Manor Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We rated safe as good. There was strong focus on safety by staff and leaders and there were good systems in place to keep people safe and to learn from mistakes. However there were staff shortages on many of the wards and there was a constant demand on managers’ time to analyse and mitigate staffing risks.

At our last assessment we rated this key question as inadequate. At this assessment, the rating has changed to good.

We have not awarded this service a score for Safe.

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

There was a clear governance system throughout the trust and the division to identify, record, investigate and respond to concerns about safety, including specific safety incidents. This mechanism was managing the transition from the previous Serious Incident Framework to the new Patient Safety Incident Response Framework (PSIRF) as mandated for all NHS trusts.

Ward 4 staff commented positively about the newly implemented PSIRF approach in respect of learning from drugs errors. Senior staff also said they were better able to deal with multifactorial issues, giving as an example, a recent increase in falls that was likely due to a rise in acuity, frailty and staffing shortages.

Other senior staff told us of initiatives working well within the new PSIRF framework included falls, tissue viability and infection prevention and control. These were being taken forward by individual steering groups within the overall PSIRF framework.

The trust used a computerised information system for all staff to use to record incidents and near misses. Every member of staff received mandatory training on this, and the completion figures did not give cause for concern.

For patient falls we saw that overall figures were analysed, and trends were identified and linked to possible contributory factors such as staffing or ward acuity. Individual incidents were properly investigated, and the patient or their relatives were involved within the PSIRF approach. Incidents of moderate harm and above were reviewed at the division’s safety huddle and there was a Falls Shared Learning Forum and a Falls Steering Group giving oversight and direction. Action plans were developed to prevent recurrence and reduce harm, and support for training and improvement was facilitated by the trust’s Corporate Quality Team. We saw samples of data and examples of reports and action plans which were suitable.

For pressure ulcers there was a similar reporting, analysis, investigation and remedial action process. There was an incident management model, explained in a flow chart, that supported the initial diagnosis and grading of the wound and ensured that the clinical management was suitable. The incident was then classified as to the harm caused and managed within the PSIRF framework, including, as necessary the duty of candour. There was oversight and support within the division and the trust, and the overall governance was through the trust’s Tissue Viability Steering Group. We saw evidence of a comprehensive pressure area care audit programme overseen by the Tissue Viability Steering group

Individual staff to whom we spoke said they would be confident to report incidents and errors and that people were treated fairly when they did so. This was backed up by the division’s staff survey results reported positive responses to this topic.

Staff understood the duty of candour and were generally open and transparent in their approach to untoward incidents. When things went wrong, staff apologised and provided a full explanation.

There were good systems in place to admit patients who came to the medical wards through the hospital’s emergency portals including the emergency department and the assessment units.

There was a specialist frailty assessment unit, and this worked well with the emergency department to identify those patients who could benefit and to ensure they were quickly transferred there. This area was staffed by nurses and doctors who had specialist knowledge of the care of the elderly meaning that they were kept safe, got suitable treatment, and decisions as to whether they needed to be admitted or could go home were made quicker.

However, patients who needed mental health assessment often waited too long for assessments and placements, although this was the responsibility of those other providers. Staff told us they had good relationships with the local mental health trust and there were good liaison arrangements, but their resources were limited, and this resulted in delays and patients spending time in what might be an unsuitable place.

Once a patient was medically fit for discharge there were challenges to getting them to their own homes or a care home. Some of this was outside of the trust’s control as it was the responsibility of other providers and local authorities to provide continuing health and adult social care. Medically fit patients who needed a mental health bed frequently had their discharge delayed because of a lack of suitable places. At the time of our inspection, 2-week waits were common, and this was not good for the health of the patients as well as the beds not being available for others. These issues were always escalated, and considerable amounts of management time was spent by senior staff trying to solve these problems.

There were staff known as “progress chasers” whose role was to facilitate quicker discharges. Their main role was to identify what was preventing individual patients from being discharged. This included getting diagnostic tests back so decisions could be made, ensuring safeguarding concerns were addressed, and ensuring patients were discharged to a safe and suitable place.

