Manchester Royal Infirmary

Updated 19 March 2019

Manchester Royal Infirmary provides district general hospital services for the local population and specialist tertiary services.

The hospital has approximately 763 inpatient beds. These provide a wide range of medical and surgical acute care services including outpatients.

The emergency department provides care and treatment to approximately 225 adults a day. In addition, there is a walk-in centre located next to the emergency department which provides care and treatment to approximately 97 adults and children per day.

There is an adult intensive care unit at the hospital which has 20 intensive care beds. There is also a high dependency unit which has 20 beds.

The hospital was previously part of the Central Manchester University NHS Foundation Trust; on 1 October 2017 the trust merged with the University of South Manchester NHS Foundation Trust to become a new organisation, Manchester University NHS Foundation Trust.

Within the new structure, the urgent and emergency care, medical, surgical, end of life care and outpatient services are managed by the leadership team at Manchester Royal Infirmary. Critical care services are led by a managed clinical services team.

During our announced inspection we spoke with over 230 members of staff of all grades. We also spoke with over 35 patients and their relatives about the care they received and observed direct care and treatment being delivered. We reviewed 65 sets of patient records. We reviewed information that was provided by the trust before and after the inspection.

Updated 19 March 2019

We had not previously rated this location for this provider. We rated it them as requires improvement because:

• We rated urgent and emergency care, surgery and outpatients as requires improvement.
• People could not always access the service when they needed it. The urgent and emergency care service had consistently struggled to meet the four hour standard to admit, treat or discharge patients. Within surgical services, the cancelled operation rate was higher than the England average, the service was not meeting the 62 day cancer target, and there were a number of breaches of the 52 week target. We observed patients that had waited in the main outpatient department, from time of booking to consultation for up to two hours.
• The surgical service was not consistently complying with the surgical safety checklist which meant that opportunities to minimise or prevent harm could be missed. The surgical services risk assurance systems were not sufficiently robust to identify areas of concerns surrounding the surgical safety checklist.
• Within the emergency department, there were a high number of occasions when the planned number of nursing staff had not been achieved to provide the right care and treatment.
• We found that records were not always available within surgical services and the outpatients department. Records were not always completed in the urgent and emergency care service or outpatients.
• The urgent and emergency care service and surgical services did not always ensure its premises were suitable or that equipment was looked after.
• The urgent and emergency care service and surgical services. We found several areas of the emergency department, including some equipment to be visibly dirty and inconsistent infection control practices in theatres.
• There was not a consistently positive culture within surgical services.

However:

• We rated critical care as outstanding. Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care and there was a strong leadership structure. Patients and relatives felt that staff went the extra mile and their care and support exceeded their expectations.
• We rated medical care and end of life care as good. Staffing levels and skill mix were planned, implemented and reviewed to keep people safe and staff understood risks and gave a clear, and current picture of safety. Effective processes were in place so lessons were learned when things went wrong.
• Across all services we found that staff cared for patients with dignity and compassion.

Updated 19 March 2019

We had not previously inspected this service. We rated the service as good because:

• There were systems, processes and standard operating procedures to keep people safe and safeguarded from abuse, using local safeguarding procedures as necessary.
• Staffing levels and skill mix were planned, implemented and reviewed to keep people safe and staff shortages were responded to quickly and adequately.
• Monitoring and reviewing performance activity enabled staff to understand risks and gave a clear, and current picture of safety. Lessons were learned and communicated widely to support improvement in other areas where relevant, as well as services that are directly affected.
• Patients’ care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice, legislation and technologies. This was monitored to ensure consistency of practice.
• There was participation in relevant local and national clinical audits and other monitoring activities such as quality improvement projects including ward accreditation and bench marking.
• The needs and preferences of different people were considered when delivering and coordinating services. Systems were in place to identify those who needed extra support.
• The leadership, governance and culture promoted the delivery of high-quality person-centred care.

However:

• Some of the equipment on the wards was overdue for replacement.
• Early warning scores were not always responded to in a timely manner.

Updated 19 March 2019

This is the first time we have inspected and rated the service since the trust was formed in October 2017.

We rated it as outstanding because:

