales and scoring systems were used to assess and monitor patient’s health and the effect of treatment. This was used routinely to inform the care of patients. The team had developed its own rating scale to measure distress caused to patients by eating, including when they were fed under restraint.
• Patients had access to a range of psychological therapies.
• Care and treatment was provided by a multidisciplinary team who worked effectively together.
• Patients had a detailed assessment and a person centred plan of care was developed from this.
• The service followed recognised guidance for the treatment of young people with an eating disorder.
• Staff were experienced at working with patients who refused food. This included safely inserting a nasogastric tube under restraint when necessary.
• The trust had implemented an outpatient eating disorder service to reduce the pressure on beds, facilitate earlier discharge, and to support patients to stay out of hospital where possible.
• The trust had an improving quality programme that monitored standard areas of the ward. This included checking medication and resuscitation equipment. It also made relatively minor but effective changes such as shortening the time handover took.
• Patients had their physical healthcare needs monitored and met.
• The service provided quarterly reports to their commissioners. This included specific care pathways and related targets for admission, treatment and discharge for patients with pervasive arousal withdrawal syndrome and for patients over 13 with an eating disorder.
• Staff had individual management and clinical or professional supervision, and there was a fortnightly reflective practice group led by a psychologist.
• Most staff had had an appraisal within the last year.
• There were positive working relationships between the ward staff and teams based in the community, and other stakeholders.
• There were small numbers of patients detained under the Mental Health Act, and there was a Mental Health Act administrator who ensured it was applied correctly. The administrator received support and advice from a mental health NHS trust.
• Staff from various professional groups were positive about their jobs and the staff and patients they worked with. They felt supported by the colleagues and managers.
• Staff treated patients with kindness and respect, and were keen to improve the quality of the service and the experience of patients.
• Staff felt able to raise their concerns.
• The service had a corporate governance structure that included monitoring of incidents, complaints, and safeguarding and developing the service.
• There were adequate numbers of skilled and experienced staff. Most staff had completed most of their mandatory training. All patients had a risk assessment carried out which was regularly reviewed. Staff were able to identify safeguarding concerns and take action when necessary. Medical equipment was available and maintained. When it was necessary to restrain a patient, staff did this as safely as possible. Medication was administered, managed and stored safely and securely. Incidents were reported and acted on appropriately.
• Environmental risks had been removed where possible, and those that remained were managed through risk assessment and observation. The ward was clean and well maintained. Boys and girls had single bedrooms. However, all but two of these were on a shared corridor with shared bathrooms and toilets.
• The interactions we observed between staff and patients were friendly and respectful. Carers told us that staff were kind, respectful and polite and that they felt their child was safe on the ward. Patients received a welcome pack on admission to the ward. Carers were provided with information about the ward and what to expect. Copies of care plans were provided to patients initially or when the plan was updated. The care plans had a section for recording the patients view, but this was not completed. The care plans were tailored to the patient’s needs, and patients had a copy of this in their room. The plans were not written from the patients’ perspective or in a child or young person friendly language. However, the care plans were detailed and tailored to the individual.
• The ward held a parent engagement meeting to review parents’ experience and how this could be improved. Patients were discussed in the multidisciplinary team meeting once a fortnight. However, they did not attend the meeting. Instead they were invited to fill out a form, either on their own or with staff support, where they were asked for their views. This form was taken into the multidisciplinary team meeting so that the patient’s views were heard. Feedback from the MDT meeting was given to each patient individually in the afternoon of the meeting. A note of this feedback and any discussion was recorded on the form.
• The service had a process for handling referrals, and prioritising patients for admission. There was pressure on beds, but the service managed this by regularly reviewing patients on the waiting list and assessing who was most urgent to be admitted. The service had taken steps to address the demand for beds by introducing an outpatient eating disorder service, and was reviewing how services were accessed and provided in the broader CAMHS service. All patients were subject to the care programme approach and had discharge plans. There were lounges, games, quiet areas and outdoor space for patients. There was a school, which patients attended every weekday. Food was prepared offsite, and finished on the ward to make it more appealing to patients. There were bedrooms that were accessible by people in a wheelchair. Staff and carers were familiar with the complaints policy. The ward had received few complaints, but had responded to concerns raised by carers.

