Archived: Manchester Royal Infirmary

Updated 13 June 2016

Manchester Royal Infirmary is a large teaching hospital that is part of Central Manchester University Hospitals NHS Foundation Trust. The trust has 1721 beds in total and employs 9,930 staff.

Manchester Royal Infirmary (MRI) provides a full range of general and specialist services including emergency care, critical care, general medicine including elderly care, surgery and outpatient services. The hospital is one of three designated major trauma centres in Greater Manchester. The accident & emergency departments at MRI and the Royal Manchester Children’s Hospital see around 145,000 patients each year. The hospital is also a specialist regional centre for kidney and pancreas transplants, haematology and sickle cell disease. The Heart Centre is a major provider of cardiac services in the region, specialising in cardiothoracic surgery and cardiology. Located on the same site as the Manchester Royal Infirmary are the following specialist hospitals:

St Mary’s Hospital is a specialist hospital for women, babies and families. More than 1,400 staff, including doctors, nurses, midwives, scientists, clinical and non-clinical support staff work in Saint Mary's hospital. The maternity service offers pregnant women and their families antenatal, delivery and postnatal care. St Mary’s hospital also provides a range of specialist gynaecology services for women including: general gynaecology, gynaecology oncology, termination of pregnancy and an emergency gynaecology unit (EGU). The EGU provides 24-hour direct access for patients who have urgent gynaecological problems or women with problems in early pregnancy. The hospital also provides reproductive medicine services and rapid access services for victims of sexual assault. Saint Mary's Hospital is a tertiary unit which includes a nationally designated tertiary Fetal Medicine Unit. Genomics clinics are also provided in the Manchester centre for genomic medicine, one of the largest and most comprehensive multidisciplinary clinical genetics units in UK. Here, services support pre-natal genetics, dysmorphology, neuromuscular genetics, neuropsychiatric genetics, ophthalmic genetics, cardiac genetics and cancer genetics

The Royal Manchester Children's Hospital (RMCH) provides specialist healthcare services for children and young people throughout the North West, as well as nationally and internationally. With 371 beds it is the largest single-site children's hospital in the UK.

Manchester Royal Eye Hospital (MREH) is a large, specialist ophthalmic teaching hospital. The hospital provides a range of outpatient and elective and unplanned ophthalmology surgical services including: emergency eye surgery, ophthalmic imaging, ultrasound, macular treatment, cataract surgery, electro-diagnosis, laser vison correction surgery, optometry, orthoptics, bionic eye implants and ocular prosthetics.

Each hospital is based on the trust’s main site along with the Manchester Royal Infirmary but is a separate, purpose-built building with its own identity as a specialist hospital.

We carried out this inspection as part of our comprehensive inspection programme. As part of the inspection we have reported on the core services within each hospital as follows:

- Urgent and Emergency Services at MRI and RMCH

- Medical care services at MRI

- Surgery services at MRI and MREH

- Critical care services at MRI

- Maternity and gynaecology services at St Mary’s Hospital

- Neonatal services at St Mary’s Hospital

- Children and young people’s services at RMCH

- End of life care services at MRI

- Outpatient services at MRI and MREH.

Updated 13 June 2016

Manchester Royal Infirmary is a large teaching hospital that is part of Central Manchester University Hospitals NHS Foundation Trust. The hospital provides a full range of general and specialist services including emergency care, critical care, general medicine including elderly care, surgery and outpatient services. The hospital is also a specialist regional centre for kidney and pancreas transplants, haematology and sickle cell disease. The Heart Centre is a major provider of cardiac services in the region, specialising in cardiothoracic surgery and cardiology. Located on the same site as the Manchester Royal Infirmary are the following specialist hospitals:

St Mary’s Hospital - a specialist hospital for women, babies and families

Royal Manchester Children’s Hospital (RMCH) - provides specialist healthcare services for children and young people. With 371 beds it is the largest single-site children's hospital in the UK.

Manchester Royal Eye Hospital (MREH) - a large, specialist ophthalmic teaching hospital.

Each hospital is based on the trust’s main site along with the Manchester Royal Infirmary (MRI) but is a separate, purpose-built building with its own identity as a specialist hospital.