• Staff had a strong patient centred approach to patients and cared for them with compassion. Feedback from patients and those close to them was continually positive, they felt that all staff went the extra mile and the care and support exceeded their expectations.
• Patients emotional and social needs were seen as being as important as their physical needs and emotional support was given to patients to minimise their distress. Staff were committed to working in partnership with patients and those close to them in decisions about their care and treatment and were seen as active partners.
• Leaders demonstrated high levels of experience, capacity and capability needed to deliver excellent and sustainable care. The strategy was fully aligned with plans in the trust and wider health economy and the service aimed to be recognised as a centre of excellence within the region, nationally and internationally.
• Leaders across the service had a shared purpose and were motivated and enthusiastic. They promoted a positive culture that supported and valued staff. There was a focus on teamwork across all functions with a common purpose to improve patient care and the quality of the service.
• The service had effective systems for identifying risks, and demonstrated a commitment to planning to eliminate or reduce them. Improved patient care was a focus and there was a proactive approach to seeking out and embedding new working processes and innovation was encouraged within the teams.
• The service ensured that there were enough staff in the right areas to keep people safe. Staff had received mandatory training, knew what to do to protect patients from abuse and how to report an incident if things went wrong.
• The service had suitable premises and equipment and were compliant with the Department of Health Building Note 04-02 for critical care units. The environment was visibly clean and tidy.
• Staff completed and updated risk assessments for patients and kept clear records of their care. The service managed medicines well and adhered to antimicrobial prescribing policies.
• The service provided care and treatment based on national guidance. The Intensive Care National Research and Audit Centre demonstrated the service was performing better than the national average for patient outcomes.
• The service assessed and monitored patients’ nutritional and pain needs effectively.
• The service made sure staff were competent for their roles. The number of staff with the post graduate critical care qualification met the national core standards for critical care.
• Staff of different kinds worked together as a team to benefit patients and patients were empowered to take an active role in their care and take control of their recovery.
• The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs.
• People could access the service when they needed it, the service used a ‘go ahead’ system to manage flow through the unit.

However

• The service did not always ensure that equipment was tested within the re-test dates and staff could not be assured it was fit for use.
• We found that delirium assessments were not always being completed in line with the trust policy.
• The service did not provide a full seven-day service to patients which included dietetics, speech and language therapy, occupational therapy and pharmacy. This did not meet with the national core standards for critical care.
• Elective surgical procedures were cancelled and staff told us patients were nursed in the theatre recovery areas due to beds not being available on the critical care unit.

Updated 19 March 2019

We had not previously inspected this service. We rated it as good because:

• The service provided mandatory training in key skills to all staff who worked within the Specialist Palliative Care Team.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• The service had systems and procedures for responding to patient risk. Staff identified and responded appropriately to patients on the end of life care pathway. Comfort observations were used when needed to deliver relevant and appropriate care needs for patients.
• The service followed best practice when prescribing, giving, recording and storing medicines. Patients received medication when required and anticipatory prescribing was used effectively.
• The service made sure staff were competent for their roles. Staff were given annual appraisals and received training and support dependent on their job role.
• The Specialist Palliative care team worked together with other healthcare professionals to benefit patients and support them accessing their chosen place of death. End of life care champions took on extra duties to liaise with the palliative care team and ward staff.
• The Specialist Palliative care team worked together with other healthcare professionals to benefit patients and support them accessing their chosen place of death where possible.
• Staff provided emotional support to patients and relatives throughout the journey and sign posted patients and relatives to appropriate supporting services when needed.
• We found an open and honest culture within the specialist palliative care team. Staff on the wards told us they felt supported by the specialist palliative care team and were easily contactable. Staff we spoke to were passionate about their role in the end of life journey for patients.
• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However,

• Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. However, the ReSPECT documents were not completed appropriately in line with trust policy.
• Following the merger and formation of Manchester University NHS Foundation Trust the governance structure for end of life care was under review. There was no non-executive board member representation on the end of life care meetings.

Updated 19 March 2019

We had not previously inspected this service. We rated it as requires improvement because:

• Staff kept paper records of patients’ care and treatment, however; in the records we reviewed, they were not always clear or completed fully.
• Confidential patient records were not securely stored, in the main outpatients, and easily accessible, to the public when not attended.
• The reception desks, in the main out patients were close to patient waiting areas which meant that conversations could be overheard when booking in for appointments.
• The service provided mandatory training to staff and monitored compliance rates. Mandatory training, for medical staff was below the trusts target in 9 out of 12 modules including resuscitation.
• Staff were required to complete level two safeguarding training. Compliance for medical staff was below the trust target.
• Referral to treatment times were generally similar or better than the England average, however; cancer, patients receiving their first treatment within 62 days of an urgent GP referral, the trust performed below the standard for the end of 2017 and start of 2018.
• The service monitored the did not attend rates for patients, booked for the main-outpatient areas. Despite text reminders, the rates were between 11% and 15%.
• We observed patients that had waited in the main outpatient department, from time of booking to consultation for up to two hours.
• The service treated concerns and complaints seriously, however; the responses were not timely within trust policy guidelines.
• The service maintained an asset register for routine maintenance of equipment, however; there was equipment in most areas we visited that were past their due date as recorded on the equipment and the register.

