Archived: Altrincham General Hospital

Updated 13 June 2016

Altrincham Hospital is part of Central Manchester Foundation Trust. Altrincham Hospital is situated in the town of Altrincham. The Altrincham is part of the Trafford hospitals group and works closely with the neighbouring Trafford Hospital. The trust serves a population of approximately 226,600 residing in the surrounding area of Trafford, Altrincham and greater Manchester. The hospital does not have any inpatient beds.

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

• Urgent Care services; Minor injuries only
• Outpatients and diagnostic services

Updated 13 June 2016

Altrincham hospital is part of Central Manchester University Hospitals NHS Foundation Trust and provides hospital services including a minor injuries facility, renal dialysis unit and outpatient services to both adults and children.

Altrincham Hospital is situated in the borough of Altrincham and serves a population of approximately 226,600 people residing in the surrounding area of Trafford, Altrincham and Greater Manchester. The hospital has no overnight stay beds.

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

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

• The Minor injuries unit
• Outpatients and diagnostic services

Overall, we rated Altrincham Hospital as ‘good’.

Our key findings were as follows:

Leadership and management

• The hospital was led and managed by a cohesive and visible senior team. The team were very well known to staff and were regular and frequent visitors to the wards and departments. The head of nursing was well regarded by all departments who felt supported and valued by her. Staff were engaged and were committed to the Altrincham hospital providing a high quality service for patients and their friends and families.
• There was a positive culture throughout the hospital. Staff were open and honest and were very proud of the work they did and proud of the services they provided. Although there was additional work to be done to support staff in feeling part of the Central Manchester Foundation Trust as a whole.

Access and Flow

• The number of patients leaving urgent care services without being seen across the trust was consistently higher than England average from July 2014 to April 2015. Unfortunately the trust were unable to provide these figures for the Altrincham site specifically.
• The total time patients spent in urgent care services across the trust was consistently lower than the England average from November 2014 to May 2015.
• All patients we spoke with told us they were seen quickly and expressed no concerns about waiting times.
• A transfer policy was in place and this offered guidance on which escorts were required to accompany patients to other hospitals.
• There was a divisional escalation policy in place. This policy guided staff on steps to take if patients were in the unit for longer than expected or were waiting excessive times for an inpatient bed. The policy included clear steps for staff to take and we observed the shift coordinators following this process correctly.
• A winter pressures plan was in place for the Trafford Division and staff within the MIU were aware of this plan.
• We reviewed four records and all four patients were seen within their allotted triage time category.
• Urgent care services across the trust scored about the same as other trusts in England for all three standards relating to access to timely care in the 2014 A&E survey.
• Patients use a ‘choose and book’ system which allows patients choice when booking OPD appointments.
• Referral to treatment ( percentage within 18 weeks) for non-admitted from November 2014 to July 2014 the trusts performance was lower than the England average and the standard
• The failure to attend rate for new patient appointments at Altrincham was 6.9%. This was better than the England average of 8.8%
• The percentage of people waiting over six weeks for a diagnostic test at Trafford and Altrincham was 0.8%. This was better than the England average.
• The phlebotomy clinic at Altrincham was very busy. There was a treatment area with space for four staff. If there was full staffing patients were not waiting long but if not fully staffed patients were waiting up to two hours for a blood test. We spoke to staff and patients who confirmed this.
• The service ran from 8.00am-3.30 pm, though the service became busy early. This was because some patients required fasting blood tests and others were on their way to work. Managers were aware of the problems and another two staff members had been employed to rotate between the Altrincham site and the Trafford site. They were also considering evening clinics and Saturday clinics.
• The transport to the laboratory for blood samples left Altrincham at 4pm, if the service was running late; samples had to be sent by taxi.
• On the renal dialysis unit patients attended on alternate days Monday –Saturday. The first cohort of patients attended early in the morning with the next cohort of patients arriving at 11am. The dialysis treatment lasted about four hours. This meant that 40 patients were seen every day. Space could be found if patients had missed their appointments as there were spare dialysis machines.

Cleanliness and Infection control

• Patients were cared for in a visibly clean and hygienic environment.
• Staff followed the trust policy on infection control and adhered to the ‘bare below the elbows’ policy.
• Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.
• There were arrangements in place for the handling, storage and disposal of clinical waste, including sharps. There was a suitable supply of hand wash sinks and hand gels available.
• Staff were observed wearing personal protective equipment, such as gloves and aprons, while delivering care. Gowning procedures were adhered to in the theatre areas.
• We reviewed hand hygiene audit results for a two month period.The scores for these audits were consistently 100%. This meant that 100% of staff observed and audited washed their hands appropriately.

