Manor Hospital

On this page

• 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

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care. The service was in breach of Regulation 12, Safe Care and Treatment regarding staff not always following infection prevention and control guidance, particularly in relation to personal protective equipment, and being bare below the elbows, and also medicines management.

Staff stored large amounts of spare equipment in unused bedspaces. We found some equipment, including syringe drivers and patient warmers, past their service expiry dates. We noted a number of nursing staff were carrying out additional bank shifts in other areas of the trust, triggering European Union on working time directive breach notifications. Information showed that 16 out of 27 consultants did not meet the overall mandatory training compliance rates, consultant mandatory training rates were raised as a should on our last assessment. Not all staff were bare below the elbow on the first day of the assessment. Inspectors were able to tailgate staff through the staff Intensive Care Unit (ICU) entrance several times without challenge. Some soft furnishing in the relatives’ room showed significant signs of wear, with a large split in the seat of a sofa which could pose an infection control risk. In relation to medicines we found expired medicine, gaps in expiry checks, lack of action in relation to fridge temperatures not being the correct temperature and protocols were not always followed. The trust had a policy for the IV administration of potassium but none of the staff we spoke with were aware of the policy.

However;

There were processes for staff to record incidents and we saw and heard of learning as a result. The hospital was part of a pilot for Martha’s rule. As a result, they had implemented a call for concern service and had found outcomes were so far positive. Safeguarding policies were in place and staff gave us examples of when they would raise a safeguarding concern. Risk assessments were completed consistently in patient records including sepsis risk assessments. The service audited documentation and key risks were discussed in various meetings. Staff completed competency workbooks which included use of specific equipment. There was an emergency evacuation plan. Staffing levels met the recommended levels on both days of our assessment, and most staff felt staffing levels were safe. The service employed 2 part time professional development nurses. They had also received some funding which they were using towards for critical care course completion for nurses as they were slightly below the Guidelines for the Provision of Intensive Care Services (GPICS) recommendations.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff recorded incidents on the hospital’s electronic recording system. We reviewed the last 6 months incidents and saw some themes and trends relating to device related pressure ulcer development. Leaders told us there was a band 7 nurse in post with an interest in tissue viability, and that cases were reviewed in a meeting with the lead tissue viability nurse to determine if they had been avoidable. They said a head and neck document developed by a partner trust had been introduced to aid early detection of pressure ulcers for patients with ventilation devices. Leaders completed tissue viability inspection reports. We reviewed a sample of these dated December 2024 (86.1%) and January 2025 (89.2%). The audits looked at areas such as if a skin inspection/body map had been completed within 6 hours of admission, if the patient was nursed on a specialist mattress and if slide sheets were documented when used.

Staff could give examples of incidents they had or would report. One member of staff spoke about a medication error they had made. They talked through the incident with a senior, wrote a reflective piece, and carried out duty of candour with the patient. They felt they were treated fairly, without blame. We saw this example had been documented including what the nurse had learned and how this had improved their practice.

Leaders gave further examples of changes made as a result of learning from incidents. For example, following a never event involving a nasogastric (NG) tube, mandatory training was implemented across all wards and policy changed so that 2 doctors were required to sign off that the NG tube was correctly sited before use, preventing any further incidents in critical care.

We reviewed critical care ward meeting minutes and noted incidents were an agenda item. Band 7 meeting minutes dated July 2024 discussed the deterioration of a patient's condition during treatment. Incidents were also discussed in the Surgery Divisional Governance Meeting Escalation Report and the Theatres, Anaesthetics and Critical Care Group performance review Division of Surgery. There was a management of safety alerts policy which was version controlled and in date.

We reviewed a sample of team meeting minutes and found leaders discussed health and safety. For example, in January 2025 patient repositioning, standard operating procedures for mattress decontamination and tracheostomy patients and equipment box at the bedside were discussed. Duty of candour was reported on in the Theatres, Anaesthetics and Critical Care Group performance review Division of Surgery notes.

Results from the 2023 staff survey for the statement ‘We are always learning’ were roughly in line with the trust average, although this incorporated all of the surgical division.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

There was a 24/7 critical care outreach service with clear referral criteria. Staff told us the team reviewed patients requiring non-invasive ventilation at least once per shift, as well as virtually monitoring their clinical status. Leaders told us the outreach team had processes in place to ensure patients remained stable, their pain was managed and that NEWS was documented for the first 24 hours post discharge and to introduce themselves and assess clinical status prior to a more in-depth review. The service also provided a sepsis outreach service between the hours of 08:00 and 20:30, 7 days a week. The hospital was identified as a pilot site for ‘Martha’s Rule’ in November 2024; there was a roll out plan with actions required.

Posters and leaflets were on display to publicise the inpatient ‘Call for Concern’ service which had been implemented in response to ‘Martha’s Rule’. Staff and leaders told us the outcomes of this pilot were so far positive and gave examples of patients being quickly escalated to critical care as a result. Furthermore, fewer inappropriate calls for concerns were being made. Leaders were in the process of extending the service to paediatric patients.

