We inspected Manor Hospital, Walsall on an unannounced, scheduled visit to review previously identified non- compliance in Outcome 21 (records). We also reviewed concerns received by CQC from a whistle blower regarding paediatric staffing levels.

Three compliance inspectors, a paediatric specialist advisor and the CCG lead nurse inspected Manor Hospital. We visited five wards and the accident and emergency department (A&E). We spoke with 31 staff including doctors and nurses, eight patients and five relatives.

At the previous inspection it was identified that improved record keeping was required to provide assurance that people would receive the care they needed. During this inspection we saw that many new, improved records were in place. We found that all areas we visited were adequately staffed, both in terms of nursing, care staff and medical personnel.

We reviewed the staffing levels at all grades for paediatric care in the hospital. We found that medical and nursing staff levels were appropriate for the delivery of care at the current time and these were continually under review. The staff we spoke with were all keen to demonstrate innovation and were enthusiastic about working for the trust.

One relative we spoke with told us: “I am very impressed with the care my mother has received”.

Whilst in A&E we identified that the consideration of safeguarding was not always documented. We brought this concern to the attention of the matron

This inspection reviewed the trust's action in response to a compliance action in relation to records.

We visited wards 4, 10, 11, 16, 17 and the accident and emergency department. We looked at care records for 26 people, spoke with 24 people about the care they or their relative received and spoke with 15 staff about the needs of people whose care records we looked at.

We visited each person whose care records we checked. People we spoke with were positive about the care provided at Manor Hospital. People told us, "The care has been excellent", and "The care is great, the nurses have all been so good". We were able to see that dependent people on the wards were comfortably positioned, clean and cared for.

On the day of our visit the accident and emergency department was very busy causing challenges for staff. Before our visit we were contacted anonymously and told that the department was reliant on agency staff which put people at risk. We found that there were appropriate arrangements in place to cover staff absence. However improved records were needed to provide assurance that people would receive the care they needed whilst in the department.

We found that improvements had been made to the completion and availability of care records since our last inspection in July 2012. The trust told us that they would ensure that improvement continued. We shall assess the completion and availability of records again during our next inspection of the hospital.

We visited Walsall Manor Hospital as part of our planned programme of inspections and to review the improvements made since our previous visit. The visit was unannounced and neither the provider nor staff knew that we would be visiting.

A team of four inspectors visited Walsall Manor Hospital on the 10 and 11 July 2012. We visited wards: 1, 4, 10, 11, 14, 15, 16, 17, 20 and the Accident and Emergency Department. The inspection included the observation of care experienced by people in the hospital, talking to people who were in receipt of care, talking with staff on duty including ward managers and specialist nurse advisors, looking in detail at all aspects of care for 18 people, some of whom had complex needs and discussing their care with staff. This process is known as pathway tracking. During the two days of our inspection we spoke with 46 patients and relatives and 33 staff.

People were positive about the care they received. All but one person we spoke to told us that they were informed about the treatment options including possible risks of the treatment. One person told us, “I couldn’t fault the place, everyone is wonderful, they treat me with respect and always keep me private when they are doing any personal care". They were satisfied with the level of care and support they received.

We spoke with a visitor they told us they felt the staff were kind and supported their relative well.

People told us that they were informed about the treatment they needed and they were asked for their consent to treatment.

People we spoke with made positive comments about staff. Comments we received about staff included, "I could not fault them, they do a marvellous job". People told us that staff were respectful and maintained their dignity. One person told us, "They are very good, they cannot do enough for you", and "They are very respectful and have excellent manners". We observed that staff assisted people when needed and were polite and respectful.

The hospital had appropriate systems in place to protect people from harm and undertake required action to protect people from abuse and the risk of abuse or harm.

We have been told that the hospital has considerably reduced its incidence of reportable infections. People told us, "The hospital is always very clean", and "Staff are always washing their hands and I also see them using the handgels".

Staff all told us that they felt supported and were kept informed by senior staff and board members. We were told, "We have really good training opportunities".

We found that the trust which manages the hospital had responded positively to concerns and had appropriate systems in place to respond and learn from these concerns. There were appropriate systems in place to protect people from harm.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

People were very positive about their experience and care they had received at the Manor hospital. We saw that staff promoted people's privacy and dignity. People told us that their treatment had been discussed with them and they felt well informed about their care and treatment. There were many complimentary comments about the staff including," Can't fault the staff,they are all kind, polite and patient and they have listened to me, nothing is too much trouble".