However:

• Nursing and administrative staff received mandatory and safeguarding training that included recognising and reporting possible abuse and they knew how to raise any safeguarding issue.
• Staff kept themselves, equipment and most areas clean. They used precautions and protective equipment to help prevent the spread of infection.
• The service had recently recruited staff with the skills, training and experience to provide care and treatment.
• The service followed best practice when storing medicines. Processes were in place in each area.
• Staff recognised incidents and reported them appropriately. Managers investigated incidents and we were told that lessons were shared with the teams either at team meetings or daily staff huddles.
• The service provided care and treatment based on national guidance, such as the National Institute for Health and Care Excellence.
• Staff worked together to benefit patients. and understood how and when to assess whether a patient had the capacity to make decisions about their care.
• Staff cared for patients with compassion, provided emotional support to minimise their distress and involved those close to them in decisions about their care and treatment.
• The service took account of patients’ individual needs, such as a sensory room was available away from the main waiting area and patients on trolleys were seen quickly.
• Clinical managers had the right skills and abilities to run a service providing high-quality sustainable care. Values were displayed in all areas visited and had systems for recording and reviewing risks
• Managers across the service promoted a positive culture with an open-door policy.

The service engaged with patients and staff to plan and manage appropriate services.

• The service was committed to improving services and promoted training, research and innovation.

Updated 19 March 2019

We had not previously rated this service. We rated it as requires improvement because:

• The service was not consistently complying with the surgical safety checklist which meant that opportunities to minimise or prevent harm could be missed. The services risk assurance systems were not sufficiently robust to identify areas of concerns surrounding the surgical safety checklist.
• Staff did not always manage infection prevention risk well.
• The service did not look after its equipment well and its premises were not always suitable.
• Staff did not consistently receive feedback on incidents they reported.
• The service was not performing consistently well with higher than average readmission rates, length of stays, and cancelled operations as a percentage of elective admissions.
• The service did not utilise its theatres as efficiently as it should have.
• Patients could not always access treatment when they needed do.
• The service took too long to investigate and close complaints and was not meeting the targets set out in its complaints policy.
• There was not a consistently positive culture and staff were not always open to change. There were low levels of staff satisfaction with some staff, and poor collaboration and cooperation between some teams.
• The management arrangements of the emergency surgery trauma unit were not clear and did not promote effective staff working.

However:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• There were positive examples of multidisciplinary working.
• Staff cared for patients with compassion and kindness. We observed some excellent patient care particularly on the intestinal failure ward. Staff ensured that patients understood the care they would receive, and helped to minimise their distress.
• Staff provided pain relief and monitored its effectiveness.
• Staff had good knowledge of their responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005
• The service engaged well with staff and patients, and there were several staff recognition schemes.
• The service was committed to improving its services.

Updated 19 March 2019

This was our first inspection of this service since it the trust registered with us. We rated it as requires improvement because:

• Staff had not always completed patient risk assessments consistently. For example, there had been three out of five occasions when falls, bed rails and pressure ulcer risk assessments had not been fully completed. In addition, intentional rounding had not always been completed when required. Recent audits completed by the management team also indicated that the completion of these had been inconsistent.
• Although the service had achieved the planned number of medical staff on a regular basis, records indicated that there had been a high number of occasions when the planned number of nursing staff had not been achieved to provide the right care and treatment.
• Although the emergency department used a triage system to prioritise patients, a triage system was not used in the walk-in centre. This was not in line with national guidance. Compliance with the time taken to complete a clinical assessment was not monitored, meaning that we were not assured that all patients, particularly children had always been triaged in a timely manner.
• The service did not always have suitable premises and had not always looked after them well. There had been a number of occasions when emergency equipment had not been checked regularly.
• The service did not always control infection risk well. We found several areas of the department, including some equipment to be visibly dirty. This meant that there was an increased risk that infection would be spread.
• The service provided care and treatment based on national guidance. However, records indicated that there had been poor compliance across a number of different patient pathways.
• Managers monitored the effectiveness of care and treatment in the emergency department and used the findings to improve them. They compared local results to other services to learn from them. However, the service had not monitored the effectiveness of the care and treatment provided in the walk-in centre.
• The service had not always planned and provided services in a way that met the needs of local people. For example, the waiting areas in the emergency department and the walk-in centre did not have sufficient seating to meet the high number of patients attending the departments.
• People could not always access the service when they needed it. The service had consistently struggled to meet the four hour standard to admit, treat or discharge patients. In addition, there were several occasions when patients spent between 12 and 16 hours in the department.
• The service had not always used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment by which excellence in clinical care would flourish.
• The service had not always collected, analysed and managed information well to support all of its activities. For example, records that were kept locally were sometimes different to those kept centrally.

However,

• The service had a vision of what it wanted to achieve and workable plans to turn it into action, with involvement from patients and staff.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose and shared values.
• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.
• The service understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned when needed.
• The service took account of patient’s individual need. There were a number of link nurses in the department who had special interests in topics such as learning disabilities. They were available to support other staff in the department when needed.
• Staff cared for patients with compassion. Feedback from patients and relatives confirmed that staff treated them well and with kindness.