- NHS hospital
Manor Hospital
Report from 23 January 2025 assessment
Ratings - Critical care
Our view of the service
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.
People's experience of this service
Overall, people's experience of the service was positive. Patients and relatives spoke positively about staff, who were kind, explained their care and treatment, answered call bells quickly and provided pain relief when required. Patients consistently rated feeling able to talk to staff and feeling they were treated with dignity and respect above the national average in surveys. We viewed a number of thank you cards from patients and their loved ones on display.