The Care Quality Commission
  • Hospital
  • NHS hospital

Saint Mary's Hospital

Overall: Requires improvement read more about inspection ratings

3 The Boulevard, Oxford Road, Manchester, M13 9WL (0161) 276 1234

Provided and run by:
Manchester University NHS Foundation Trust

All Inspections

7 March 2023

During an inspection looking at part of the service

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Saint Mary’s Hospital.

We inspected the maternity service at Saint Mary’s Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out an announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

The inspection was carried out using a pre-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.

Following the site visit, we conducted interviews with senior leaders, specialist staff and stakeholders. We held focus groups for staff of different grades and roles and reviewed feedback from women and families about the trust. We ran a poster campaign during our inspection to encourage women and birthing people who had used the service to give us feedback regarding care. We received feedback from 30 women, birthing people and families and analysed the results to identify themes and trends.

Saint Mary’s Hospital is 1 of 3 sites for maternity services for the trust. It comprises of a central delivery unit with 14 birthing rooms, 1 room with a birthing pool and has adjacent maternity theatres. There are 4 enhanced maternal care rooms within the central delivery suite and induction of labour beds. There are post and antenatal wards, an antenatal assessment unit and maternity day unit. The service has a triage unit with 10 beds. The service also has a fetal medicine unit and a maternal medicine service which provide services to women and birthing people from across Greater Manchester and the Northwest region. Ante and postnatal clinics are also provided at this location.

The local maternity population come from areas of higher levels of deprivation than the national average with 30% in the most deprived decile compared to 14% nationally. A higher proportion of mothers were Asian or Asian British compared to the national averages.

Our rating of this hospital went down. We rated it as requires improvement because:

  • Our ratings of the maternity service changed the ratings for the hospital overall. We rated maternity services as inadequate in safe and requires improvement in well-led and the hospital as requires improvement.

We also inspected 2 other maternity services run by Manchester University NHS Foundation Trust. Our reports are here:

Wythenshawe Hospital – https://www.cqc.org.uk/location/R0A07

North Manchester General Hospital – https://www.cqc.org.uk/location/R0A66

Following this inspection, under Section 29A of the Health and Social Care Act 2008, we issued a warning notice to the provider. We took this urgent action as we believed a person would or may be exposed to the risk of harm if we had not done so.

How we carried out the inspection

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

8 September 2021

During a routine inspection

We carried out this announced inspection of Saint Mary’s Sexual Assault Referral Centre (SARC) over three days on 7, 8 and 9 September 2021 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. Four CQC inspectors carried out the inspection. To reduce the risks presented by Covid-19, we used a combination of remote and face to face interviews.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

These questions form the framework for the areas we look at during the inspection.

Background

Saint Mary’s sexual assault referral centre (SARC) is located within Saint Mary’s Oxford Road Hospital grounds with discrete sign posting. Patients are always met and accompanied to the suite by a staff member. The SARC is in an old building, access for anyone using a wheelchair needs to be managed, as there is no lift directly to the centre on the first floor of the building. Staff assist patients to the suite via the main hospital. There is parking available on site for patients although it is limited.

The SARC services are a directorate of Saint Mary’s Hospital Manchester which is a managed clinical service within Manchester University NHS Foundation Trust (MFT).

Saint Mary’s SARC commissioning contracts are managed by the police and NHS England and Improvement (NHSE/I). They commission Saint Mary’s SARC to provide a forensic service to all genders and all ages. People who access the service who live in Greater Manchester (GM) or have been sexually assaulted in GM also access aftercare services there. We will explain the aftercare services further on in this report. Saint Mary’s is commissioned to provide a forensic medical service to Cheshire residents and those patients are referred to local services for aftercare.

Patients accessing the SARC can be referred by professionals or self refer, although children under 14 years of age must be referred by children’s social care or police . Aftercare at Saint Mary’s SARC includes advice regarding sexually transmitted infections (STI), specific paediatric STI clinics, access to crisis support workers, independent sexual violence advisors (ISVA’s) and counsellors. The staff group are multi-disciplinary and are made up of forensic physicians, crisis support workers (CSW), ISVAs, a counselling team, administrative support and a children’s team. The children’s team consists of ISVA's, counsellors and a young person's advocate who specialises in child sexual exploitation.

There are three forensic examination rooms. Each of these has access to a forensically cleaned bathroom and waiting room. There are additional comfortable waiting areas and suitable rooms for counselling services.

There are 22 forensic physicians that undertake forensic examinations at the SARC. They are from a range of specialisms that cover general practice, paediatric and child health and obstetrics and gynaecology. SARC leaders appreciated the different skills and partnership benefits that the forensic medical examiners (FMEs) brought and they felt this contributes to good patient outcomes. Most FMEs have completed the Forensic Medical Examination in Rape and Sexual Assault (FMERSA) course and over half are members or fellows of the Faculty of Forensic and Legal Medicine (FFLM). Some FMEs teach on the FMERSA and some of those are examiners on the course.

