Midland Metropolitan University Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first assessment for this service. This key question has been rated good. This meant people’s outcomes were good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

During our assessment visit we looked at 29 sets of patient records. There was a standardised approach to assessing each patient’s condition using nationally recognised tools. Patients received a comprehensive assessment on arrival, and this was updated dependent on their condition, needs and risk score. Examples included assessments of risk from pressure ulcers, deep vein thrombosis, nutrition and hydration, and falls. Because of much longer stays in the department there had been modifications to these assessments because of the risks of being on trolleys and seats rather than in beds.

Assessments included patient’s social circumstances, mental health issues and vulnerabilities including any protected characteristics. They also included reviews of previous attendance to the department.

Patients were assessed in different areas of the department. For example, those walking in would be triaged in cubicles using the Manchester Triage System and if necessary, directed to other areas such as the majors where further assessment might take place in the senior medical assessment and rapid treatment (SMART) area. Patients arriving by ambulance went to a ‘pitstop’ area within the ambulance assessment area where they were assessed and either held in the area for further assessment or directed to another part of the department. Patients arriving by ambulance who the ambulance service had pre-alerted were taken directly to the resuscitation area, or in some cases directly for treatment or imaging.

The nursing staff in the ambulance assessment area had access to the ambulance service’s computer aided dispatch system and so could see when patients were to arrive and a description of their condition. This meant they could prepare a provisional assessment and treatment plan for the patient, an approach which was effective.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and

Staff gave people good information about their care and treatment and additional information to support their physical and mental wellbeing.

There were internal systems to ensure policies and procedures were designed in line with current national legislation and evidence-based good practice. Clinical protocols and treatment were based on guidance from bodies such as the National Institute for Health and Care Excellence (NICE) and the Royal College of Emergency Medicine (RCEM). Changes to treatment guidance were effectively shared.

While individualised, when appropriate, care plans were based around defined clinical pathways and packages or bundles of treatment. This approach ensured patients received care in line with established best practice and adherence to these requirements could be audited.

The department participated in audits. These included those from external bodies such as RCEM and NICE, those programmed by the trust’s clinical audit department, and local initiatives. We saw examples of these, and they were diligently carried out with identified shortfalls subjected to root cause analysis and action plans implemented to make improvements.

The department had recognised the length of stay in the emergency department for patients was often far beyond the established standard of 4 hours. This meant patients needed to be provided with food and drink during their stay. This was done for reasons of comfort but also for clinical necessity. Examples were those patients with diabetes or those who were at risk of skin damage should they become dehydrated, and this concern was identified on the department’s risk register.

There was drinking water available almost everywhere in the department through jugs and plastic cups. Importantly, this meant patients could help themselves. Tea and biscuits were on offer several times a day. Within the main waiting area there was a snack bar and there were vending machines for snacks and hot drinks when it was closed. The department had a standing order for 30 hot meals for breakfast and dinner each day plus 50 cold meals for lunch. There was a supply of powdered instant soup and high energy snack bars should they be needed. Patients and relative to who we spoke told us they valued this service and it met their needs.

There were policies and procedures to ensure patients had their pain assessed and treated promptly. The department had learned from patient feedback that pain was not always dealt with promptly by moving some pain medicines into triage rooms so they could be immediately provided. However, we still saw some patient feedback that pain was not always promptly assessed or treated.

The service worked well across teams and services to support people although there was not always sufficient support from other specialties in the hospital.

Staff in the department told us there were good relationships between nurses, doctors, and the professions allied to medicine. We saw this in practice, and we also noted the positive working relationships between the hospital staff and ambulance crews. The ambulance service provided hospital ambulance liaison officers (HALOs) at its instigation as the role was funded by the ambulance service.

HALOs spoke positively of their experience within the department and said it was a good place to work.

The zonal safety huddles that took place, including those involving the most senior nurse and doctor in charge of the shift were effective. These conversations were honest and there was good professional challenge as well as the exploration of options. When decisions were made, the actions were carried out quickly and effectively. Similarly, handovers passed information about both the running of the department or zone, and individual patients.

Expectations as to how other parts of the hospital supported the emergency department were described through specialty specific quality standards. These set expectations as to how and when other specialities in the hospital should review patients in the emergency department. This performance was reviewed and was a topic for discussion in the bed and flow meetings that took place several times a day. Some specialities, including medicine were supporting the emergency department well, while we were told others were a “work in progress”.

We noted during our attendance at these bed and flow meetings there was sometimes frustration that patients were waiting in the emergency department when there appeared to be empty beds in all specialities. When this happened, senior staff emphasised the importance of keeping to the quality standards to maintain flow.

Staff in the children’s area of the department spoke positively of the support they were given by their colleagues from paediatrics.

The service supported people to manage their health and wellbeing to maximise their independence, choice, and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported patients to live healthier lives – for example, through participation in smoking cessation schemes and healthy eating advice. Many patients attended the department as the result of chronic health conditions or social circumstances. These included homelessness, addiction and unhealthy lifestyles. The department worked with the trust’s internal homelessness team to offer support and there was a multidisciplinary high-intensity users group within the department that aimed to reduce the need for some people to attend as often through improvements in their health and circumstances.

The department also signposted people to other services including those from the voluntary sector. We saw examples of this where there was in-reach from charities who supported vulnerable children as well as those addressing knife crime and gang membership.

The department worked well with other mental health providers and their staff were embedded within the department with their own office space.

The service routinely monitored people’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. However, because of the demands on the department, audits showed that care was sometimes not always timely.

The department participated in audit and quality improvement programmes. These were internal as well as those initiated by external agencies such as RCEM and NICE. These were of differing scales. For example, some were large and comprehensive such as those which were a national initiative while others were smaller internal audits often done as part of staff’s professional development. However, all were managed within a suitable governance framework.

There were audits that assessed the department’s compliance with the guidance that was used to deliver care. This was reported monthly to a trust clinical effectiveness group that signed off new guidelines and assessed and monitored compliance. Reports showed this audit activity was subject to oversight and that and gaps were identified, responded to and any ensuing action plans were monitored.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. Consent usually relied on verbal assent which was appropriate in the context of an emergency department.

There were suitable procedures and guidelines which were reflective of best practice and legislation. These covered situations where patients were unconscious or unable to consent for other reasons.

Staff were trained in obtaining consent and were able to articulate what they would do under different circumstances. The special considerations for children and their competence to make certain decisions were also implemented and staff who looked after children were suitably trained.

Patients with a reduced capacity to make decisions for reasons of their mental health or other circumstances were given capacity assessments and if best interest decisions needed to be made, they were. The department worked well with mental health providers to make sure that people had their rights protected. It was recognised that an individual’s capacity might change over time and this was of particular importance in a department where patients might alter their state of consciousness or have their judgment affected by medicines or substance abuse.

When we looked at patient records, we saw, when necessary, mental capacity assessments had been carried out and recorded as had any best interest decisions.