Generally staff felt supported but there was a lack of ongoing formal supervision in place. The frequency of staff meetings varied from ward to ward resulting in some staff not feeling fully informed.

There was a good system of quality monitoring in place. The hospital actively gains feedback from people who use their service to continually improve the quality of service it delivers. The hospital is actively trying to reduce the rates of clostridium difficile, however, systems need to impove further to reduce rates of infection.

Patients and their relatives we spoke to said they were treated with respect and their care and treatment needs were met. They said they had been involved in discussing and agreeing their care and were given clear information about treatment. Patients we spoke to on the whole said they enjoyed the food and felt their nutritional needs were being met. Everyone said someone came round with a menu to help them to choose what they wanted to eat. They said staff always checked to make sure they have had enough to eat and that they have never missed a meal. Comments have included:

“I have never been in hospital before and found it reassuring when staff have explained what is happening next”.

“The staff were wonderful to mother and I feel less anxious about her mother now she was on this ward.”

“The food is very good on the whole. I left my meal today as I was not very hungry and staff asked if I was alright or if I wanted something else.”

Walsall Healthcare NHS Trust provides acute hospital and community health services for people living in Walsall and the surrounding areas. The trust serves a population of around 270,000. Acute hospital services are provided from one site, Walsall Manor Hospital. Walsall Manor Hospital has 550 acute beds. There is a separate midwifery-led birthing unit (this is currently not operating), and the trust’s palliative care centre in Goscote is their base for a wide range of palliative care and end of life services.

The trust was placed in special measures by the Secretary of State for Health in February 2016 following our announced comprehensive inspection in September 2015.

After a further inspection in June 2017 the Care Quality Commission served the trust with a Section 29a Warning Notice of the Health and Social Care Act 2008. This outlined the quality of healthcare provided by Walsall Healthcare NHS Trust for the following regulated activities required significant improvement:

• Diagnostic and screening procedures

• Maternity and midwifery services

• Surgical procedures

• Treatment of disease, disorder or injury

The warning notice set out the points of concern and timescales to address this and was wholly related to maternity services. The trust responded to this with a detailed plan for remedial action.

This inspection was an unannounced focussed follow-up inspection of maternity services on 5, 6 and 12 June 2018. The purpose of our inspection was to determine if the maternity service at Walsall Healthcare NHS Trust had made the improvements we highlighted were required following our 2017 inspection and establish if work had progressed to meet the requirements of the warning notice.

During this inspection, we visited all areas of the maternity service at Manor Hospital. We did not inspect community midwifery services or the standalone midwifery led unit.

We spoke with nine patients and relatives, and 32 staff members at all levels, including consultants, midwives, student midwives, maternity support workers and administration staff.

We reviewed 20 prescription charts and 17 patient medical records.

A range of data was requested from the trust as part of this inspection.

We also held maternity staff focus groups for all staff levels and community staff following the inspection to give staff the opportunity to feedback about the service. In total, there were 46 attendees.

We rated this service as requires improvement because:

• The number of never events had increased in the service from no never events between June 2016 to June 2017 to two never events for the following year.
• The service did not effectively address the findings from audits to demonstrate effective management of infection control risks.
• Overall, the incident reporting process had improved however, further improvement was still required as staff told us feedback from incident investigations was not always shared with staff and action plans were not always circulated to all appropriate staff.
• Breastfeeding support provision for patients was insufficient.
• Fridges to store breast milk were unsecured during our inspection. The service addressed this in a timely way however, there was not a process in place to ensure these fridges remained locked.

• There had not been any recent infant abduction drills conducted.

