Manor Hospital

Updated 25 June 2025

Date of assessment: 26 to 27 February 2025 and 3 March 2025. Manor Hospital provides a range of NHS hospital services. This assessment looked at Critical Care services only, which we rated as Requires Improvement. The rating from Critical Care has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at Manor Hospital. The overall rating of Manor Hospital remains Requires Improvement.

In our assessment of Critical Care services we found that the service did not always make sure equipment, facilities and technology supported the delivery of safe care. A number of nursing staff were carrying out additional bank shifts in other areas of the trust triggering European Union working time directive breach notifications. A large number of consultants did not meet mandatory training compliance rates. Infection control measures such as arms bare below the elbow were not always followed. Inspectors were able to tailgate staff through the intensive care unit several times without challenge. We found expired medicine, gaps in expiry dates, and a lack of action in relation to fridge temperatures not being the correct temperature. The trust had a policy for the IV administration of potassium but none of the staff we spoke with were aware of the policy. Guidelines for the Provision of Intensive Care Services (GPICS) were not met in relation to physiotherapy, dietetics, speech and language therapy, occupational therapy and pharmacy, though action plans were in place. Rehabilitation services were being reduced. Compliance with learning disability and mental health training was low. Not all policies were in date with documents stored on the intranet past their review dates and policies were not always followed. Freedom to speak up guardians did not complete walkarounds of the critical care unit. 

However;

There were processes to record incidents and we heard of learning as a result. Risk assessments were completed consistently. Staffing levels met the recommended levels on both days of the assessment. The service audited key risks. The latest intensive care national audit research centre (ICNARC) quarterly report dashboard showed all areas were within or below the 95% expected range. Leaders completed a programme of local audits. There was a virtual post intensive care unit (ICU) rehabilitation class delivered by physiotherapists. The service told people about their rights around consent. The service did well in its audits around compliance with pain management and nutrition and hydration audits. There was a discharge pathway which contained escalation routes when beds were not available. We found ward rounds and safety huddles were thorough and holistic. The service had identified initiatives to improve teamworking. Following a previous CQC inspection, a Sepsis Outreach Response Team had been formed which had led to improvement in the hospital’s sepsis figures. Staff used the Gold Standard Framework to holistically plan for patients and the Friends and Family Test (FFT) result was above 90% over the last 3 months. Medics referred patients for one stop shop imaging as part of follow up clinics. Staff were able to access information in different languages.  

Updated 23 January 2025

The on-site assessment took place on the 26 and 27 February 2025, and 3 March 2025. The assessment took place due to concerns raised about the service. We have rated the service as Requires Improvement overall. We found 3 breaches of Regulation 12, Safe Care and Treatment and 2 breaches of Regulation 17, Good Governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

During the assessment we found:

The service did not always make sure equipment, facilities and technology supported the delivery of safe care. A number of nursing staff were carrying out additional bank shifts in other areas of the trust triggering European Union working time directive breach notifications. A large number of consultants did not meet mandatory training compliance rates. Infection control measures such as arms bare below the elbow were not always followed. Inspectors were able to tailgate staff through the intensive care unit several times without challenge. We found expired medicine, gaps in expiry dates, lack of action in relation to fridge temperatures not being the correct temperature. The trust had a policy for the IV administration of potassium but none of the staff we spoke with were aware of the policy. Guidelines for the Provision of Intensive Care Services (GPICS) were not met in relation to physiotherapy, dietetics, speech and language therapy, occupational therapy and pharmacy, though action plans were in place. Rehabilitation services were being reduced. Compliance with learning disability and mental health training was low. Not all policies were in date with documents stored on the intranet past their review dates and policies were not always followed. Freedom to speak up guardians did not complete walkarounds of the critical care unit.