We carried out this inspection as part of our comprehensive inspection programme. We carried out an announced inspection of Manchester Royal Infirmary, Royal Manchester Children’s Hospital, St Mary’s Hospital and the Manchester Royal Eye Hospital between 3 and 6 November 2015. In addition an unannounced inspection was carried out between 3pm and 8pm on 23 November 2015 at Manchester Royal Infirmary, St Mary’s Hospital and Royal Manchester Children’s Hospital. As part of the unannounced visit we looked at triage and safeguarding processes in accident and emergency services and staffing levels in maternity services. We have reported our findings for all four hospitals within this report.

Overall we rated Manchester Royal Infirmary as ‘Good’. We have judged the service as ‘good’ for safe, caring, effective and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

• The areas we inspected were visibly clean and well maintained.
• Staff were aware of current infection prevention and control guidelines.
• We observed good practices in relation to hand hygiene, ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
• Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

Nurse and midwifery staffing

• Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services.
• However nurse staffing levels, although improved, remained a challenge. There were still a high number of nursing vacancies across most services including midwifery, general medicine, A&E and surgery. The trust was actively recruiting nursing staff from overseas to try and improve staffing levels.
• Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased demand, or short notice sickness and absence.
• St Mary’s Hospital had implemented a number of initiatives to continually assess patient acuity and staffing levels using a designated co-ordinator. There was a commitment to increase the number of midwives available and recruitment was ongoing.
• Services tried to use the same bank and agency staff to ensure they had the required skills to work on the ward. Agency staff were given an induction before commencing work.
• The Intensive Care Society standard for nurse staffing states there should be a band 6 or 7 supernumerary clinical coordinator on duty 24 hours a day, seven days a week. At the time of inspection this was not always happening on the cardiac intensive care unit as there was not a supernumerary clinical coordinator on duty during the night shift.We were told of occasions when this supernumerary provision was met but a staff member may then be moved during the night to assist other areas within the hospital. We raised this matter with the directorate senior staff at the time of inspection. They responded promptly by immediately implementing an action plan which gave the cardiac intensive care unit their supernumerary clinical coordinator at night.
• Data showed there had been a 33% increase in the demand for end of life care services. The need for sufficient specialist palliative care staff to meet the demand for the service had been identified by the service and was on the end of life risk register. A business case had been submitted to seek investment in services to enable staff to respond in a timely manner and provide access seven days a week and out of hours.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• There were sufficient numbers of consultants and medical staff to provide patients with safe care and treatment.
• Locum doctors were used to cover existing vacancies and for staff during leave. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures.
• There was 168 hours of consultant presence on Maternity and NICU. The trust was one of only two in the country to implement this standard.
• For patients with palliative/end of life care needs, medical cover was provided on the general wards in MRI.
• Palliative care consultant cover was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland and the National Council for Palliative Care guidance.

Access and flow

• Due to the number of emergency admissions and increased demand for services there was continual pressure on the availability of beds across the hospitals, particularly the MRI and RMCH. As a result the management of patient access and flow across the hospitals remained a significant challenge for managers. There were sound arrangements to ensure the timely medical review of patients.
• The trust’s performance for patients being seen within 4 hours was similar to the England average and the trust exceeded the 95% target between March and May 2015. However, the adult emergency department at MRI consistently failed to meet national targets for time to treatment, time to discharge and ambulance handovers.
• Both the adult’s and children’s departments were often overcrowded. At the time of our visit, the children’s emergency department reached full capacity and we saw the matron and the clinical lead contact operational managers across the hospital to increase the flow of patients. Records showed that between April and September 2015, 15% of patients waiting in the adult emergency department to be admitted to the MRI were waiting on a trolley for between four and 12 hours. This was worse than the England average of around 2%.
• In MRI and RMCH, patients were sometimes placed on wards that were not best suited to meet their needs (also known as outliers).However, there were good systems in place for the management of these patients to ensure they received a regular medical review.
• The hospital held bed management meetings regularly throughout the day during the week to review and plan bed capacity and respond to acute bed availability pressures.
• There was a clear focus on discharge planning although there were a number of patients experiencing delayed discharge because they were waiting for packages of care.
• Adult surgery services achieved the 18 week referral to treatment standards across all specialties. Elective operations were frequently cancelled due to a lack of available beds and theatre lists running late. The rate of cancelled elective operations had been higher than the England average since July 2014. However, the division of surgery transformation plan included actions to improve theatre efficiency and reduce cancelled operations.
• At RMCH surgery services faced ongoing challenges in meeting the 18 week referral to treatment time standards, with some specialist services experiencing waiting list pressures.
• There had been significant improvements in adult critical care services in reducing the number of patients discharged out of hours. However, challenges with access and flow within the wider hospital impacted on patients’ discharge from the critical care units. Similarly capacity issues in the cardiac intensive care unit (and wider cardiac wards) meant beds were not always available to allow patients to be discharged onto a ward.
• Bed occupancy rates in maternity services were 25% higher than the England average throughout April, May and June 2015. This meant there was insufficient capacity for the numbers of patients attending the maternity unit. A policy to divert patients to other units in the area was in place however, the threshold for the use of this policy was not clearly defined and there was no risk assessment to support the process.
• The system at St Mary’s Hospital was to plan eight inductions per day, however due to bed capacity and staffing, these were often not completed on the day. This led to some patients being admitted to wait for induction and others being sent home to wait.