We were told one of the biggest challenges was getting packages of care in place; some staff said they thought the commissioners of the care packages sometimes found reasons why a patient was not medically fit for discharge. An example we were given was a patient for whom a care package could not be arranged until they had received the results of a blood test, that would not determine whether they were suitable for discharge, but simply the medicine dose they would be prescribed in the community.

There was a trust wide discharge check list in use, which was detailed and comprehensive. However, we noted that some wards, such as Ward 6, used their own locally designed forms which were much simpler. While these addressed basic patient safety issues, they did not include more nuanced discharge arrangements such as the provision of information, infection risk, further appointments or ongoing care needs.

There was good handover communication between wards and the discharge lounge with a referral form and a patient checklist which was different to the trust wide discharge checklist but largely contained the same information and level of detail.

The trust recorded and analysed the reasons why a patient’s discharge did not happen, or happen as planned, known as “failed discharges”. For patients going to their own homes, delays were often because of problems with transport, patients deteriorating and not being well enough to go home, and administrative problems including delays in medicines to take home. For patients going to a placement, such as a care home, the reasons were similar.

While many failed discharges were complex, and specific to the patient and their individual circumstances, the trust had reviewed specific failed discharges and identified some common root causes. From this, they had developed a plan to introduce nurse led discharge, but this was waiting on a funding decision for a discharge matron.

Staff were trained in safeguarding, knew how to identify a concern and how to make a safeguarding alert. Mandatory training figures showed that across medicine the target of 90% completion was largely met for level 1 & 2 training for adults, but for level 3, training figures were rated as “amber”, at 80% to 89%.

There was a specialist safeguarding team available to provide advice and support. Staff told us they were usually responsive and provided good advice, but they were sometimes “stretched”.

We spoke to staff about safeguarding, and they were confident in their knowledge and were able to give us examples. Staff were also familiar with the legislation around restraint including the Deprivation of Liberty Safeguards (DoLS) and contextualised this in the context of care for the elderly, for example the use of bedrails and prevention of “wandering”.

We looked at the notes of patients who were identified as having DoLS in place and saw several good examples of how patients had their safety ensured in the least restrictive manner. We also saw an example of an ill-advised self-discharge where the patient had been assessed as having the capacity to make the decision but was also “safety netted” through contact after their discharge.

The National Early Warning Score 2 (NEWS2), a nationally recognised tool was used to identify deteriorating patients. When we reviewed patient notes, we saw that observations generally completed to the frequency required for each patient. Staff were supported by the trust’s sepsis team who were available 24/7 for advice, who conducted audits and identified any instances of harm for review. If a patient was noted as a concern, staff had access to outreach teams from critical care including a specialist sepsis outreach team during normal working hours.

The trust applied the “sepsis six” approach, which is a time critical bundle of clinical interventions which need to be started within an hour of the patient being suspected of having sepsis based on the NEWS2 score. The adherence to this was audited using a commercially available audit product. Data showed that the trust performed above average in comparison to other benchmarked NHS providers and that there had been progress since this audit package had been used to drive improvement. We also noted that other indicators, such as a reduction in the number of “late” admissions to critical care for sepsis showed improvement.

When we looked at patient’s records, we saw several good examples of how deteriorating patients had been identified and appropriately treated. At our previous inspection, we found that observations were not being done often enough and required improvements be made, but this time our examination of notes did not raise concerns.

The trust had implemented a “Compassionate engagement” initiative with patients talking about risks and plans for end-of-life care.

In our previous inspection we were concerned to find that refurbishment to the estate had introduced risks including blocked fire exits, broken door frames and electrical cables presenting a trip hazard. We made a requirement that this be addressed. At this on site visit we found the environment was now safe.

