Manor Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Staff used the Gold Standard Framework to holistically plan for patients, ensuring that the right care, interventions and referrals were in place. Staff were able to access information some information for patients in different languages.

The Friends and Family Test (FFT) results achieved 100% in December 2024 and February 2025 and 90% in January 2025.

The premises was accessible, with services located on one level.

However;

Leaders audited ReSPECT forms; however, the last 3 audits found the department did not meet the hospitals target rate on them.

Leaders organised learning disability and mental health training. However, compliance was low with only 67.5% of staff completing Oliver McGowan eLearning and 2.6% completing Oliver McGowan Tier 2.

This service scored 71 (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 made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

We observed a display regarding the Gold Standard Framework, a national framework around end-of-life care based on an individual’s prognosis. Staff told us they used the framework to holistically plan for patients, ensuring that the right care, interventions and referrals were in place. We noted that the framework was referred to in a safety huddle.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

There was a large display explaining each part of the critical care journey in the relative’s room. This included information on long-term recovery, a prompt to ask staff about support groups, as well as quick response codes to relevant charities and online forums.

Patients did not have access to a regional ventilation and weaning unit, but a team from another trust visited patients to assess their needs before discharge. Leaders said that medics referred patients for ‘one stop shop’ imaging such as computed tomography scans and chest X-rays as part of follow-up clinics, particularly post COVID-19. This prevented patients having to make multiple trips.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff were able to access information for patients in different languages which included Bengali, Arabic, Chinese, Danish and Hindu. They were also able to utilise communication cards for people to complete as well as the Royal National Institute for Deaf People leaflet communication ‘Tips for the general public’.

We were provided with a copy of a slide deck for staff which had information around Accessible Information Standards which included what professionals had to do, types of communication support and what the hospital already provided to patients.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved people in decisions about their care and told them what had changed as a result.

Posters with quick response (QR) codes for The Friends and Family Test (FFT) and trust Mystery Patient Scheme were on display in the relative's room. Staff we spoke with could not recall a complaint they had dealt with but understood the complaints process. We reviewed a sample of Patient Voice Reports for the Intensive Care Unit and found FFT results achieved 100% in December 2024 and February 2025 and 90% in January 2025. The reports included a section on Inpatient Mystery Patient Feedback. The most recent report February 2025 showed the most negative theme as nutrition and hydration with varied results around treatment and care, communications and systems and processes. There were QR codes to access the FFT dashboard and the themed analysis dashboard. The reports also contained the number of complaints, concerns and compliments.

There was a model complaint handling procedure with information for staff on areas such as timescales, complaints involving multiple organisations and referral to the ombudsman. We reviewed 3 complaints responses and found they had details of the investigations, answered questions from the family, contained apologies and the ombudsman details should the complainant be unhappy with how the hospital had investigated their complaint. We also reviewed some team meeting minutes and found complaints had been discussed.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The unit design adhered to standards in Health Building Note 04-01. The premises were accessible, with services located on one level. There was a large wet room with a shower, bath and hoist for patient use. A patient who used a personal mobility aid said staff supported them to use this on the ward.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcome. However, there was low compliance in training on learning disability.

Leaders organised learning disability and mental health training. However, compliance was low with only 67.5% of staff completing Oliver McGowan eLearning and 2.6% completing Oliver McGowan Tier 2. Leaders told us training was off site and new dates were being updated. Staff had access to communication cards for patients who were unable to communicate verbally. They told us it was easy to book telephone and face to face interpreters; this was particularly important when discussing treatment plans or having potentially difficult conversations with families.

We reviewed an Intensive Care Guide folder in the relatives’ room and found that information was available in several languages. We saw that leaflets were available in languages other than English from the Patient Liaison and Advisory Service on request.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Leaders audited ReSPECT forms. We reviewed a sample of 3 audits and found the service did not meet the hospital target on any of these. The compliance rate for October 2024 was 84.2%, November 81.6% and February 2025 83.3% and each audit was rated as amber. Areas which repeatedly required improvement included the sections on the form that asked if legal welfare proxy was in place, what I fear most and what I value most. However, a sample of forms we reviewed on site were correctly filled.

Staff told us they always referred to the Specialist Nurse in Organ Donation (SNOD) to lead on conversations about organ donation. They said that once referred, the SNOD quickly visited to assess the patient, and if suitable, approach their family.