Mortality rates

• Mortality and morbidity meetings were held monthly and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for every patient who had died in the hospital within the previous week. Any learning identified was shared and applied.
• The trust had previously been identified as an outlier for puerperal sepsis and other infections as part of the CQC intelligent monitoring programme. On request, the trust had provided the CQC’s maternity outliers panel with the requested information and could evidence that a full investigation had taken place to understand the data and identify areas for improvement. As a result the service had an action plan in place and this had reduced the rate of infection from 6.8% to 4% between April 2015 and July 2015.

Nutrition and hydration

• Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.
• A coloured tray and jug system was in place to highlight which patients needed assistance with eating and drinking.
• Some wards had ‘protected mealtimes’ in place when all other activities on the wards stopped, if it was safe for them to do so. This meant staff were available to help serve food and assist those patients who needed help.
• The food and drink provision had been reviewed since the last inspection in 2013, which highlighted that the choice of food across the hospital was limited. As a result, actions had been taken to improve food provision. Work however, across the trust was ongoing. The standard of food was an identified risk on the trust’s risk register and a programme of work was being undertaken to understand where and what improvements were required.

We saw several areas of outstanding practice including:

• Staff monitored patients by using an electronic early warning score system that automatically notified medical staff and some non-medical staff (such as the surgical lead pharmacist) if there was deterioration in a patient’s medical condition. This process was fully embedded across the main site and all the staff we spoke with were positive about using this system.
• The diagnostic imaging department used innovative new technology for assessing coronary artery disease which was available in only two centres in the UK. This meant that patients only required a single one hour visit rather than two visits and three hour appointments. It also meant lower radiation doses were administered to both staff and patient when compared with conventional technology.
• The neonatal unit used video technology to support women who were not well enough to visit their baby, and a bleep system for parents so that they were involved when decisions were being made by medical teams.
• The gynaecology emergency unit was locally unique in that it allowed patients to refer themselves to a specific unit for assessment and treatment of gynaecological emergencies and problems in early pregnancy.
• The development of a nationally unique service relating to developmental sexual dysfunction. This specialist clinic met the very specific needs of patients suffering a variety of sexual development issues. Patients who attended this clinic had the opportunity to be seen by consultant gynaecologists, endrocinologists and psychologists. Counselling services specific to the patients who attended the clinic was also available.
• Staff at St Mary’s hospital participated in an extensive programme of local, national and internationally recognised research. In areas such as female genital mutilation (FGM), senior staff within St Marys were participating in the development and implementation of national guidelines.
• The adult rheumatology ward had really thought about the feelings of young people transitioning into their department. They considered how young people would feel sitting in waiting rooms predominately designed for older patients and had developed a separate young person clinic, which was due to start in January 2016. They had involved young people in the re-design of the waiting room, using a mural of photographs of the young patients. The ward had set up a youth group who communicated via social media, which the staff monitored. They had developed their own education sessions for young people, in particular a session called ‘Sex, drugs, rock and roll’, to inform the young people of their condition and the impact of their life style choices.
• The baby hip clinic was the first example of a one stop assessment and treatment service for children with developmental dysplasia of the hip to be a collaboration between all consultants, rotating through the clinic, with agreed protocols and pathways, allowing standardisation of care and facilitating audit and research. This innovation placed the clinical needs of children and ease of accessing assessment and treatment for parents at the forefront of service redesign.
• Trained nurses were able to undertake eye screening for retinopathy of prematurity (ROP) using a web cam for babies in the neo-natal unit and were able to get immediate clinical review by ophthalmology consultants. The service had been evaluated as successful and was provided in other units as a result.
• The MREH was identified as a NICE exemplar (best practice) service for the management of glaucoma.

