North Manchester General Hospital, Manchester

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 141

• Of these how many have an ensuite toilet: 94

• Of these how many have an ensuite toilet and shower or bath: 81

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0

• Does this hospital have a named private unit/service:

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:

• What is the reporting system for a foreign body being left post surgery: Incident Reporting System

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: Theatre Information Management System

• 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: Incident Reporting System

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 1

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 9

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

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 5 The Trust has developed customised RCA templates for a number of incident types e.g. Grade 3/4 Pressure Sores, Pulmonary Embolism, MRSA and Falls. Full incident investigations are conducted on red graded incidents using the NPSA Level 1 or 2 templates. The Trust also requests external investigations as appropriate.

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 0-30% All have a full investigation using the NPSA Level 1 or 2 templates and are followed up at either Board, Sub-Committee or Divisional Governance Committees.

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 91-99%

• 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:

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): Does the trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support)

• Is safety and quality data available on a central platform and actively disseminated to users: The Trust has a central data warehouse which supports data from the key Trust information systems. Regular audit/monitoring reports are set up and routinely created and disseminated to a number of system managers and to the DQ team. Likewise for the patient safety committee, but data for a number of the patient safety KPIs have to be currently manually collated, this data is planned to be transferred into the Trust's data warehouse by the end of September 2011.

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• 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

• 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: Culture based in 24-48hrs

• On admission, does topical suppression take place immediately: If known MRSA positive or on admission to ITU, Orthopaedic emergency admissions

• 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:

• Does the Trust have a dedicated isolation ward:

• How many beds does it contain: 56 Regional Infectious Diseases Unit

• Does the Trust have an isolation policy:

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• 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:

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 To be reconfigured into a combined unit in 2012

• Number of beds in the unit: 33 18 Acute. 15 Stroke Rehab

Trust Questions

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

• Is the Trust part of a stroke care network:

• Details: Greater Manchester and Cheshire Cardiac and Stroke 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): 1068

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 904

• 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: a 24 hr service is provided but the PSC opening hours for this service has been commissioned 7.00am to 7.00pm mon to fri. Out of these hours thrombolysis is provided at the Comprehensive Stroke Unit (CSC) at Salford Royal Hospital

• These arrangements are with: Salford Royal Foundation Trust

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service: trauma services currently run on three out of four sites.

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday): dedicated weekend trauma sessions available in hours on two out of three trauma sites.

• 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: ward based geritrician input at one site at present which will expand to both trauma centres post reconfiguration.

• 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: 60

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

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 90

• 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 - estimated figure: 0 The Trust has physiotherapy services at weekends so if a patient's discharge was delayed it would not be due to lack of physio services.

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery:

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

• 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: The majority of paediatric surgery from the North East Sector of Manchester is undertaken at Central Manchester Hospital NHS Foundation Trust. This Trust does not operate on children under 2 years of age. Elective surgery is provided in a limited number of surgical specialties/ENT/Ophthalmology/Eurology and Orthopaedics - and there are designated surgeons who have the requisite training and experience.

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week: This is one of the key drivers behind the Healthy Futures and Making it Better service reconfiguration programmes currently being implemented.

• 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 Oldham - integrated multi-professional palliative care team working across primary and secondary care. Rochdale integrated specialist palliative care team based in primary care in-reaching into secondary care. Fairfield General Hospital - Bury - specialist palliative care team. North Manchester General Hospital - specialist palliative care team working with Manchester community specialist palliative care team.

• Does the hospital's specialist palliative team includes: Other (please specify) A consultant in palliative medicine is provided in all teams with the exception of Rochdale. CNSs are in each of the teams. No counsellors are employed. In Oldham there are Macmillan AHPs (physio, dietician and OT)

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week:

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital: This is limited and facilties vary from ward to ward.

• 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:

Maternity Care

Maternity Sites

• North Manchester General Hospital - Midwife Led

• How many women gave birth in the unit during the year? (not including home births): 0 MLU opens 2011

• How many babies were born in the unit during the year? (not including home births): 0 MLU opens 2011

• How many women were booked for a home birth: 0 MLU opens 2011

• How many women had a home birth? (not including births at home by accident): 0 MLU opens 2011

• Number of antenatal rooms: 0 MLU opens 2011

• Total antenatal beds: 0 MLU opens 2011

• Number of assessment area rooms (for monitoring and / or induction): 0 MLU opens 2011

• Total assessment area beds: 0 MLU opens 2011

• Number of delivery rooms: 4 1 in use, 3 not in use at present due to reconfiguration.