Wards were generally clean and tidy, although some were cluttered because of lack of storage space. Ward 2 had introduced “tidy up Tuesday” where nursing staff carried out a deeper clean and addressed clutter. Most bathrooms and toilets were clean although some were described as “tired”. Treatment rooms were secured and generally well equipped.

Areas that had recently been refurbished or upgraded were of a good standard and some were notable. The frailty facilities on AMU were clean, suitable and very spacious. The discharge lounge area had been designed and fitted to a high standard with a good deal of care and thoughtfulness in regard of the needs of the people who would use it.

Access to good beds was identified as an important factor by the tissue viability group, and for those wards where pressure area injury prevention was a key issue almost all beds had hybrid mattresses which were comfortable for most patients, while having the option to use a powered airflow mattress if needed. This meant that there was no delay in providing this therapy. For more complex beds the trust called on rented equipment and staff told us that this was readily available.

Equipment was suitable, maintained and usually available in sufficient quantities. Staff on ward 17 told us they sometimes had to wait for a vital signs monitor to become available.

Equipment received daily checks as required through local arrangements. These differed between wards but were generally in the form of paper checklists, either independent or combined with other daily tasks. These were of variable quality, with some duplicating information or having very small boxes for information to be entered. When we looked ourselves, we generally found that checks had been done correctly but we did find some discrepancies. For example, on the resuscitation trolley on ward 29 the suction machine had a sticker saying not to use after May 2024 and there was a mixing needle that was out of date.

The service was challenged to provide enough nursing staff of the correct grades and skills to staff the medical wards. Throughout our on-site visit this was the main thing that staff wanted to talk to us about and many showed signs of distress when they did so. Leaders at all levels were fully aware of the situation and the narrative that we heard was consistent with junior staff not afraid to speak up and leaders being honest about the situation.

Medical staffing was generally better although there was still a use of locums to provide cover, particularly out of hours.

The NICE approved Safer Nursing Care Toolkit was used to define model staffing levels. Twice a year the division carried out a skill mix review and, if necessary, altered the nursing establishment. This review was comprehensive, detailed and provided a sound basis for decision making about the number of staff needed. We noted that there was a continued increase in the need for 1:1 care, largely because of increased number of patients with mental health needs and dementia as well as frailty.

Divisional nurse staffing meetings took place each weekday where senior staff discussed staffing levels alongside the acuity of individual wards. This information fed into the trust level nursing staff meetings. Individual wards addressed staffing concerns through the day in safety huddles where it was judged as to whether additional staff were needed to keep patients safe. If it was not possible to meet this need through bank or redeployment across the trust, managers could apply for bank staff. However, this needed to be approved at the level of the Divisional Director of Nursing. Out of hours, an identified, onsite senior staff member was available for escalation.

We observed the pressures on leaders to staff the wards safely through the observation of site safety meetings. These took place several times a day and the frequency and seniority of attendance was flexed dependent on pressures. Flow and discharge to give capacity was one of the focuses of the meeting, but we also noted that discussions about staffing and safety was down to individual wards and staff member level, with managers juggling the acuity of wards and even individual patients against sickness and bank availability. Several senior staff were noted as staying beyond their shift to keep their ward safe.

On individual wards staff, particularly ward managers, were keen to talk to us and describe the staffing challenges they faced every day. On ward 4 a sister told us they were “very short”, there should have been 6 nurses, but they had only got 4. They said, “this makes the day very tough”. The nurse in charge was seen giving medications despite being supernumerary.

On Ward 15 we were told January had been busy and staffing was a struggle. They were “almost always 1 nurse short”, it was “very rare” to have the “full 5 SRNs on shift”. We were told on wards 1, 14 and 15 that they too were always 1 nurse short.