We rated specialist community mental health services for children and young people as outstanding because:

• CAMHS community services were continually reviewing, adapting and extending the services they provided to meet the changing needs of the local population.

• The service had developed standardised, integrated care pathways, delivered by multi-disciplinary/multi-agency teams, to provide effective care for patients with complex health needs.

• The service had made a strong commitment to research participation, in partnership with academic institutions, to improve the quality of service provision.

• The service had built positive relationships with partner agencies to deliver effective care and treatment. They ran regular multi-agency meetings to discuss how patients were progressing and how they could improve the service.

• The service ran fortnightly peer educational sessions so that best practice was shared throughout the multi-disciplinary and agency teams.

• CAMHS staff delivered specialist training to partner agencies. This included working with staff from the local authority to raise awareness of emotional health difficulties. They also delivered training to GP’s to support children and young people diagnosed with attention deficit and hyperactive disorder.

• Patients were encouraged to identify what they wanted to change in the service to meet their needs. Patients identified that there was a lack of awareness of gender dysphoria, and how this affected young people in the local population. They produced a training video to raise awareness of these issues. The video was used as part of a training programme for new medical staff employed by the trust.

• A Patient Participation Group (PPG) was well established. Patients were encouraged to share their views and experiences so that changes to service delivery were made to meet their needs. There was a standing agenda item within clinical governance meetings where ideas for service improvement, expressed by the PPG, were discussed.

• Patients were actively involved in the recruitment of new staff to the service.

• Staff used rating scales and scoring systems to assess and monitor patients’ health and the effect of treatment. This was used routinely to inform the care of patients.

• Carers said that the staff valued their well-being, as well as their children. The service ran educational courses to equip carers and parents with the skills, knowledge and emotional resilience to support their child with a specific mental health need.

• Carers said that CAMHS staff would go exceed their expectations to meet their child’s individual needs. Examples given to us included a psychologist going into a child’s school to explain and raise awareness of their condition to their peers.

• Staff received regular, monthly supervision from senior staff members.

• Staff felt valued by the organisation and thoroughly supported in their role by senior management.

• Every patient had a thorough risk assessment that was completed on referral to the service. Risk assessments were appropriately reviewed following any contact with the patient or following a change in their level of risk to self and/or others.

• Referrals to the community teams were triaged immediately upon receipt. Both teams had an effective on-call duty rota to deal with any emergency referrals to the service both within and out of service hours. The service set an indicative target from initial referral to treatment at 11 weeks for non-urgent, routine referrals. The service were consistently meeting this target, seeing most non-urgent, routine referrals within nine weeks.

However,

• Hand-washing facilities were not available in all clinical areas at the Winnicott Centre. This increased the risk of cross-contamination.

• At the 16-17 Emerge team at Moss Side, alarms were not available for staff use in all clinical areas. Staff did not have access to personal alarms.

• Staff could not access care records electronically. This made it difficult for staff to have timely access to a child or young person’s case history when conducting an emergency assessment off-site.

• The multi-disciplinary team did not use a standard, formalised care plan template to document a child or young person’s current plan of care. This made it difficult to locate the care plan within the care records, and identify what the most current plan of treatment for the individual was.

Overall, we rated the community health services for adults as 'good' because;

Staff were committed, enthusiastic and proud of the services they provide. Staff treated patients with dignity and offered support when required. Staff explained treatment and interacted well with patients. Patients were encouraged to agree treatment aims and to be involved in their care.

Services used National Institute of Health and Care Excellence (NICE) best practice guidance and national guidelines to support the care and treatment provided to patients. Multi-disciplinary, patient–centred care was evident and integration to locality teams meant there was involvement of a range of specialist staff to meet the needs of patients. Adult community services’ monitored performance through quality dashboards and key performance indicator reports.