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

Importantly, the trust must:

• Ensure that sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed in all services, particularly urgent and emergency services, medical care, surgery services and end of life care. This also includes midwives in all areas of the maternity services and sufficient doctors to provide timely review of patients when requested.
• Improve patient flow through the Manchester Royal Infirmary, St Mary’s Hospital and Royal Manchester Children’s Hospital, particularly in maternity services, medical care, surgery services and A&E.

In addition the trust should:

• Ensure checks of resuscitation equipment are carried out and recorded in line with trust policy and procedures.
• Ensure medicine fridge temperatures are recorded daily and staff take appropriate action if and when a temperature is outside the recommended range.
• Continue to improve the quality and storage of patient records to ensure they are fully completed and all contents are securely stored.
• Ensure that all staff receive appraisals and mandatory training to enable them to carry out their role and responsibilities.
• Have a vision and strategy in place for end of life care for adults, children and young people. The trust should review the leadership for palliative care across the service to ensure it reflects the needs of patients.
• The trust should ensure that appropriate systems are in place to assess, monitor and improve the quality of end of life care provision for patients and their families.

In urgent & emergency services

• Upgrade the mental health rooms as planned.
• Ensure that there are established systems in place to effectively document adult safeguarding concerns.
• Ensure the risk register is regularly updated and clearly reflects actions taken to control and mitigate risks.
• Consider how to prevent or manage the spread of infection on OMU.
• Consider how side rooms without nurse call bells are used in ED.
• Consider how to make services in the WIC more child friendly.
• Ensure staff in the children’s emergency department hand hygiene protocols to prevent the spread of infections.
• Review safeguarding processes for triaging a patient and the electronic patient record system to ensure that every opportunity is taken to identify and make staff aware of safeguarding or child protection concerns when a child or young person presents at the children’s emergency department or walk in centre.

In medical care services

• Consider the review of training around the medicines policy in relation to the administration of patients own medication and the administration of when required medication.
• Ensure that all staff understand and follow the correct process when completing DoLS applications.
• Ensure that all equipment has up to date electrical safety certificates and that oxygen cylinders are stored in line with guidelines.
• Ensure that patients’ privacy and dignity is maintained at all times on the endoscopy unit.
• Ensure that all staff seek consent for the use of bedrails and if patients lack capacity apply the Mental Capacity Act (2005) principles.

In surgery services

• Improve availability of patient notes for patients admitted as part of the rapid access process.

In critical care services

• Should review the medical staffing model operated in the paediatric high dependency unit (PHDU) to ensure that it fully supports effective care for children on the unit.
• Should ensure there is a clear vision and strategic plan in place for the cardiac intensive care unit.

In maternity and gynaecology services

• Ensure that all areas of the maternity services are clean and tidy at all times.
• Ensure that personal protective clothing used in the operating theatres meets with current guidance.
• Ensure there is adequate seating made available for patients to wait in comfort in the day assessment unit and the maternity triage area.
• Ensure their policy and procedures for the induction of labour meet with current guidance.
• Take action to ensure that there is a robust system for protecting babies from abduction.

In children and young people’s services

• Ensure there is a clear policy in place for transition services based on current guidelines and relevant legislation that considers how services can work in a joined up way to provide a person centred approach across children and adult services.
• Ensure medicines are labelled with the date they are opened so that they are disposed of in a timely manner.
• Consider having a designated isolation area, for patients that enter the children’s emergency department with infectious diseases.
• Consider how blood sample tubes can be transported form ward 85 to the pathology laboratory in a timely manner.
• Continue to work with children, young people and their families to ensure that food and menu options are child friendly and appeal to patients using the service.

