Midland Metropolitan University Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that people and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of people and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that people could access care in ways that met their personal circumstances and protected equality characteristics.

People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

The evidence showed a good standard. The service was good at making sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff offered patients options for care, support and treatment and helped patients feel empowered to make decisions about how this was delivered. This included making reasonable adjustments if patients met the criteria for the service.

Staff worked with patients when their needs changed to consider the care and treatment options that best met their changing needs. Staff responded to changes in patients after their surgery and when patients’ needs changed. For example, staff adjusted patient pain assessments during the first 24 hours on the ward and adjusted their care plans for any new care needs.

Staff completed care plans that looked at patient needs and preferences. Staff delivered care in line with care plans and records of care reflected this. Care plans reflected physical and emotional needs.

Warning markers were used to indicate if a patient had extra needs or was vulnerable. The markers were visible on screen and notes could be typed next to a patient’s name to indicate any concerns. For example, a patient with diabetes or other comorbidities, would have an indicator by their name.

The trust provided dementia awareness training for clinical staff and dementia friends information sessions for non-clinical staff. The trust also provided additional training on learning disabilities and mental health.

All patients located in the waiting areas received a leaflet that gave some simple information for patients and those waiting for family members to be seen. There were visiting times for wards, Wi-Fi password information, important telephone numbers and a reminder to tell staff about any concerns.

Translation services were available to patients whose first language was not English, and staff were aware of how to access the service. If interpreters were required, this was identified during pre-operative assessments and then booked to suit.

Chaplaincy services were available to patients 24 hours a day. Patients with different cultural or religious needs could request support as required. In most cases these requirements would be discussed at the preoperative assessment and staff told us it would be noted in the care plan or general patient notes.

Patient care and treatment was accessible, prompt and in line with evidence-based practice. Reasonable adjustments were made to ensure equal access to the service. Staff took account of both physical needs and cognitive needs including specific fears and preferences associated with healthcare conditions. This included learning disabilities, autism spectrum disorder and neurodiverse needs. Managers and staff had training on the awareness of these needs. Managers highlighted their private rooms would be used, which would be more suitable for patients who needed a quieter environment for their recovery.

The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The service understood the health and care needs of people, so care was joined-up, flexible and supported choice and continuity.

Staff understood the health and social care needs of patients by ensuring their surgery was suitable and within the inclusion criteria of the service.

We saw examples where the trust had considered not only the needs of local people but provided services for patients throughout England and Wales.

When a patient was supported by more than 1 service, staff worked in a collaborative way to make sure care was joined up. Staff worked with staff teams from their neighbouring NHS trust. This included teams from tissue viability, physiotherapy, and occupational therapy. Managers and staff acted when discharge needs changed from their pre-assessment.

The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information was available to patients through the trust’s website and leaflets. The information followed accessible information standard guidelines which included font enlargement, Braille, and translation services including British Sign Language. Managers provided information in line with information governance policies. This included security and access considerations and followed general data protection regulations (GDPR). Managers ensured compliance by completing a data security and protection toolkit to ensure compliance with GDPR and other relevant laws.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

Information was available for patients on how to raise concerns or make a complaint. There were posters on the wards, waiting areas and around the hospital publicising the complaints process.

We also saw leaflets in the waiting areas providing information on how to make a complaint and contained the details of the patient advice and liaison service.

The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. Complaints were discussed at quality improvement meetings and learning from complaints was discussed at staff safety huddles and staff meetings. We saw information regarding complaints was shared with staff in regular meetings and displayed on noticeboards in staff areas.

Lessons learned from complaints were identified, we saw learning had been discussed and an action plan had been written to address concerns locally.

Patients and their family understood how to give feedback or complain about their care. Learning would be identified for each complaint, and any themes would be shared at ward level and through the patient experience committee.

Managers supported people to give their feedback to a complaint. Managers acknowledged written complaints within 48 hours and answered in full within 30 working days. Where this was not possible, a further letter would be sent to explain why. There had been 42 complaints for the month of August 2025, 19 relating to general surgery and 22 for specialist surgery and 1 for theatres. We saw from meeting minutes that these had been discussed. The general surgery and theatre complaints had been responded to within the time frame in their complaints policy. However, there were some outstanding in specialist surgery.