MFT is responsible for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

During the inspection we spoke with nine staff. We looked at policies and procedures and other records about how the service is managed. We reviewed comments cards that we had asked patients to complete to get their feedback on the service.

Throughout this report we have used the term ‘patients’ to describe people who use the service to reflect our inspection of the clinical aspects of the SARC’.

Our key findings were:

  • The service had systems to help them manage risk.
  • The staff had suitable safeguarding processes and staff knew their responsibilities for safeguarding adults and children.
  • Staff identified vulnerable patients and those assessments informed aftercare.
  • Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment/referral system met clients’ needs.
  • The service had effective leadership and a strong culture of continuous improvement.
  • Staff felt involved and supported and worked well as a team.
  • The service asked staff and clients for feedback about the services they provided.
  • There were suitable information governance arrangements.
  • The service appeared clean and well maintained.
  • The staff had infection control procedures which reflected published guidance.

There were areas where the provider could make improvements. They should:

  • Be assured that the frequency of Disclosure and Barring Service (DBS) checks is proportionate to the work that SARC staff deliver

5 and 6 March 2019

During a routine inspection

Background

Services for the support and examination of people who have experienced sexual assault are commissioned by NHS England and Merseyside Police and provided by Manchester University NHS Foundation Trust through Safe Place Merseyside based in Liverpool city centre. The service is part of the St Marys Hospital Manchester provider services.

Forensic Physicians (FPs) and Crisis Workers (CWs) work on an on-call rota to cover daytime, nights and weekends and are available to respond to adults and young people(16-17yrs) over a 24-hour period. The service for children under 16yrs is provided by The Alder Hey Hospital and does not form part of this inspection. Any professional can refer to the Safe Place service. Self-referrals, for safety reasons, are seen during the daytime only. The staff are supported by a full-time administrator.

Safe Place Merseyside has 15 FPs and 10 CWs, both disciplines have two staff currently in training, all staff are permanent. There are two managers who work across both Safe Place Merseyside and the SARC based at St Marys Hospital Manchester.

The centre is a self-contained unit within a service building which also hosts a walk-in centre and community sexual health services. The centre meets the needs of the patients, it is discreetly signposted, and the entrance has access for people with physical disabilities. Accommodation includes a forensic medical room, bathroom, a forensic waiting room and a non-forensic waiting room.

Safe Place Merseyside are not commissioned to provide counselling or talking therapies and referrals are made to a number of local services commissioned to offer follow on care.

During the inspection we spoke with the clinical director, clinical lead, operational manager, forensic physician, two crisis workers, ISVA worker, talking therapies worker and a police officer.

Prior to and during the inspection we looked at policies and procedures and other records about how the service is managed.

Patients spoke positively about the service and the quality of care that was provided.

Our key findings were:

  • The provider had adequate systems and processes in place to identify where quality and safety were compromised.
  • The service had effective leadership and staff told us they felt well supported.
  • The premises appeared clean and well maintained.
  • The staff used infection control procedures which reflected published guidance.
  • Staff knew how to deal with emergencies.
  • Appropriate medicines and life-saving equipment were available.
  • The staff followed suitable safeguarding processes and knew their responsibilities for safeguarding adults and children.
  • Systems were in place to support multi-agency working.
  • The clinical staff provided patients’ care and treatment in line with current guidelines.
  • Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
  • The appointment and referral system met patient’s needs.
  • The provider asked patients for feedback to obtain their views about the services provided.
  • The staff had suitable information governance arrangements.
  • The provider had thorough staff recruitment procedures.

We identified an area of notable service.

The majority of forensic practitioners are members of the Faculty of Forensic & Legal Medicine (FFLM) or working towards membership.

There were areas where the provider could make improvements. They should:

  • Formalise an audit programme of activity including an environmental infection control and prevention audit.
  • Risk assess bathroom areas for ligature risk to patients
  • Continue to ensure policies and paperwork reflect the Safe Place Merseyside service and local partnerships processes and procedures.

2nd October - 8th November 2018

During a routine inspection

We had not previously rated this hospital. We rated services as good because:

  • We rated maternity services as good for safe, effective, caring, responsive and well-led.
  • We rated neonatal services as good for safe, effective, responsive, well- led and outstanding for caring.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Services took account of patients’ individual needs.
  • Services controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Staff received appropriate education and training to enable them to provide safe care and treatment.
  • The service planned and provided services in a way that met the needs of local people. People could access the service when they needed.
  • Staff gave patients enough food and drink to meet their needs and improve their health.
  • Managers across the services had the right skills and abilities to run a service providing high-quality sustainable care.
  • Staff were committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation.

However:

  • Not all mandatory training particularly for medical staff met trust targets.
  • Staffing was a challenge: although most shifts, over the period reviewed, met the national guidance from the British Association of Perinatal Medicine, there remained gaps in staffing on occasions.