However;

There were processes to record incidents and we heard of learning as a result. Risk assessments were completed consistently. Staffing levels met the recommended levels on both days of the assessment. The service audited key risks. The latest intensive care national audit research centre (ICNARC) quarterly report dashboard showed all areas were within or below the 95% expected range. Leaders completed a programme of local audits. There was a virtual post intensive care unit (ICU) rehabilitation class delivered by physiotherapists. The service told people about their rights around consent. The service did well in its audits around compliance with pain management and nutrition and hydration audits. There was a discharge pathway which contained escalation routes when beds were not available. We found ward rounds and safety huddles were thorough and holistic. The service had identified initiatives to improve teamworking. Following a previous CQC inspection, a Sepsis Outreach Response Team had been formed which had led to improvement in the hospital’s sepsis figures. Staff used the Gold Standard Framework to holistically plan for patients and the Friends and Family Test (FFT) result was above 90% over the last 3 months. Medics referred patients for one stop shop imaging as part of follow up clinics. Staff were able to access information in different languages.

Updated 26 March 2024

Date of assessment 29 May 2024 to 31 May 2024. This assessment was carried out following concerns over how a complaint had been handled in the Emergency Department. We only assessed one quality statement from the responsive key question in relation to the Emergency Department only and found areas of good practice. The score for this area has been combined with scores based on the key question ratings from the last inspection. Through the assessment of this quality statement indicated areas of good practice our overall service rating remains requires improvement.

Walsall Healthcare NHS Trust provides local general hospital and community services to around 260,000 people in Walsall and the surrounding areas. The trust is the only provider of NHS acute care in Walsall, providing inpatients and outpatients at the Manor Hospital, as well as a wide range of services in the community. Manor Hospital has 554 acute beds (501 overnight beds and 53-day case beds) and provides a wide range of services including a 24-hour accident and emergency department and maternity services. We only assessed one quality statement from the responsive key question and found areas of good practice. The score for this area has been combined with scores based on the key question ratings from the last inspection. Through the assessment of this quality statement indicated areas of good practice our overall service rating remains requires improvement.

Updated 25 January 2023

Updated 25 January 2023

Updated 20 December 2017

We rated this service as good because:

• Between April 2016 and March 2017, the trust reported no incidents that were classified as never events for end of life care.

• The trust reported no serious incidents (SIs) for end of life care that met the reporting criteria set by NHS England between April 2016 and March 2017.

• There had been no end of life care incident, which required duty of candour (DoC) investigation in the palliative, and end of life care service.

• The service monitored patient outcomes through national and local audits; these were fed back to the board and end of life dashboard along with the trust’s quality report.

• Multi-Disciplinary Team (MDT) working was effective within the end of life care service. The team worked as a one integrated team across the acute and community sites.

• DNACPR forms were filed out correctly in front of patient records so that staff could locate them quickly. Since the last inspection 2015, the trust has improved significantly around the DNACPR documentation.

• Staff cared for patients in a compassionate, dignified, and respectful manner.

• We saw in one of the viewing rooms at the mortuary that there were facilities for washing the body for religious and cultural reasons. We saw this as an understanding and respect for patients’ cultural and religious needs.

• The chaplain service offered spiritual support to patients 24-hours a day, seven days a week.

• Patient discharge, including moving patients between acute and community care settings, followed patient-centred care best practice.

• The SPCT worked closely with commissioners and other providers to ensure patients’ needs were met.

• The ensured patients who required end of life and palliative care were seen promptly and were identified in a timely way, that deceased bodies were cared for, and that religious and spiritual beliefs were respected and dignified.

• The professional lead chaired a multi-professional group. Membership included the acute and community , palliative care team, and representation from the clinical commissioning group (CCG) as well as the director of nursing.

• The service leaders had a clear direction of the service. Their aim was for an effective integrated service to ensure patients were provided with quality end of life care.

• Staff of all levels felt supported from the end of life and palliative care team.

• We saw the trust’s five-year strategy plan for 2017-2022 called, “Becoming your partners for first-class integrated care”.

However:

• We spoke with the hospital porters around incidents and learning from incidents, they told us they did not have access to a computer or IT access. The porters told us they received no feedback or actions in relation to incidents.

• Ward staff knowledge and awareness of when to use individualised care plans when caring for end of life patients varied from ward to ward.

• Porters we spoke with during our unannounced visit on 6 July 2017 informed us that they were never informed if a patient had an infection, especially when transporting patients from one department to another.