People felt confident in the service to take the right action if they raised a concern or complaint. This included looking into the issue thoroughly, communicating what was happening, being open about what had been found out and what the outcome was.

The service worked with people to agree solutions to the concerns they raised and measured the impact of the changes made. Staff accepted feedback as an opportunity to improve the service, and the quality-of-care people received.

The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service made sure that people could access the care, support and treatment they needed when they needed it.

Surgical patients were usually booked a bed at pre-operative assessment, following review by a surgeon and anaesthetist. Patients were admitted to the hospital through the admission unit and supported in preparation for a procedure. At the time of the assessment the preoperative clinic was based at the City Health Campus site, there was a plan for this to be centralised at the MMUH site.

The process for booking beds for elective surgical patients worked well and was managed through the electronic bed booking system.

Patients would be assessed and prepared for theatre and located in a room or bed, depending if they were on a ward or surgical day case, to wait for their slot in theatre. Each room had a number which generally corresponded to the number of the theatre to be used for the operation.

The potential need for a high dependency bed was discussed at pre-operative assessment and consultants would risk assess the procedure to determine if a bed needed to be booked.

Managers held weekly theatre planning meetings to ensure theatres were optimised. This meant that scheduling ensured any cancellation of surgery could be filled quickly by a patient who needed it. However, managers acknowledged that some cancellations could not be avoided. There were 24 clinical cancellations reported for August 2025 and 24 patient cancellations for the previous month. The primary reason for cancellation was the patients not being medically fit. There were clear action plans looking at the cancellations on the day of surgery. The 24 patient cancellations were beyond the trusts control. The surgery service had a plan in place for preoperative assessment clinics, as they were not held on site at the new hospital at the time of the inspection.

Theatre utilisation for August 2025 was at an average of 82.2% for the whole of the surgery service. However general surgery for the same month was at 90.7%.

We reviewed divisional referral to treatment times (RTT) monthly data for incomplete pathways for surgery 2025/2026. Surgical services are expected to ensure that patients are seen and treated within national standards. The trust performance was 58% against a national average of 61%.

Against a national target of 18 weeks, as of August 2025, the trusts percentage of elective (incomplete) RTT pathways within 18 weeks or less was 59.3%, in the same period, the percentage of elective pathways waiting over 52 weeks was 1.4%.

The data showed that the percentage of patient’s were referred and treated within 18 weeks: for general surgery 61%, urology 58%, trauma and orthopaedics 51%, cardiothoracic 84% and gastroenterology at 53%. This meant that patients waiting for general surgery were waiting for 17 weeks, gastroenterology were waiting for 21 weeks.

During this assessment we looked at the national average for RTT, and this showed that the trust was performing better that the national average on long waits. Fewer patients were experiencing long delays over a year. This indicated that there was effective prioritisation for the longest waiting patients, even though the overall RTT was high.

The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff had a good understanding of patients that used the service and were most likely to experience inequality in their care. Staff completed equality, diversity and inclusion training as part of their mandatory training. The completion rate was 94%.

However, there is a limited detailed data collection in this field at present. There may be potential inequalities in surgical access, experience, and outcomes. At this time, these cannot be reported on at this time of this assessment.

The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Patients were supported to plan for life changes following surgery if this was suitable. Patients were given a cooling off period before starting their care to make sure the surgery was the correct decision for their medical and psychological needs. Staff ensured patients were informed about all aspects of the surgery and this started at the booking stage of their care. Staff approached these conversations in a sensitive manner and supported patients to feel as well as possible prior to their surgery.

The trust has a 5-year strategy. The first step had been completed by the opening of the Midland Metropolitan University Hospital. The surgical division was focusing on length of stay. By targeting reduced stays and higher day case rates the trust would be able to manage bed occupancy more intelligently, by means of a ‘surgical hub’ model.

Overall, this hub model would aim to optimise surgical capacity, improve patient flow and reduce waiting times. The hub would form strategic integration with the integrated care system and other collaborative hubs within the patch to further good outcomes.