On ward 7 the coronary care unit, which was comprised of 2, 5 bedded bays, staff told us of their continual worries about staffing levels and the safety of their patients. We were shown that staffing rarely met the model for the acuity of patients. While managers could call on bank and agency staff, those nurses from other specialities such as the emergency department did not always have the specialist skills needed on the unit. On several occasions this had resulted in senior staff returning to work after their shift to keep the unit safe. The unit did not close for admission, and while staff believed no patient had come to harm it was having serious effects on staff welfare as well as retention and sickness. This situation was on the trust’s risk register and there were steps being taken to recruit nurses.

On the day of our visit the Medical Same Day Emergency Care Unit was 3 registered nurses short because of sickness but staff told this did not cause concern because of lower number of patients and their acuity on the days we visited, and some of their staff had reallocated to other wards.

Ward 1 was 2 CSWs short and the nurse in charge told us there was a lot of sickness, a mix of both long and short term. Wards 2 was 1 RN & 1 CSW short and the nurse in charge told us it was “busy but not unsafe”. On wards 5 & 6 there were no staffing issues for both medical and nursing staff during our visit.

Ward 17, an acute respiratory ward was really challenged because of an unusually high number of patients with tracheostomies in the trust. An increase in these patients was a overall trend, but it was particularly difficult on the days of our inspection where not only were there patients on the ward but also in the emergency department where skilled staff from the respiratory ward supported their colleagues. Although the ward had been allocated extra staff because of the increased acuity of patients, the skills to safely care for a patient with a tracheotomy are relatively scarce and the ward was still under stress. While ward managers assured us that it was safe, staff were clearly stressed.

There was daily therapist and pharmacy input to all wards and we were told of good in-reach from other specialities.

We asked about the impact on patients from these staffing issues. One ward manager told us that repositioning of patients was often a challenge, they had a good team but the time needed to do this impacted on other tasks. Another told us of the impact on discharges and that sometimes patients who were medically fit were delayed in getting home. Senior staff told us they had noted recent increases in falls. While this was multifactorial including a rise in patient acuity and admissions with people living with dementia, low staffing was also considered a factor. We were told that leaders always stepped in to help, but they were meant to be supernumerary, and this impacted n their management time and hence activities like supervision. Similarly mandatory and other training was made more difficult to access. We noted in governance notes that meetings had been curtailed because of site pressures.

A significant concern was that this pressure was having an impact on the health and wellbeing of staff, particularly ward managers. Sickness rates, at 6.86%, were higher than the national average and the top reason was stress and anxiety although this was not always attributable to work. The sickness rate was lower for professional staff including nurses and significantly lower for medical staff. Turnover rates were at around 11% but this included staff who resigned for promotion or for roles in other parts of the hospital, so it was not easy to draw conclusions from the figures.

Where shifts were not filled ward managers could fill these by going to the nursing bank. Prior to the introduction of the capacity ward they were able to staff safe wards from establishment. Now they had to use bank and agency to keep safe, but the bank fill rate was the lowest it had ever been, particularly amongst healthcare assistants. Ward managers said that that this was since the pay rise required for the national living wage standard as some staff no longer needed the extra shifts, and this was a particular issue at the time that they had received the backpay from the pay settlement. Managers told us that a recent policy change meant that band 7 nurses doing a band bank 6 shift got band 6 pay rather than band 7 pay as previously. This had resulted in staff not wanting to pick up those shifts and so the bank fill rate was the lowest for a while.

Ward managers told us recruitment was not the problem however, these managers told us of their frustration in getting posts approved. They said that there were vacancy panels at trust executive and commissioner levels and it was difficult get cases passed. They believed that when business cases were rejected, it was often not the fundamental case that was poor, but the “quality of the application” as cases would be rejected for poor presentation. Some staff felt this was a deliberate mechanism to prevent or defer recruitment and save money.

Senior leaders told us that they didn’t generally struggle to recruit staff but changes to the location of hospitals in the Black Country had resulted in 20 vacancies across the division. This was because of recruitment initiatives by other hospitals as well as preferences of staff as to where they wanted to work to suit their personal circumstances. Changes in location had resulted in ambulances bringing more patients to the hospital meaning that they were busier. In response, to keep people safe, the trust had opened Ward 5 as a capacity ward and this was funded internally, not by commissioners. Many staff told us that the strain of staffing this ward was a significant cause of the staffing challenges on other wards. We understood there was some money planned to be available to compensate for the extra work the division took on, as a result but only some had been released.