In end of life care services

• Ensure staff have access to suitable and sufficient equipment, such as syringe drivers to deliver person centred care in a safe and effective way to meet people’s needs.
• Review its access to specialist palliative care over 24 hours (seven days) in line with national guidance for end of life care.
• Ensure that it fully implements the national recommendations following the removal of the Liverpool Care Pathway.
• Reduce the frequency of delays above 60 minutes for patients attending appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 13 June 2016

We rated medical care services as ‘Good’ overall because;

Care was provided in line with national best practice guidelines and medical care services participated in the majority of clinical audits where they were eligible to take part. National audits indicated that the majority of patients experienced good outcomes. Improvements had been made in the provision of stroke care although some improvements were still required. Action plans were in progress where areas for improvement had been identified. There was a focus on discharge planning from the moment of admission and there was good multidisciplinary working to support this.

Incidents were reported and investigated appropriately. Lessons were learnt and improvements made following incidents and findings were fed back to staff. There were systems in place to keep people safe and staff were aware of how to ensure patients’ were safeguarded from abuse. The hospital was clean and staff followed good hygiene practices. Staff understood the key principles around obtaining informed consent, the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLS). However DoLS paperwork could be variable, particularly in relation to emergency applications.

Medical services met the 18 week standards for referral to treatment times in all specialities from September 2013 to July 2015. Patients were sometimes placed on wards that were not best suited to meet their needs (also known as outliers). However, there were good systems in place for the management of these patients to ensure they received a regular medical review. Services took into account the needs of the local people. The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not scheme for people living with dementia or a cognitive impairment and the falling leaf symbol to indicate that a patient was at risk of falls. There was access to translation services and leaflets were available for patients about the services and the care they were receiving.

There were governance systems in place which included a risk register. Some risks on the register had no actions or control measures identified so it was not clear if they were being managed effectively. It was unclear from the evidence provided if services were implementing the agreed governance framework or discussing risks at the relevant meetings. All staff knew the trust vision and values framework. Staff felt supported and morale was good. All staff were committed to delivering good quality care and were motivated to work at the hospital.

However, nursing staffing levels on some of the wards did not meet the planned requirements, especially at night, on the endoscopy unit and the acute medical unit. Records were left unsecured on the wards we visited and there was a risk that personal information was available to members of the public.  There were standards for record keeping that required improvement but records did include a treatment plan for each patient. There were a number of patients who were moved during the night on some wards and half of all patients experienced one or more moves during their stay. Patients’ privacy and dignity was not always maintained on the endoscopy unit as there were male and female patients in hospital gowns in the same waiting room with only a temporary screen to separate them.  Plans were in place to address this.

Updated 13 June 2016

We rated children and young people’s services as ‘Good’ overall because;

Incidents were reported appropriately using an electronic reporting system. Staff were aware of the system and how to use it. There were examples of learning from incidents and how this learning was shared across the service and trust wide. Cleanliness and hygiene was of a high standard in the areas we visited and staff followed good practice guidance in relation to the control and prevention of infection. However, improvements were required in relation to the monitoring of medicine fridge temperatures and resuscitation equipment.

Patients received care in line with current evidence-based guidance and standards. Policies and procedures were in place and staff were aware of how to access them. Frequent audits were completed and subsequent action plans implemented. Children and young people’s services were delivered by caring, committed and compassionate staff that treated people with dignity and respect. Staff actively involved young people and their parents and carers in all aspects of their care. Policies and procedures were in place to identify and refer cases of suspected abuse and staff knew the type of concerns they should escalate. However, the processes to highlight previous or ongoing safeguarding or child protection concerns were not robust.

Services were planned and delivered in a way that met the needs of the local population. There were facilities to enable parents to be with their child at all times. We observed that each ward provided a child friendly environment. Interpreting services were available as required. However, improvements were required in relation to referral to treatment times in outpatient services. Long wait times for elective treatment at RMCH remained a challenge with a number of specialities failing to meet the 18 week referral to treatment target.