Staff had access to training and development opportunities. Staff across all services received annual appraisals. However, rates for completion of appraisals were below the trust target of 90%. Staff had training on consent and deprivation of liberty safeguards. They discussed treatment and care planning with patients and obtained their consent before providing care. Staff understood and were able to explain the process for reporting safeguarding concerns. There was an incident reporting system in place and staff knew how to access it. We observed good hand hygiene practice and personal protective equipment (PPE) was available and used appropriately. Complaints were discussed at team level and at clinical effectiveness meetings. Learning from complaints was used to improve services. Where possible staff tried to resolve complaints locally.

Services were responsive to patients’ needs and could be flexible where required. The trust collated data on the 18 week referral to treatment time (RTT) standard. Referral to treatment and waiting times were variable across the community services, however the majority of services were meeting the 18 week RTT standard. District nurses saw patients when required and had no waiting times. Nursing assessments identified patients living with dementia or a learning disability and care was provided to meet their needs. Staff regularly used an interpretation and translation service when required to support patient care and treatment.

Risk registers were in place and risks were discussed at team meetings. Staff were aware of the trust’s values and vision. Staff felt well supported by managers and colleagues.

However, there were maintenance issues with base buildings across the locality. We raised the matter with the trust at the time of inspection and immediate action taken to address our concerns. There was a shortage of staff across all services in the locality teams. Staff worked extra hours and utilised bank staff to cover shifts. This had been recognised as a risk and had been added to the risk register. The trust had jobs advertised and had held recruitment events. Improvements were required to reduce the ‘Did not attend’ rates for some services, particularly MSK physiotherapy and the nutrition service.

We rated community health services for children, young people and families as ‘requires improvement’ overall because;

Staff were familiar with the safeguarding policy and procedures and had an effective working relationship with the trust’s safeguarding team.

A daily child protection clinic was held by community paediatricians who would see any child where a professional had raised safeguarding concerns.

Records were stored securely and were accessible to health visitors and health professionals as appropriate. We observed contemporaneous record keeping that reflected national guidance. However documentation audits were requested from the trust but not received in order to provide assurance on the standard of the records.

Although 57% of the school age population in the Manchester area were from ethnic minority groups, appointment letters were only sent out in the English language. Staff had not raised this as a concern. Staff did have access to a translation service, which included telephone services. However, staff told us they did not utilise this to arrange initial appointments.

The environment and some equipment used by health visitors at Longsight Health Centre was not fit for purpose. There was evidence of rodent infestation within the building, a ripped baby changing mat, visible dust on service tops and window shutters, and baby weighing scales balanced unsafely on a stand. Risk assessments completed prior to the clinics did not identify the main risks. Also at Longsight Health Centre we observed a poor level of hygiene in respect of dirty stairwells, clinical and storage areas. We observed two out of five vaccination fridges, at Alexandra Park, that were visibly dirty. The fridge temperatures were not checked daily as per the trust policy and we found one fridge that was only checked on seven occasions throughout October 2015 which was against trust policy.

Patients received care in line with current evidence-based guidance and standards. Policies and procedures were in place and staff were aware of how to access them. Frequent audits were completed and subsequent action plans implemented.

Incidents were reported via an electronic reporting system within community children and young people's services. The incidents reported were predominantly in relation to personal accident or injury, which resulted in no harm. However, other incidents staff told us about, such as delays in the completion of development checks, dirty clinical rooms and difficulties with IT, were not reported on the system. Staff gave examples of where positive changes had been implemented in practice.

The services were delivered by caring, committed and compassionate staff who treated people with dignity and respect. Staff actively involved young people and those close to them in all aspects of their care. The service met the needs of the children, young people and their families. Services were planned and delivered in a way that met the needs of the local population. However, the heath visiting service were only compliant with the trust target of 95% completion for the new birth visit. They were not compliant with the trust target of 95 % completion for antenatal contacts (maximum compliance of 20%, July 2015) and two year developmental reviews (average 50% compliance). The service as a whole was meeting their key performance indicators for referral to assessment times. For all services we inspected, the referral to assessment time was less than 12 weeks.