Mandatory training targets were generally met, and while there were some shortfalls these were not significant and were always in respect of refresher training. New staff did not start without receiving a full mandatory training package and induction. Similarly, staff got supervision and development, and we noted that the staff survey noted that staff saying they got this this was one of the most positive aspects of that survey.

Wards were generally clean and tidy, although some were cluttered because of lack of storage space. Ward 2 had introduced “tidy up Tuesday” where nursing staff carried out a deeper clean and addressed clutter. Bathrooms, toilets and sluices were clean although some were described by inspectors as “tired”.

Side rooms for isolation were provided on most wards and where they were in use we observed staff and noted that they observed the correct procedures. There was plenty of personal protective equipment available. Staff adhered to infection control principles, including handwashing.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly. We noted some minor cleanliness issues but these were drawn to the attention of staff and dealt with quickly. The only significant issue was that the mattress store on ward 29 suffered from a problem with mould and needed to be cleaned every day. Hand hygiene and environmental audits took place, the latter addressing housekeeping and general cleaning standards.

Staff cleaned medical devices between patients. Any ‘clean’ stickers were visible and in date. Where patients needed slide sheets they were provided with their own ones as was the case for slings.

There was a trust governance structure to manage the risk of Healthcare Associated Infections (HCAI). Within the division the appropriate professionals were involved, and the division was given targets to achieve.

At the divisional level, governance of Infection Prevention and Control (IPC) was managed through the Medicine IPC Improvement Group. Ward level audits infection prevention and control took place and were recorded on a trust wide computer system. We saw good evidence that if IPC shortfalls were identified plans were developed and remedial action taken.

Overall trends and the root causes of incidents were identified and remedial actions identified and initiated through action plans. For the examples we saw these included reminders to staff, education at division, ward or individual level and changes to processes and procedures.

Data that we requested showed that IPC mandatory training met the target for all staff groups
for level 1 training and was largely met for level 2.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

Medicines Management was governed through the Medicines Management Group which had a standing agenda. Amongst other topics this covered audits, risk and examined medicines incidents. Audits included overall medicines management, controlled drugs and the safe storage of drugs.

The management of controlled drugs was good, there being twice daily checks and accurate records of administration, loss and disposal.

Medicines storage was generally good. Rooms were locked, as were cupboards, usually by a keypad, they were tidy and kept at the correct temperature. Except for one, all medicines that we looked at were in date. However, a pharmacy technician told us they sometimes came across out of date medicines when they were checking stock.

Medicines trollies were locked except when staff were actively engaged in medicines rounds and close by.

All wards were supported through daily pharmacist visits on weekdays, and they did monthly audits. There was no on call pharmacist out of hours meaning To Take Out (TTO) medicines needed to wait until the next day. However, there was an on-call pharmacist at weekends.

We reviewed 12 drugs charts on wards 1, 2, 5 and 6 and the quality and the standard was acceptable. On ward 16, 2 charts out of the 6 we looked at demonstrated problems with legibility and recording of GMC numbers but there were no other issues.

There was a trust level medicines management group and a divisional medicines management group. We were told electronic prescribing would be introduced from April 2025 and this was seen as something that would improve prescribing and administration resulting in fewer mistakes.

Senior staff were able to talk about themes from medicines incidents. They told us that one of the biggest areas of concern was the management of insulin and as a result an insulin group had been setup. There was also a concern about patients not having their own medicines with them on admission, even time critical ones and this meant a lot of time was spent getting them prescribed.

Overall trends and the root causes of incidents were identified and remedial actions identified and initiated through action plans. The examples we saw these included reminders to staff, education at division, ward or individual level and changes to processes and procedures.