The hospital had recently undergone an organisational restructure and had moved to having clinical service units. The clinical leads described a very clear vision for their departments. At the time of the inspection, we found this was not yet embedded in practice. There was a robust governance structure in place within the children’s division which fed into the trust risk management committee. Monthly governance meetings were held and attended by key professionals. The framework also enabled the dissemination of shared learning and service improvements and a pathway for reporting and escalation to the trust board. Risk registers were in place and well maintained, although we found that some risks identified by managers were not on the risk register.

There was strong clinical and managerial leadership at unit and divisional level. However, the model of care in the PHDU meant that at certain times (out of hours) overall responsibility for the patient’s care and treatment was with the parent team and not the intensive care consultant. This represented a risk to timely and consistent decision making. Whilst some progress had been made to meet national guidance following the removal of the Liverpool care pathway in 2014 we found a lack of clarity about what documentation was in place for end of life care at RMCH. There was no clear strategy for end of life care throughout children’s services. Similarly, there was no clear policy or strategy in place for transition services.

Updated 13 June 2016

We rated critical care services as ‘Good’ overall because;

There were sufficient numbers of suitably skilled nursing and medical staff to care for the patients. There was not always a supernumerary shift coordinator on shift on the cardiac intensive care unit at night. However, we raised this with the trust and they responded immediately to this shortfall, implementing an action plan which ensured that staffing numbers on night duty met with the intensive care society standard. We found a culture where incident reporting and learning was embedded and used by staff.

The clinical areas benefited from recent refurbishment and met with the latest health building note guidance. The units also benefited from excellent levels of equipment and maintenance with dedicated critical care technologists supporting the service. There was strong clinical and managerial leadership at unit and divisional level. The unit had a vision and business plan for the next five years. There was an effective governance structure in place which ensured that all risks to the service were captured and discussed. The framework also enabled the dissemination of shared learning and service improvements and a pathway for reporting and escalation to the trust board.

The units continued to collect and submit data for the intensive care national audit and research centre (ICNARC) and the central cardiac audit database (CCAD) for validation, so they were able to benchmark  performance against comparable units. These data showed that apart from delayed discharges, patient outcomes were within the expected ranges when compared with similar critical care units nationally. In terms of unit acquired infections the data indicated much better performance than comparable units. We saw patients, their relatives and friends being treated with care, compassion, dignity and respect.

Updated 13 June 2016

We have rated end of life care services as ‘Requires improvement’ overall because;

Access to specialist palliative care was not available seven days a week other than an advice line provided by the local hospice. Consultant staffing was below the recommended levels for palliative/end of life care. The trust had identified that the service required improvement and had submitted a business case to increase both nursing and medical staff to meet the demands on the SPCT.

Whilst some progress had been made to meet national guidance following the removal of the Liverpool care pathway in 2014 there was some confusion and a lack of clarity about what alternative documentation was in place. There was a need to identify and formalise a clear strategy for end of life care throughout adult services. The trust had identified an executive director to lead end of life care for the trust. This was introduced at the time of our inspection.

However; there was a dedicated specialist palliative care team (SPCT) who provided support to patients at end of life and to staff caring for patients on the general wards. End of life care provided by staff on wards was found to be safe and personalised to the needs of individual patients. Staff worked hard to meet the individual patient’s needs and wishes. They were caring and committed to supporting people at end of life. Individual clinical teams used a combination of evidence based guidance, such as National Institute for Health and Care Excellence (NICE) guidance, Royal Colleges’ guidance and quality standards to determine the care provided.

Updated 13 June 2016

We have rated the maternity and gynaecology services as ‘Good’ overall. However, some areas required improvement particularly in maternity services.

Gynaecology services (including outpatient services) consistently met national access targets. This included referral to treatment times in all specialties. Urgent 2-week referral timescales were also met, and there were rapid access clinics available. Gynaecology services provided effective care with outcomes comparable with, or better than expected standards.

Across maternity and gynaecology services, medicines were safely stored and the necessary records were maintained. Medical and nursing records were accurate, complete, and securely stored. Patient safety was monitored and incidents were investigated to assist learning and improve care. There was an open culture to support the reporting of incidents. There were good systems in place to identify and support patients who were at risk due to social or emotional circumstances. The senior management team was visible and accessible to staff and managers were seen as supportive and approachable. Patients were very positive about the care and treatment they received at the hospital. Staff were committed, passionate about their work, and proud of the services they offered to patients. Staff were keen to learn and continuously improve the services they offered to patients.

