Wythenshawe Hospital, Manchester

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 289

• Of these how many have an ensuite toilet: 20 218 of the single rooms have an ensuite toilet as a minimum

• Of these how many have an ensuite toilet and shower or bath: 198

• 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: Hospital Incident Reporting System (HIRS)/ Clinical Coding

• 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: Hospital Incident Reporting System (HIRS)

• 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: Hospital Incident Reporting System (HIRS)

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 4

• 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

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 119 UHSM has a safety culture which encourages incident investigation to facilitate learning and support safe care.

• 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% All relevant wards have a track and trigger system in place.

• What percentage of patients are risk assessed for venous thromboembolism on admission: 91-99% During the period Jun 10 - Mar 11 31-60% of patients were assessed. The Trust steadily improved its performance and in the last 4 months has exceeded the national target of 90%

• 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: One-to-one training is offered to clinicians on the use of Clinical Indicator Benchmark tools

• 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: Central platforms include monthly and annual Quality Account, risk systems (HIRS) and also the clinical benchmarking system (CHKS)

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 Elective Surgical & Medical patients as per Trust MRSA screening policy, including orthopaedic and cardiothoracic.

• 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:

• 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:

• Protocol for isolating patients with infections: The Trust has an isolation policy, all patients with known or suspected Infections are isolated in a single room or cohort nursed.

• 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 prescribe probiotics to any patient groups as a prophylactic measure to reduce C.difficile infections: Clinicians prescribe probiotics on an individual patient basis; they are not prescribed on a routine basis

• 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

• Number of beds in the unit: 22

Trust Questions

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

• Is the Trust part of a stroke care network:

• Details: Manchester 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): 425 The methodology used is similar to SINAP. It includes emergency admissions with a primary diagnosis of I60, I61, I62, I63 or I64 (spells)

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 337 The methodology used is similar to SINAP. It includes emergency admissions with a primary diagnosis of I60, I61, I62, I63 or I64 (spells) and the number of those that had a CT Scan within 24 hours of arriving in hospital

• 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:

• These arrangements are with: Salford Royal NHS FT and Stockport NHS FT

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:

• 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)? :

• Not able to put a figure on the percentage of all patients that attend the class prior to surgery:

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

• Not able to put a figure on the percentage compliance to this protocol:

• Not able to put a figure on the percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery:

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

• Not able to put a figure Patients' discharge delayed due to lack of physiotherapy services at weekends:

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

• What is the principle reason for patients not being admitted on the day of surgery: Patients exhibiting existing co-morbidities are admitted prior to the day of surgery; otherwise patients are admitted on 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: High-risk patients are contacted after discharge

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) Other: Nurse consultant, Clinical Psychologist, Pharmacist

• 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:

• 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: The views of patients are obtained

Maternity Care

Maternity Sites

• Wythenshawe Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 4023

• How many babies were born in the unit during the year? (not including home births): 4080

• How many women were booked for a home birth: 23

• How many women had a home birth? (not including births at home by accident): 19

• Number of antenatal rooms: 7

• Total antenatal beds: 16

• Number of assessment area rooms (for monitoring and / or induction): 2

• Total assessment area beds: 7

• Number of delivery rooms: 13

• Total delivery beds: 13

• Number of postnatal rooms: 11

• Total postnatal beds: 29

• Number of rooms in obstetric high dependency unit: 2

• Total obstetric high dependency beds: 2

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 2

• 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 not applicable

• 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: N/A

• 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: Provided by unit

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

• Pain relief available - Intramuscular injection: Provided by unit

• Other pain relief: not applicable

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 143

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 143

• 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:

• Also available for: Teenage pregnancy,Twin group

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 11- 14 weeks

• Scan 2 available between: 19-21 weeks

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: University Hospital of South Manchester NHS Foundation Trust