Manor Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

During this assessment we found a positive culture that supported staff to deliver care against high workloads and staffing challenges. This was done within a clear governance structure where people knew and worked within their roles as responsibilities.

At our last assessment we rated this key question requires improvement. At this assessment, the rating remained requires improvement.

We have not awarded this service a score for Well-led.

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

Staff were generally familiar with the trust’s core values of respect, compassion, professionalism and teamwork although few could articulate the reasoning behind it. Staff were complimentary of their leadership, particularly at the ward level and those we spoke to were capable and well able to describe the challenges to the division as well as their own wards.

Most staff described that leaders showed a positive and compassionate culture and that their concerns were listened to. Many staff said the culture had improved, that they felt respected and their opinions were valued. Staff told us they thought their concerns were listened to and most staff felt they could raise them without fear of reprisal.

There had been an increase in complaints about staff attitude and behaviour, and the trust had responded with training in civility and respect, plus targeted culture work for identified groups of individuals.

The division was working to improve culture across the wards and to encourage staff not to ignore unacceptable practice by walking by. They had seen an increase in reporting of poor behaviour but recognised that this needed to be properly investigated. There were examples given where poor behaviour had been recognised as abuse and dealt with as such, but another when it was capability and the staff member supported through training and mentorship.

The division had the trust’s highest response rate to the staff survey for the last two years. Aside from the actual responses, staff engagement is recognised as a good indicator for morale. Most responses were rated as amber or red and often indicated staff under pressure of work and tensions in teams and working relationships. Positive responses were about staff’s engagement with their role, the way the organisation dealt with concerns about incidents and clinical practice, and access to training and personal development. It was also noticeable that despite their concerns, staff were positive about their ability to speak up and would recommend the trust as a place to work and be treated.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There was a clear framework of what needed to be discussed at a ward, team or directorate level in team meetings, to ensure that essential information, such as learning from incidents and complaints, were shared and discussed. We saw examples of notes or minutes at different organisational levels and the topics discussed were appropriate and ones we recognised from our discussions and observations.

These discussions included recommendations and actions from incidents, complaints and reviews of deaths.

Staff undertook or participated in local audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Audits were planned on a rolling basis around standard topics but also initiated in response to events and concerns about quality.

There was a trust wide framework for managing risk, and the division had oversight of the medical wards that was governed through this. When we reviewed the trust’s risk register, we saw that the risks, action plans and mitigations were often ones staff and leaders had raised with us. Action plans were monitored and, when appropriate, measures for success were stipulated and outcomes measured.

Following our last inspection, we had concerns about the quality and storage of paper medical and nursing records. At this inspection, while we found nursing notes were sometimes unsecured in the trollies when not being accessed, they were always close to or behind the nursing station when this happened. We reviewed 18 sets of patient records, and these were of a suitable standard.

Senior leaders were aware of the challenges facing the medical wards, particularly those resulting from increased admissions because of changes to intelligent conveyance by the ambulance service following the changes to acute hospital provision in the Black Country. However, while they could suggest solutions to the issues that they faced, these often-required resources, primarily staff and money that were not available.

Data showed that the target for information governance and data security training was met across all staff groups on the medical wards.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.