• The service did not always ensure vaccination provision was sufficient to protect women and their babies.
• There was limited availability of accessible information in different languages, picture formats, and cue cards. The use of the translation phone service was variable and did not always protect patient privacy.
• The service did not currently have any internal services dedicated for counselling parents who had experienced the loss of a baby.
• The closure of the midwifery led unit in July 2017 had improved staffing levels in the acute setting however, women who may have chosen to birth in the MLU may not have access to the same facilities and equipment to support a normal birth on the main site.
• Leaders recognised further leadership improvements were required however, we were not wholly assured the pace of change was sufficient to drive improvement in a timely way.
• Some long-standing midwives felt excluded as they perceived they had fewer opportunities than recently recruited midwives.
• Some cultural issues remained an issue with some pockets of staff and reports of staff undermining other staff. The coherence of some consultants required further improvement.
• Some staff felt they were not sufficiently involved in discussions regarding the closure of the MLU. However, we saw a phased plan to re-open the MLU to accept patients to birth there.
• The maternity improvement action plan did not sufficiently document specific individual actions identified by the 2017 CQC report or external reviews of culture in the maternity service.
• Service leaders did not sufficiently prioritise or support the normality agenda.
• Governance was more organised and process driven but there was still a long way to go to be fully functional by ensuring all staff were fully engaged with the governance process of the department.

• Improvements in the sustainability of the service and improved staffing levels in the hospital setting had been partly achieved by having a birth cap in place and by closing the midwifery led unit. We had concerns that the service may not be sustainable if the unit was delivering to its capped level and the midwifery led unit re-opened.

The service had made improvements against all of the concerns we raised in the 2017 warning notice:

• Monitoring, recording and escalation of concerns for Cardiotocography (CTG)

• Insufficient numbers of midwives with HDU training to ensure that women in HDU

  are cared for by staff with the appropriate skills.

• Safeguarding training was insufficient to protect women and babies on the unit who

  may be at risk.

• There were insufficient numbers of suitably qualified staff in the delivery suite and on the maternity wards

At this inspection, we saw the following improvements for maternity services:

• Maternity staff safeguarding training compliance rates had significantly improved since our last inspection. As of 30 May 2018, midwives and support staff and medical staff safeguarding training compliance exceeded the trust target of 90% for all levels of adult and children’s safeguarding they were required to conduct.
• Midwifery staffing levels had significantly increased since the last inspection.
• Between May 2017 and April 2018, mandatory training rates had improved across the service.
• The service had reduced the average combined elective and emergency caesarean section rate since the last inspection.
• Maternity staff fully completed early warnings scores consistently well and could identify a patient’s deterioration.
• Overall, patients reported positive care experiences.
• We observed all staff interactions with patients were caring and supportive.
• Patients received compassionate and supportive care for as long as they needed.
• The bereavement midwife offered patients emotional support following pregnancy loss.
• The transitional care service was an innovative and dedicated approach to postnatal care.
• Since the last inspection, the service now had a leadership structure in place with clear lines of escalation. The corporate leadership team and frontline staff were more linked and confidence in leaders had improved.
• Overall, consultants were now more engaged with the improvement process in maternity services.
• Service leaders and members of the trust’s executive team demonstrated they had improved oversight of the challenges the maternity service was facing.
• Staff felt their contributions to the maternity service were more valued by the senior leadership team.
• Community staff told us they felt well supported by the community leaders who formed part of the changed leadership structure.
• Junior doctors told us the maternity leadership team were approachable and they to felt comfortable to raised issues with the Clinical Director if necessary.
• The maternity service leaders had developed a clearer vision and strategy for the service in place compared to our previous inspection. This included expanding the bereavement service provision.
• Senior staff were most proud of the improvement in staff morale and staff engagement in the improvement journey of the service.
• The local maternity risk register accurately documented the main risks to the service.
• A new purpose built second theatre was being constructed which mitigated risks identified at our previous inspection relating to the
• Following the inspection, we saw evidence the service had implemented procedures to manage staff who were openly not adhering to guidelines and procedures.
• The maternity service supported a multidisciplinary forum ‘Walsall Maternity Voices Partnership’ which met bi-monthly.
• The maternity service had been nominated for an award in transitional care.

We saw several areas of outstanding practice including:

• Funding had been secured for 170 midwives to conduct PHI learning. This learning is endorsed and supported by the Royal College of Midwives.

• The transitional care service was an innovative and dedicated approach to postnatal care.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure information in different languages, picture formats, and cue cards are available to patients.

In addition, the trust should:

• Ensure all staff complete mandatory training as required for their role.

• Ensure actions on action plans to address non-compliance for infection prevention and control are followed through.

• Ensure regular infant abduction exercises are conducted in the department to check for any gaps in the process and assess staff awareness of their role.

• Ensure gases were stored with the required signage on the doors

• Ensure processes are in place to store breast milk safely.

Professor Ted Baker

Chief Inspector of Hospitals