Source · CQC inspection

North Manchester General Hospital

Provider Manchester University NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 28 Jul 2023

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Good

Earlier inspection findings

pre-2024 framework · 8 must-do 7 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8

Must do

Safe

The trust must ensure they assess and do all that is reasonably practicable to mitigate risks to women, birthing people and newborns. Regulation 12(1)(2)(a)(b) 1. This includes but is not limited to: • operating effective and timely triage processes to protect women, birthing people and newborns • facilitating timely access to appropriate treatment and birth settings for women, birthing people and newborns

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not always assess, monitor nor manage risks to women, birthing people and babies. Opportunities to prevent or minimise harm were missed as the service did not operate effective and timely triage processes. There were delays in initial assessment of women and birthing people presenting to maternity triage, and …

Must-do action 2 of 8

Must do

Safe

The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)

Regulation: Regulation 18(1)

⚠ The service did not always have enough maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment. Staffing levels did not always match the planned numbers putting the safety of women and birthing people and …

Must-do action 3 of 8

Must do

Safe

The service must ensure staff are up to date with mandatory training modules. Regulation 12(1)(2)(c)

Regulation: Regulation 12(1)(2)(c)

⚠ The service did not make sure everyone completed mandatory training. Staff were not up-to-date with their mandatory training.

Must-do action 4 of 8

Must do

Safe

The service must ensure that staff complete safeguarding training appropriate to their roles. Regulation 12(1)(2)(c)

Regulation: Regulation 12(1)(2)(c)

⚠ Not all staff had training on how to recognise and report abuse. Not all staff received training specific for their role on how to recognise and report abuse.

Must-do action 5 of 8

Must do

Safe

The service must ensure staff follow safe practice in theatres to assess and mitigate risks to women, birthing people and babies. This includes but is not limited to completion of safer surgery checklists and procedures, use of positive identification and labelling of babies. Regulation 12(1)(2)(a)(b)

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Poor compliance with completion of WHO checklists in theatre. Team introductions, positive identification of patients and application of identification bands were not completed in line with the trust’s process. Staff did not give a new-born baby a label before removing them to the resuscitation room.

Must-do action 6 of 8

Must do

Safe

The service must ensure staff carry out effective monitoring of women, birthing people and babies during labour, including use of ‘fresh eyes’ in line with guidance. Regulation 12(1)(2)(a)(b)

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Audit of how effectively staff monitored women and birthing people during labour having continuous cardiotocograph (CTG) showed poor compliance, including with 'fresh eyes' reviews.

Must-do action 7 of 8

Must do

Safe

The service must ensure the proper and safe management of medicines. Regulation 12(1)(2)(g)

Regulation: Regulation 12(1)(2)(g)

⚠ The service did not consistently use systems and processes to safely prescribe, administer, record and store medicines. Staff did not always store and manage all medicines and prescribing documents safely. Medicines records were not always clear and up-to-date. Not all staff completed medicines management training.

Must-do action 8 of 8

Must do

Well-led

The service must assess, monitor and improve the quality and safety of the services provided in a timely way. Regulation 17(2)(a)

Regulation: Regulation 17(2)(a)

⚠ Leaders did not always operate effective governance processes and action was not always taken to address risks in a timely way. Incidents were not always graded appropriately, and issues in triage and elective pathways had not been fully addressed at pace. It was not always clear how taking action was …

Should-do actions (7)

Recommended improvements to enhance service quality.

Should-do action 1 of 7

Should do

Safe

The service should ensure premises and equipment are kept clean and in good repair to prevent, detect and control the spread of infection.

Should-do action 2 of 7

Should do

Safe

The service should ensure checks of specialist equipment including resuscitation equipment are carried out.

Should-do action 3 of 7

Should do

Safe

The service should continue the roll out of use of bilirubinometers.

Should-do action 4 of 7

Should do

Well-led

The service should ensure that incidents are appropriately graded to ensure they can assess, monitor and improve the quality of services to women and birthing people.

Should-do action 5 of 7

Should do

Well-led

The service should continue to address issues and concerns using quality improvement initiatives and ensure they can evidence the impact of improvements made.

Should-do action 6 of 7

Should do

Well-led

The service should continue to complete audits in line with the audit plan and keep the plan updated.

Should-do action 7 of 7

Should do

Well-led

The service should continue to address the identified issues in culture at the service to ensure safe service delivery.