Good practice was observed throughout maternity and gynaecology services but increased demand and a high number of staff vacancies led to ongoing challenges in the maternity service. In the maternity unit, there were a high number of incidents reported that were due to staffing issues. Managers were aware of this and recruitment was underway. However although we found staffing levels were adequate at the time of our inspection, the situation was not sustainable and there was limited flexibility in numbers to cope with increased demand, or short notice sickness and absence. Due to the pressures of work, morale was low but staff of all professions supported each other well to work as a team. Medical notes were not always available in maternity clinics and delays in caesarean sections had occurred due to a lack of information. The electronic baby tagging system was not robust.

Bed occupancy rates in maternity services were 25% higher than the England average throughout April, May and June 2015. This meant there was insufficient capacity for the numbers of patients attending the maternity unit. This lead to patients waiting to be seen in unsuitable areas, waiting for beds, discharging themselves and delays in treatment.

Updated 13 June 2016

We have rated neonatal services as ‘Good’ overall because;

Treatment was based on current best practice guidance and was constantly reviewed to ensure that care met the needs of the baby and identified ways to improve treatment. The service responded to the outcomes of audits and worked collaboratively with other units, research agencies, royal colleges and universities both nationally and internationally to make sure the best possible outcomes were achieved. Patients and parents were supported by a team of specialist nurses who worked in a co-ordinated way to provide care, advice and support throughout the baby’s admission. Parents were treated well and involved in the care of their babies. They were positive about their experiences. We observed compassionate care that promoted the wellbeing and future emotional development of babies.

The neonatal team included highly skilled expert practitioners. Staff had opportunities to maintained their competencies and develop additional skills. Nurses were consistently deployed according to best practice guidance, seven days a week and a consultant neonatologist was on site 24 hours a day, seven days a week. There were two consultants and a range of specialist support such as specialist nurses available at weekends. Staff complied with infection control measures and the environment and facilities on the unit were clean, well maintained and promoted the safety of babies. Adequate and appropriately maintained emergency equipment was available to quickly meet the needs of deteriorating babies.

The service fostered an open culture and provided training and guidance to staff to ensure they were able to raise all incidents and concerns. Processes were in place to effectively deal with concerns raised. Investigations were robust and action was taken to prevent repeat incidents and ensure lessons learnt were shared with staff and appropriate changes made. The direct leadership team were motivational, focussed and effective in supporting staff and involving stakeholders in relation to providing a good service. There were robust governance systems in place to monitor performance and promote improvements.

Updated 13 June 2016

We have rated outpatient and diagnostic services as ‘Good’ overall because;

Incidents were reported and investigated and action taken to limit recurrence. The areas we visited were visibly clean and tidy. Cleanliness, hygiene and infection control was monitored monthly and results demonstrated compliance. Records were of good quality but were not always available; staff used electronic records ensuring minimal impact to patients.

Staff were aware of safeguarding processes and knew what to do when they had concerns relating to abuse and neglect. Patient risks were identified and managed with appropriate measures put in place. Nurse staffing was adequate but there were vacancies in radiology due to national shortages of radiologist staff. Actions were in place to manage the shortfalls. Clinics did not operate seven days a week but on call radiology cover was available at all times. Patients received care based on national and local guidance. Audits were undertaken and discussed monthly in multi-disciplinary teams. The diagnostic imaging department at the MRI used special technology when caring for patients which was available in only two centres in the UK.

We observed staff treating patients with a caring manner and patients described them as kind and courteous. Patients and their carers felt involved in care and that staff explained treatment options in a way they could understand. Key staff acted as leads for care relating to the Mental Capacity Act and Deprivation of Liberty Safeguards. Most patients received appointments within 18 weeks of referral. However, almost a quarter of patients at the MRI waited longer than 60 minutes to be seen once they arrived. The number of patients’ not attending appointments had improved from 14% to 10% following actions such as text or phone call reminders. At the MRI, diagnostic reports were not always received in a timely way; however staff were aware of the reasons why and had implemented actions to try to address this.

Risk and governance processes were in place. Action plans were monitored to ensure that risks were mitigated. The culture in services was positive and the majority of staff felt valued. There was a strong ethos in ophthalmology services to drive innovation and research to improve patient outcomes experience and improve service provision.

