Manor Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

The latest Intensive care national audit and research centre (ICNARC) Quarterly Quality Report dashboard showed all areas were within or below the 95% predicted range.

Following a previous CQC inspection a Sepsis Outreach Response Team had been formed which had led to improvement in the hospitals sepsis figures.

Leaders completed local audits such as nutrition and hydration, pain management and documentation.

Critical care had access to 24-hour respiratory physiotherapy as required via an on-call service. We observed critical care ward rounds, which occurred twice daily, staffing handovers and safety huddles and found them to be thorough, with a holistic approach.

There was a virtual post ICU rehabilitation class delivered by physiotherapists once a week which consisted of 30 minutes of exercise and 30 minutes of education. Results showed overall feedback from patients was positive with many discussing the positive benefits that participation in the programme had on their physical and mental health.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment. There was a discharge pathway including escalation routes when time critical beds were not available. The service had identified initiatives to improve teamwork.

However;

At the time of the assessment, the service did not meet Guidelines for the Provision of Intensive Care Services (GPICS) in relation to provision of physiotherapy, dietetics, speech and language therapy (SALT) and occupational therapy. This was a breach of Regulation 12, Safe Care and Treatment.

Rehabilitation services were being reduced which was a source of disappointment for staff.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Leaders completed pain management audits. We reviewed 3 audit reports from October 2024, December 2024 and February 2025; all met the hospitals compliance rates scoring above 90%. They also completed documentation audits on record keeping standards. Reports showed a varied picture with compliance rates of 43.2% in October 2024, 91.4% in November 2024 and 83.1% in February 2025. The most recent report from February 2025 showed areas for improvement such as had the medical admission page been fully completed (0%), and were all entries dated (80.0%).

There were forms for families to complete called "All about Me". The information was gathered from families to provide more individualised person-centred care. The idea was that this information was transferred onto "All about Me" boards in the patients' bed space. Staff were able to print off communication cards a resource by a charity.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

We reviewed the Intensive care national audit and research centre Quarterly Quality Report dashboard dated April to September 2024. The quality indicator dashboard showed all areas of the observed value was within or below the 95% predicted range - there was no evidence that the QI value was worse than expected. Areas covered included potential mis-triage to the ward, unplanned readmissions, high risk sepsis admissions from the ward and risk-adjusted acute hospital mortality.

Leaders audited nutrition and hydration. We reviewed the Nutrition and Hydration inspection audit reports which included mealtime observations nutritional screening tools and hydration. The most recent audits showed compliance of 100% in December 2024 and February 2025.

There was a management of deteriorating patient policy. The policy had information for staff on sepsis such as sepsis training and the management and escalation of sepsis. We reviewed some staff training slides on neutropenic sepsis and found they contained information on sepsis six, red flags, suspected neutropenic pathway and case studies.

The service did not always work well across teams and services to support people. Staff did not always share their assessment of people’s needs when people moved between different services.

The service accepted level 1, 2 and 3 patients. There was a discharge pathway for critical care services which included escalation routes when beds were not available for time critical, urgent and routine patients. The process was that if the patient was not transferred within 12 hours, then the nurse in charge was to raise it as a clinical incident. We also noted there was a patient flow pathway for critical care services with a set of actions including at 4 hours of no bed availability and out of hours and weekends.

At the time of the assessment, the service did not meet Guidelines for the Provision of Intensive Care Services (GPICS) in relation to provision of physiotherapy, dietetics, speech and language therapy (SALT) and occupational therapy. This had also been highlighted in a peer review which took place in July 2024. A business case document provided by the service to acquire funding for additional provision services stated that dietetic input was 2-3 days per week, and nutritional assessment, education, ward round input and audit were not provided as per guidance. Access to SALT was 1 session per week via a referral service. Physiotherapy provision was 1.2 whole time equivalent staff across the critical care pathway, including the ICU rehabilitation service – more than twice this number was required to provide a 7-day service. However, critical care had access to 24-hour respiratory physiotherapy as required via an on-call service. There was no routine occupational therapy provision. However, therapy and dietetic staff met with rehabilitation nurses weekly to discuss patients requiring input.

Staff and leaders told us they received good support from hospital microbiology services, who carried out a daily ward round. However, out of hours laboratory services were covered by an external provider which staff said caused some delays in results. We reviewed an incident report regarding a patient pathway delay as there was no MRI capacity for a patient over the weekend.