• The trust set out a target of 90% for completion of safeguarding training; as at 31 March 2017 nursing staff for end of life care services failed to meet training targets.

• There was a low completion rate for major incident training at Walsall Hospital. As at 31 March 2017, only 56 out of 188 eligible staff (30%) had completed this training.

• The trust had the amber care bundle on some wards as part of a phased roll out programme from the . This was being introduced in the last inspection in 2015 but this had still not been fully embedded throughout the wards.

• We saw nutritional assessments were being carried out, but was not always documented as part of the individualised care plan.

• Documented evidence of completed advance care plans (ACP) was only noted in 63 patients and these were predominantly within the community setting, only five patients in the acute setting had an ACP in place.

• Combined results across both sites (community and acute) demonstrated that the use of the individualised end of life care plan was 20% (45 patients in acute setting).

• Registered nurses on the wards had received training to enable them to safely administer medications through the T34s McKinley infusion pumps; however this was not consistent, some staff were not trained or did not know which syringe drivers were being used.

• Porters we spoke with said they had not received any specific end of life training; they told us that newly appointed staff learnt from and shadowed porters that were more senior.

• Ward staff told us that it was difficult at times to support relatives during an emotional time, as there were no specific rooms to speak with relatives in private.

• The trust did not have any dedicated beds for end of life care patients, they were cared for on general wards throughout the hospital.

• The route that people had to walk to the mortuary for the general office was long and poorly signposted.

Updated 1 October 2021

Updated 17 November 2020

The service has 62 maternity beds across two sites:  

The Manor Hospital has 49 maternity beds, these are located within two wards and a delivery suite.  

There is a consultant led delivery suite with nine rooms plus an enhanced maternity care room and an obstetric theatre, a fetal assessment unit, a triage area, induction of labour suite, outpatient antenatal clinic, antenatal/postnatal ward and a community-based midwifery service.  

Elective Caesarean sections are currently performed in the elective theatres in main theatres and a Delivery Suite Theatre was opened in January 2020. There is a four-bedded transitional care unit on one of the wards. 

The Freestanding Midwifery Led Unit (MLU) has three maternity beds. This was closed during our inspection so wasn’t visited however has since reopened. Some community outpatient clinics took place at the MLU.   

This inspection was a focussed inspection of maternity services on 8 and 9 September 2020. 

We spoke to 22 staff and reviewed four prescription charts and five patient records. 

We last inspected maternity services at Walsall Healthcare NHS Trust in 19 March 2019.  

We rated safe as requires improvement and effective, responsive, caring and well-led as good. The overall rating for the service was good.  

A range of data was requested from the service as part of this inspection.

Updated 20 December 2017

We rated this service as good because:

• Staff reported incidents in a timely manner and we found evidence of learning from incidents. We found the radiology department met the requirements of Ionising Radiation (Medical Exposure) Regulations 2000. We found good infection control and waste management systems in place. Staff had a robust system in place to manage medication and the distribution of prescriptions.

• We found evidence based policies and procedures across all departments. Staff worked in facilities that promoted the effective treatment of patients. We found good evidence of multidisciplinary working across outpatients and imaging service. All registered nurses and doctors asked understood the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards 2010. However, three unregistered staff did not understand the legislation.

• All staff provided compassionate, supportive, and understanding care to patients. Staff encouraged patients to ask questions and be involved in the decision made about their care. Patient feedback about the service was positive. However, the latest Friends and Family Test results showed a lower than national average positive response.

• The trust was not meeting the national standard for the 18-week referral pathway. The fracture clinic environment was not easily accessible for patients who required a wheel chair or crutches to mobilise. Staff within outpatients had not undertaken any dementia awareness training. However, outpatients and imaging had received a low number of complaints.

• Staff had a positive attitude and we found an ethos of team working across the departments. Staff felt included within the team and that they could and did make a difference. We found good engagement with the public in the form of health promotion. However, we found meetings often lacked structure and detail, and did not routinely discuss feedback from complaints and incidents.

Updated 25 January 2023