Nursing staffing

• The minor injuries unit (MIU) was staffed by band 6 emergency nurse practitioners, with two working on each shift.
• The number of staff on duty was reflective of the duty rota and met the agreed establishment during the time the inspection team was in the unit.
• The MIU had low levels of agency and bank staff usage. The unit manager told us that to mitigate the risks associated with agency or bank staff they would be placed in the urgent care centre at Trafford and a permanent member of staff would be moved to the MIU. This was because there were more permanent staff on duty in the urgent care centre on a daily basis than in the minor injuries unit. We viewed induction checklists completed for agency and bank staff and these were completed fully. These checklists were audited by senior staff within the MIU.
• Staff told us that they had enough time to care for patients and were able to take their breaks when required.
• Nursing staff in the outpatient and diagnostic unit could be rotated between the Trafford and the Altrincham site to cover gaps in staffing. Agency staff could be booked to cover shortfalls in staffing and no clinics had ever been cancelled due to a shortage of nurses. The morning safety huddle identified any gaps in staffing due to sickness or staff training and decisions were made about the allocation of staff for each clinic. Agency staff were generally from the hospital bank staff and had worked in the OPD before
• A consultant we spoke to said that there was sufficient nurse staffing for the OPD clinics.
• Managers at the renal clinic reported that there were occasional staff shortages. Agency staff needed to have training in renal nursing.

Diagnostic imaging staffing

• There were two radiographers on site Monday to Friday and one to provide cover at weekends. Staff rotated between the Altrincham and Trafford hospital sites.

Medical staffing

• The MIU was staffed by Emergency Nurse Practitioners. However the practitioners had access to medical advice by telephoning the urgent care centre at Trafford General Hospital.
• There was a doctor based on the renal unit but they were not there all the time as they would attend other clinics medical assistance could be contacted via the telephone/bleep system if required urgently
• There were three consultants in post and two consultant radiologist vacancies at Trafford and Altrincham. There was a plan in place to mitigate for these shortages by recruiting an additional consultant and introducing a consultant rota across the trust. This was on the risk register with a review date of October 2015. There was no radiologist on site at Altrincham.

Nutrition and hydration

• There were facilities for making drinks in the hospital and snacks could be sourced where necessary

We saw several areas of outstanding practise including

• The staff approach to patient care and commitment to providing compassionate care to patients.
• The use of reporting radiographers on the Trafford/Altrincham sites provided a rapid reporting service 9.00am -5pm Monday – Friday. X-rays for patients attending A&E or the MIU were reported in in a timely fashion that facilitated diagnosis and discharge.
• The production of dialysate fluid for renal patients on site to reduce costs and the carbon footprint of the unit.
• The training programme and competency assessment for patients who want to dialyse at home. This was supported by renal patients giving advice and support.

Action the hospital SHOULD take to improve

In Minor Injury services:

• The trust should ensure that all oral medications are clearly labelled with an opened date recorded clearly on the bottle.
• The trust should ensure that the temperatures of the fridges used to store medication are recorded daily.

In outpatients and diagnostic imaging services:

• The trust should reduce their waiting times for phlebotomy services at Altrincham hospital
• The trust should consider upgrading the tympanometers in audiology OPD as the equipment is outdated and giving inaccurate results which could affect patient outcomes.
• The trust should look at different ways of working to address the recruitment and retention of radiologists and radiographers.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 13 June 2016

We rated the minor injuries service as ‘good’ overall because;

Incident reporting was good with very low rates of avoidable harm to patients. Staff completed patient’s records fully and in legible handwriting. Risk assessments were completed fully and implemented measures to minimise risk to patients.

The management of medicines was managed well and staff undertook appropriate checks when administering medication. The facilities and equipment across the service were well maintained.

Care and treatment was provided in line with national and best practice guidance. Regular auditing of care and treatment and how effective these were was undertaken. Patients received timely pain relief and were treated with kindness, dignity and compassion and patients and their relatives were involved in their care and treatment.

Staff went above and beyond their duty to ensure that patients received compassionate care. The MIU was responsive to patients needs and provided timely access to care and treatment with minimal delays. The service managed complaints well and responded to them in a timely manner.

The MIU was well led and staff were clear on the divisional vision. Managers and leaders were visible and staff felt able to approach them.

There were areas of innovation including examples of collaborative working with national and local organisations to seek patient’s views.

Updated 13 June 2016

We have rated outpatients and diagnostic imaging services as ‘good’ overall because;

Staff were aware of how to report incidents and were confident about raising incidents through the reporting system. There were systems in place to raise awareness about incidents on a daily basis.

There were appropriate protocols for safeguarding vulnerable adults and children and staff were aware of the requirements of their roles and responsibilities in relation to safeguarding.

Staffing levels and skill mix were planned to ensure the delivery of outpatient services at all required times. When there were shortages of staff this was addressed by senior managers. In the diagnostic imaging service there were consultant vacancies but the trust were aware of these and systems were in place to mitigate any risks.

Outpatient and diagnostic imaging services were delivered by caring, committed and compassionate staff who treated people with dignity and respect. Care was planned and delivered in a way that took patients’ wishes into account. Their confidentiality and privacy were respected whenever possible.

The renal dialysis unit provided good effective care for their patients and education and support for patients who wanted to dialyse at home. Care was holistic and consideration was given to try to reduce the impact that dialysis had on people’s lives. The diagnostic imaging department ran a seven day service which was responsive to patient’s needs.

However, the diagnostic imaging department did not have access to information relating to ionising radiation medical exposure regulations (IR(ME)R regulations). There had been patient complaints about the phlebotomy service. There were long waiting times if the service was not fully staffed. The trust was aware of this and was working to reduce the waiting times.

There was a trust wide out-patient transformation programme group. The aim of this was to develop and implement service standards for OPD clinic. The group also led on improving patient experience across all the trust sites. The standards would deliver a consistent, reliable and quality clinic experience to patients and their families. Altrincham was used as an exemplar site for other services.