• Total delivery beds: 0 MLU opens 2011

• Number of postnatal rooms: 0 MLU opens 2011

• Total postnatal beds: 0 MLU opens 2011

• Number of rooms in obstetric high dependency unit: 0 MLU opens 2011

• Total obstetric high dependency beds: 0 MLU opens 2011

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0 MLU opens 2011

• Amenity rooms; Are women able to book a single room in advance of their birth: MLU opens 2011

• If women can pay for a single room what is the average cost per night (GBP): 0 MLU opens 2011

• 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:

• Pain relief available - bath or shower: Provided by unit MLU open 2011

• Pain relief available - birthing pool: Provided by unit MLU open 2011

• Pain relief available - birth ball: Provided by unit MLU open 2011

• Pain relief available - Massage: Provided by women MLU opens 2011

• Pain relief available - Aromatherapy: Provided by women MLU open 2011

• Pain relief available - TENS: Provided by women MLU opens 2011

• Pain relief available - Epidural: Not available

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit MLU open 2011

• Pain relief available - Intramuscular injection: Provided by unit MLU open 2011

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 0 MLU open 2011

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 0 MLU open 2011

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site MLU open 2011

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call MLU open 2011

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On site MLU open 2011

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

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

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

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

• Fairfield General Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2230

• How many babies were born in the unit during the year? (not including home births): 2264

• How many women were booked for a home birth: 32 We do not have a midwife led unit at Fairfield at present; however all home births are under midwife led care not consultant.

• How many women had a home birth? (not including births at home by accident): 40 We do not have a midwife led unit at Fairfield at present; however all home births are under midwife led care not consultant

• Number of antenatal rooms: 6

• Total antenatal beds: 14

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 7

• Total delivery beds: 7

• Number of postnatal rooms: 6

• Total postnatal beds: 18

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 11

• Amenity rooms; Are women able to book a single room in advance of their birth: Whilst in labour women can request PN sideward for amenity bed if one is available.

• If women can pay for a single room what is the average cost per night (GBP): 45

• 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:

• 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: Not available

• Pain relief available - Aromatherapy: Provided by women

• Pain relief available - TENS: Provided by unit and by women

• 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

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 74

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 74

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

• 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 and On Call

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

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

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

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

• North Manchester General Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2807

• How many babies were born in the unit during the year? (not including home births): 2840

• How many women were booked for a home birth: 38 Midwife led unit opens 2011; however all home births are under midwife led care not consultant.

• How many women had a home birth? (not including births at home by accident): 31 Midwife led unit opens 2011; however all home births are under midwife led care not consultant.

• Number of antenatal rooms: 10 7 in use, 3 not in use at the moment due to reconfiguration.

• Total antenatal beds: 22 14 in use, 8 not in use due to reconfiguration.

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 9 6 in use, 3 not in use at present due to reconfiguration

• Total delivery beds: 9 6 in use, 3 not in use at present due to reconfiguration.

• Number of postnatal rooms: 10

• Total postnatal beds: 22

• 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): 15 12 in use, 3 not in use at present due to reconfiguration

• Amenity rooms; Are women able to book a single room in advance of their birth: Whilst in labour women can request PN sideward for amenity bed if one is available.

• If women can pay for a single room what is the average cost per night (GBP): 45

• 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:

• 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 women

• Pain relief available - TENS: Provided by unit and by women

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Provided by unit

• Pain relief available - Entonox (gas and air): Not available

• Pain relief available - Intramuscular injection: Provided by unit

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 93

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 93

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

• 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 and On Call

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

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

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

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

• Royal Oldham Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 2987

• How many babies were born in the unit during the year? (not including home births): 3036

• How many women were booked for a home birth: 131 We do not have a midwife led unit at Royal Oldham at present; however all home births are under midwife led care not consultant.

• How many women had a home birth? (not including births at home by accident): 152 We do not have a midwife led unit at Royal Oldham at present; however all home births are under midwife led care not consultant.

• Number of antenatal rooms: 13

• Total antenatal beds: 17

• Number of assessment area rooms (for monitoring and / or induction): 0

• Total assessment area beds: 0

• Number of delivery rooms: 14

• Total delivery beds: 14

• Number of postnatal rooms: 7

• Total postnatal beds: 32

• Number of rooms in obstetric high dependency unit: 0

• Total obstetric high dependency beds: 0

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 20

• Amenity rooms; Are women able to book a single room in advance of their birth: Whilst in labour women can request PN sideward for amenity bed if one is available.

• If women can pay for a single room what is the average cost per night (GBP): 45

• 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:

• 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: Not available

• Pain relief available - Aromatherapy: Provided by women

• Pain relief available - TENS: Provided by women

• 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

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 180

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 175.12

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

• 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 and On Call

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

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

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

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

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:

• Also available for: Teenagers

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 11- 12+6

• Scan 2 available between: 18-20

Trust Statistics

Trust Questions

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