Updated 13 June 2016

We have rated surgical services as ‘Good’ overall because;

There were sufficient numbers of consultants and medical staff to provide patients with safe care and treatment. There were still a high number of nursing vacancies in the wards and theatre areas at Manchester Royal Infirmary. However, staffing levels were maintained through the use of existing staff working overtime and with agency staff. There were plans in place to recruit 60 whole time equivalent nurses through EU and international recruitment by the end of January 2016. This was in addition to a planned recruitment of approximately 150 staff from the trust’s domestic recruitment programme. Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in clean and suitably maintained premises.

Surgical services provided effective care and treatment that followed national clinical guidelines and participated in national and local clinical audits. The surgical services performed in line with similar sized hospitals and performed within the England average for most safety and clinical performance measures. Patients received care and treatment by trained, competent staff that worked well as part of a multidisciplinary team. Staff sought consent from patients before delivering care and treatment. Patients spoke positively about their care and treatment and they were treated with dignity and compassion.

The surgical services achieved the 18 week referral to treatment standards across all specialties. There were systems in place to support vulnerable patients. However, further improvements were needed in relation to how the services provided at MRI responded to patient needs. There was insufficient bed capacity in the surgical wards which meant emergency patients were routinely transferred to the elective treatment centre short stay ward. Elective operations were frequently cancelled due to the lack of available beds and theatre lists running late. The rate of cancelled elective operations was higher than the England average since July 2014. The number of patients whose operations were cancelled and were not treated within the 28 days was worse than the England average between October 2014 and June 2015. The division of surgery transformation plan included improvement actions to improve theatre efficiency and reduce cancelled operations. There was sufficient capacity in the MREH to ensure patients admitted for surgery could be seen promptly and receive the right level of care. The rate of operations cancelled at this hospital was low and within expected levels.

The trust vision and values had been cascaded across the surgical wards and departments and staff had a clear understanding of what these involved. The wards and theatres had clearly visible leadership with clinical, nursing and business leads. Most staff were positive about the culture and support available. Monthly clinical effectiveness meetings reviewed incidents, key risks and monitoring of performance. There was routine public and staff engagement and actions were taken to improve the services.

Updated 13 June 2016

We rated urgent and emergency services as ’Requires improvement’ overall because;

In the adult ED, registered nursing and care staff shifts were regularly unfilled in the emergency department. Daily checks of essential equipment were not always completed. The high risk mental health assessment room did not ensure the safety of staff. Systems to safeguard patients were not always reliable and documentation of safeguarding was not consistent.

In the children’s ED, improvements in infection control and cleanliness standards were required. Medicines were not always checked regularly or labelled appropriately with the date they were first opened. Records were not always stored securely. The processes to highlight previous or ongoing safeguarding or child protection concerns were not robust. Nurse staffing numbers in the clinical decision unit (CDU) were lower than the required levels on some occasions.

The trust’s performance for patients being seen within 4 hours was similar to the England average and the trust exceeded the 95% target between March and May 2015. However, the adult emergency department at MRI consistently failed to meet national targets for time to treatment, time to discharge and ambulance handovers. Around 40% of ambulance handovers had a turnaround time of over 30 minutes between June 2014 and May 2015. In the year from August 2014 to July 2015 there were a total of 860 black breaches across the trust (black breaches are when the time between ambulance arrival and handover of the patient to ED is over 60 minutes). Both the adult’s and children’s departments were often overcrowded.

However; care and treatment was provided in line with national guidance. The services participated in local and national audits to benchmark their practice and performance and to improve patient care. Patient outcomes were positive and staff were supported to develop their skills and knowledge to achieve these outcomes. Pain relief was provided in a timely manner. There was good multi-disciplinary working and good communication between teams. Patients were treated with dignity and respect. They were involved in their care and treatment and supported to make decisions. Patients and their families were offered emotional support and staff acted with care and compassion. Their privacy and confidentiality was respected at all times.

There were clear governance systems in place. There was an open, honest culture with a drive to improve quality. Staff felt supported by leaders and that the senior management team were visible. Departmental risks were recognised and the lessons learnt from incidents and complaints were shared. Research and quality improvement were embedded within the services.