Manor Hospital (Walsall), Walsall

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 101

• Of these how many have an ensuite toilet: 48

• Of these how many have an ensuite toilet and shower or bath: 48

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0 The Trusts Palliative care service is delivered by a Consultant led Hospital specialist Palliative care Team which supports clinical teams within base wards. A Palliative day facility is operated by the Trust alongside an inpatient Hospice operated by St Giles Hospice Charity

• Does this hospital have a named private unit/service: Where private care is delivered it is within existing service depts

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery: Yes. The Trusts incident reporting system is PRISM. Use is governed by a reporting policy in line with national and NPSA requirements. Incidents reported are graded and managed by the patient safety officer and locally investigated by clinical teams. results are returned to quality boards with actions tracked via the trusts quality dashboard

• What is the reporting system for a foreign body being left post surgery: immediate local escalation, patient information and resolution. I The trust incident reporting procedure is followed to ensure a report with immediate escalation to the Medical Director and Chief Executive as a never event with completion within the national and SHA reporting tool. A senior investigating officer is appointed who commences data collection and begins the RCA process and intial risk assessment. the medical director also undertake a clinical review to assess patient status and suitability of actions

• Is there a system for recording operations that were cancelled due to missing notes: As above. The Trusts incident policy and PRISM reporting mechanism is used to collect this information with immediate notification to service directors with investigation commenced including RCA

• What is the reporting system for operations that were cancelled due to missing notes: The Trusts incident policy and PRISM reporting mechanism is used to collect this information with immediate notification to service directors with The Trusts incident policy and PRISM reporting mechanism is used to collect this information with immediate notification to service directors with investigation commenced including RCA

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: The trust incident reporting procedure is followed to ensure a report with immediate escalation to the Medical Director and Chief Executive as a never event with completion within the national and SHA reporting tool. A senior invesitgating officer is appointed who commences data collection and begins the RCA process and intial risk assessment. the medical director also undertake a clinical review to assess patient status and suitability of actions The trust incident reporting procedure is followed to ensure a report with immediate escalation to the Medical Director and Chief Executive as a never event with completion within the national and SHA reporting tool. A senior investigating officer is appointed who commences data collection and begins the RCA process and initial risk assessment. the medical director also undertake a clinical review to assess patient status and suitability of actions

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 1 One event of this kind took place which was fully investigated as per protocol with safety enhancements made to prevent recurrence

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 0

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 100%

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99%

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators: Outcome data is provided with explanation to clinical teams, a programme of education is planned by the medical director and will be associated with policy. A board session on HSMR has been provided

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): The Trust has a patient safety team comprising of a whole time senior nurse and associate medical director with facilitator support. In addition The medical directors directorate supports this work

• Is safety and quality data available on a central platform and actively disseminated to users: There are a number of methods in place from overall quality dashboard through to individual systems such as an in house information system "chilli", Dr Foster and PROMS data

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist: Yes, An antibiotic pharmacist is in place and is supported by a antibiotic stewardship team which receives and acts upon live surveillance data. The team provides an antimicrobial policy and formularly

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical and medical

• Are all oncology patients screened at the pre-op assessment clinic: YES

• Are all chemotherapy patients screened at the pre-op assessment clinic: YES

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable Neurosurgery is not undertaken at this Trust

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Molecular or other method result in less than 24hrs Both molecular and culture are available to allow rapid results where needed

• On admission, does topical suppression take place immediately: Topical suppression is undertaken pre admission for those patients with positive samples

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment: All patients are screened on admission

• Does the Trust have a dedicated isolation ward:

• How many beds does it contain: 14 14

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority: A dedicated C Diff unit is available with a dedicated operational policy

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients:

• Does the Trust routinely isolate all patients with diarrhoea: A policy is in place to provide isolation within a 2hr maximum window with appropriate escalation where pressures indicate this may not be possible. guidance directs appropriate periods of isolation and the infection control team review each case of isolation on a daily basis using an electronic system with additional ward visits

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

• What type of stroke unit does the hospital have: combined acute and rehabilitation stroke unit

• Number of beds in the unit: 28

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: West midlands Cardiovascular Network

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 347

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 306

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week :

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment: Although 24/7 provision is available there are arrangements to undertake transfer with neurosurgical and stroke units should this be required

• These arrangements are with: A neurosurgical traansferref arrangement is in place with University Hospital Birmingham NHS Foundation Trust A neurosurgical transfer arrangement is in place with University Hospital Birmingham NHS Foundation Trust

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday):

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week: Yes, a dedicated Ortho geriatrician is in place as well as a multiprofessional Health care of the Elderly Rehab Directorate

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? :

• What is the estimated percentage of all patients that attend the class prior to surgery: 75

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Estimated percentage compliance to this protocol: 80 80%

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 100 100% Enhancements to this service have been undertaken as part of enhanced recovery work from August 2011. An audit of effectiveness is being undertaken in late 2011/12

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week:

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - audited figure was: 0 There were no delayed discharges related to therapy provision as recorded within the acute register. patients due for discharge at weekends are identified for weekend support and assessment and are seen by the weekend therapy team

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery: In the instance of clinical need this may be undertaken

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document: A pathway document is in place

• Is this data used to monitor compliance with the agreed pathway:

• Is criteria-based discharge used:

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service:

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week:

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight:

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: A multi-disciplinary specialist palliative care team

• Does the hospital's specialist palliative team includes: A consultant in palliative medicine,A palliative care nurse,Counsellor(s),Other (please specify) in addition, a Psychologist, Chaplain and Complimentary therpist are part of the team

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week: Out of hours an on all arrangement is in place

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital:

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme: This is undertaken within both acute and community teams

Maternity Care

Maternity Sites

• Manor Hospital (Walsall) - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 1939

• How many babies were born in the unit during the year? (not including home births): 3939

• How many women were booked for a home birth: 14

• How many women had a home birth? (not including births at home by accident): 14

• Number of antenatal rooms: 13

• Total antenatal beds: 32

• Number of assessment area rooms (for monitoring and / or induction): 1

• Total assessment area beds: 6

• Number of delivery rooms: 14

• Total delivery beds: 16

• Number of postnatal rooms: 13

• Total postnatal beds: 32 32 mixed antenatal and post natal beds

• Number of rooms in obstetric high dependency unit: 1

• Total obstetric high dependency beds: 1

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0 We do not offer a pay facility

• Does the maternity unit have a neonatal intensive care unit:

• Does the maternity unit have a neonatal high dependency unit:

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Other security measures: electronic tagging

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Provided by unit

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by women

• Pain relief available - Aromatherapy: Provided by unit

• Pain relief available - TENS: Provided by unit

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: Reflexology, Bithing stools/Combitrac are available

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 111.37

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 117.13

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On site

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On site

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On site

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: On site

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday):

• Available for women only groups:

• Available for other groups:

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 11-14

• Scan 2 available between: 20-22

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: Walsall Hospitals NHS Trust