The strategy for the services was aligned with the trust’s operational strategy and staff were aware of the trust’s vision and values. However, there was no clear strategy for the engagement of the diverse population including those form a BME background. Regular team meetings were held in each community children’s team where governance and risk were standard agenda items. There was an overarching risk register and local risk registers held by each service.

However we found not all identified risks were on the risk register, such as non-compliance of antenatal contacts and development reviews, lack of IT connectivity and a lack of cleanliness at Longsight health centre. Risk assessments were completed prior to well-baby clinics but these did not identify all the risks. We found some equipment used by health visitors at Longsight health centre was not fit for purpose. Risk assessments completed prior to the clinics did not identify the main risks.

We rated community inpatient services at Central Manchester University Hospitals NHS Foundation Trust as ‘good’ overall because;

There was a proactive approach to incident reporting and safety performance within the service. There was a positive culture of learning from incidents and changes had been made to improve quality and reduce patient risk. Care and treatment was delivered in line with evidence-based guidance. Multidisciplinary working was embedded throughout the service. Clinical and internal audit processes functioned well and had a positive impact in relation to quality governance with clear evidence of action to resolve concerns. The leadership was knowledgeable about quality issues and priorities, understood challenges, and took action to address them.

There were systems in place to enable staff, and patients and their carers to give feedback on the service to enable improvements. There was a strong focus on continuous learning and improvement and innovation was supported and rewarded.

The service responded to times of additional pressures and had purchased additional beds to increase services to patients during the period of winter pressures. Care and treatment was coordinated with other services to ensure continuity of care and a seamless transition when patients were returning to the community setting.

We rated community end of life care services at Central Manchester University Hospitals Foundation NHS Trust as ‘requires improvement’ overall because;

The trust did not have a strategy for the delivery of end of life care services. The lack of such a strategy may have a negative impact on the quality of end of life care and future service improvements. There was no embedded replacement for the Liverpool care pathway in adult end of life (EOL) services that had been discontinued in July 2014 following national guidance from June 2013.

We were not assured at the time of our inspection that staff in adult EOL services fully understood their role and responsibilities in relation to reporting incidents. We had several discussions with different staff members who had highlighted concerns to us but had not reported these as incidents. The lack of incidents reported by the Macmillan team could be indicative of a poor reporting culture, in turn this may impact on learning and improving services for patients.

Implementation of evidenced-based guidance was variable. Care assessments that we viewed at the time of our inspection and trust audit results, identified that standards for end of life care for adults were not being met and there had been little improvement following audits.

A process for rapid discharge from hospital was in place for patients that had identified the community as their preferred place of care. However, this process was not delivered for adults across seven days a week and there was no Macmillan service available at weekends and bank holidays.

Staff felt supported by their local team leaders but did not always feel included in decisions about service changes and felt some disconnect with the acute part of the trust.

We rated the community dental service as 'good' overall because;

There were systems in place for identifying, investigating and learning from patient safety incidents. Staff understood the processes for raising safeguarding concerns and allegations of abuse. The environments were visibly clean, safe and fit for purpose. Services were planned and delivered in line with national best practice guidance and services participated in several dental public health programmes.

The service covered a large area of Manchester and planning was undertaken to ensure all patients could access the service when needed. Dental treatment was provided for patients who were housebound and a nursery schools service provided dental education. Between April 2015 and October 2015 all patients were seen within the12 week referral to treatment timeframe. Learning from complaints was shared and discussed during team meetings.

Patients or carers who attended for treatment were positive about the staff and the treatment they received. Staff were enthusiastic and proud of the team and workplace, staff retention was good. We saw examples of good practice and innovative clinic design and equipment. Staff treated patients with compassion and respect. In the last 12 months the senior staff structure had been remodelled and the strategy for the future appeared more stable. There was a comprehensive risk management policy and strategy. Information regarding performance, risks, complaints and incidents flowed between levels via membership of groups, for example the Operational Risk Management Group, team briefs and the intranet.