We observed a critical care ward round which occurred twice daily, a nursing staffing handover and 2 safety huddles and found them to be thorough, with a holistic approach. Staff submitted incident reports describing a lack of capacity on the respiratory ward leading to patients being admitted to ICU for non-invasive ventilation. The trust told us there was an approved business case for a respiratory support unit but there was no available funding. This was on the corporate risk register.

The service had identified some initiatives to improve teamworking. For example, we saw a newsletter named ‘Improving Communication with the multidisciplinary team and the ICU Rehabilitation team’. The aim was to improve the communication and quality strategy to facilitate communication between the multidisciplinary team (MDT) to enhance patient safety and the quality of care and additionally boost staff morale and provide education.

We also saw there had been an ICU study day on the MDT approach in February 2024. The study day included topics such as the role of the physiotherapist, dietetics, oral care and post ICU recovery, as well as patient stories.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

There was a road to recovery critical care guide for patients. The guide contained advice and information on different aspects of health following a stay in critical care. It included topics such as mobility and physical activity, including exercises, fatigue management, nutrition and relaxation. It also contained contact details of other services and sources of support.

There was a band 7 and a band 6 rehabilitation nurse in post. One rehabilitation nurse had been funded by the service to undertake a qualification in counselling, and was providing counselling to patients as part of follow up clinics. However, staff told us that funding to rehabilitation services was being reduced which was a source of disappointment. Leaders explained that additional resources were given to rehabilitation services due to the increased volume of patients due to the COVID-19 pandemic, however, funding was reverting to the pre-pandemic level. Leaders expected outpatient rehabilitation clinics to continue, but at a reduced level, and work to become more focused towards inpatients on the ICU. They also suggested that patient forums may be reduced.

There was a virtual post ICU rehabilitation class delivered by physiotherapists once a week which consisted of 30 minutes of exercise and 30 minutes of education. Results showed overall feedback from patients was positive, with many discussing the benefits that participation in the programme had on their physical and mental health. It had been found addressing patients concerns and normalising their ICU stay had reduced the psychological referral numbers from 12% needing psychology in 2021 to 7% in 2023.

The service routinely monitored people’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Following a CQC inspection in 2020, the Critical Care Outreach team expanded to cover a sepsis role and the SORT (Sepsis Outreach Response Team) was formed. Since the team’s launch, sepsis figures within the hospital had improved with overall sepsis 6 compliance improving from 28% to over 60% and antibiotic treatment within the hour had improved from 56% in January 2022 to 825 in April 2023. Intensive Care National Audit Research Centre (ICNARC) data also showed that complex admissions to ICU due to sepsis had improved since the introduction of SORT.

The department had completed a quality initiative in April 2024 around delirium. They collected baseline delirium assessments on appropriate patients which had showed some gaps. This led to a series of actions being put into place including a study day, flowcharts and further audit.

We reviewed an adult critical care unit peer review visit report completed in July 2024 which summarised the findings of the West Midlands Adult Critical Care Network adult critical care unit peer review visit. The findings were based on a review of nationally agreed standards against evidence provided by the service. Serious concerns identified were around the provision of a clinical pharmacist and there being no cohesive plan or team around the patient to meet their needs in the adult critical care unit in relation to rehabilitation and therapy provision across speech and language therapy, physiotherapy, occupational therapy or dietetics. At the time good practice included there being a dedicated passionate and inclusive team, the implementation of a Sepsis Outreach Response Team (SORT) in response to high sepsis admissions. However, we noted from the incidents that there was not always a sepsis nurse available. We saw there was an action plan to address serious concerns around the clinical pharmacist provision and therapy provision.

The department completed local audits such as those around patient documentation, skin integrity, nutrition and hydration and falls. We reviewed falls and deconditioning inspection reports and noted they had scored above 93% meeting the trust target in the last 3 audits from October 2024 to February 2025.

There was a Mental Capacity Act policy which included information for staff such as the two-stage test, who should assess capacity, and best interest decisions. We saw staff had completed a Mental Capacity assessment and best interest checklist when a patient was felt not to have capacity to consent to their care and treatment.

Documentation inspection reports contained a section on if a mental capacity assessment had been completed. Where applicable, results showed 100% compliance in November 2024 and February 2025.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Patients said staff explained all care and procedures to them, and where written consent was required, patients said that staff “checked and triple checked” this had been completed. Staff could explain how they ensured patients consented to care and treatment. A “It’s OK To Ask” poster was on display in the relative’s room. It gave advice such as “it’s OK to ask again if you don’t understand something, don't’ feel rushed or embarrassed”.

There was a consent to examination and treatment policy, however this was out of date with the last review due in June 2023.