Staff were running a pilot on wards where they had received the most calls for concern. The pilot involved a daily wellness round which invited patients to say how they were feeling on a scale of very good to very bad, and comparing this to how they felt yesterday, from very good to much worse. The pilot documentation encouraged staff to escalate within their local medical teams before considering escalation to the critical care outreach team in the most serious cases.

We viewed the electronic booking system used to refer patients to the service. We found there was little information recorded on the system, including limited clinical information. We observed a patient transfer from ICU to a ward and found a thorough handover had been completed, as well as a nursing checklist and a doctor's transfer summary. There was a standard operating procedure for the safe inter and intra hospital transfer of adults receiving critical care support. Leaders were working to introduce a critical care informational system with a partner trust.

Safeguarding policies were in place for children and adults, these were in date and version controlled; they contained links to legal, professional and national guidelines.100% of ICU staff had completed their level 1 and level 3 Safeguarding training meeting the trust target. 85.7% of staff had completed level 2 safeguarding, just below the trust target. Staff gave examples of when they had or when they would raise a safeguarding referral and felt able to ask the safeguarding team for advice. Staff also told us they would report any safeguarding concerns as an incident. Staff set passwords with patients or their next of kin. Only approved visitors were allowed to visit patients or receive telephone updates on them.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed a sample of patient records and found risk assessments including sepsis risk assessments and subsequent planning were consistently completed. We saw evidence of escalation and medical review when a patient’s condition had deteriorated. Nursing staff told us there was always medical presence on the ward, and they felt able to escalate concerns.

The hospitals documentation standards report had a section on managing risks, including if observations had been completed on admission. This was scored as 50% in October 2024, 100% in November 2024 and February 2025 showing that documentation had improved. Key risks and mitigations as well as quality meetings were discussed in meetings and reports.

The service did not always detect and control potential risks in the care environment. Staff did not always make sure equipment, facilities and technology supported the delivery of safe care.

Inspectors were able to tailgate staff through the staff Intensive Care Unit (ICU) entrance several times without challenge. Visitors were supposed to be admitted through the visitors' entrance and wait in the relatives’ room for staff to collect them. However, staff told us that this did not always happen. Following the assessment, leaders said they had received approval to limit swipe card access to staff closely aligned to the service. A visitor’s guide to ICU had also been drafted.

The ward was generally tidy, however staff stored large amounts of spare equipment in unused bedspaces. Leaders told us that a room intended to be an equipment store had been repurposed as office space for another team. However, the trust highlighted that there was dedicated equipment storage space adjacent to critical care offices. We found some equipment, including syringe drivers and patient warmers were past their service expiry dates. This was escalated to ward staff at the time and the equipment was removed from the ward.

Staff told us it was easy to report defective equipment, and that it was dealt with quickly. We saw staff segregated defective equipment into a clearly labelled basket for collection by the medical devices team. Staff consistently carried out daily and weekly checks of emergency equipment including resuscitation trolleys.

We found staff had reported 4 incidents in the last 6 months due to there being no patient cooling device. However, we found the service had taken delivery of a device the week after the assessment, and training was underway. At the time of the assessment the television, water machine and vending machine in the relatives’ room were out of order.

Staff initial competency workbooks required staff to be signed off on using specific equipment such as specific ventilators and suction. We reviewed the July staff newsletter and saw it had a section specifically on equipment.

The unit had 1 double isolation room. However, the outer doors to the room did not close correctly. We saw evidence of water leaks from the unit ceiling, and incident reports detailing water leaking onto patient beds. Staff told us they had reported the leaks, and it was on the service’s risk register. Leaders told us detecting the source of the leaks had been difficult as it relied on rainy conditions, but the issue had been resolved shortly before the on-site assessment.

Staff told us there was an allocated fire warden on the unit. However, on the afternoon of 27 February, we observed that the fire door to the kitchen had been propped open with a bin; this was escalated and resolved at the time.

There was an ICU emergency evacuation plan which included actions to be taken upon hearing the fire alarm and evacuation procedures. Leaders told us due to theatre refurbishment/development works the location of the theatre recovery area had changed. This had been agreed with the senior fire safety advisor and that plans for an evacuation drill were being drawn up by the senior fire advisor to take place in 2025.

The servicemadesure there were enough qualified, skilled and experienced staff. However, leaders did not always ensure all staff had completed their mandatory training received effective support, supervision and development.

We observed staffing levels met recommended levels on both assessment days. Managers used an acuity tool to ensure that there were enough nursing staff to support the needs of patients and were flexible. Most staff felt the service was safely staffed.The service did not use agency staff.

We reviewed live rosters on site and noted 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. Not all staff had opted out of the directive.

Leaders generally rostered 3 supernumerary senior nursing staff per shift, 1 more than Guidelines for the Provision of Intensive Care Services recommendations for a unit of this size. In the 3 months before the assessment, there was a 24/7 nurse in charge 100% of the time, and a 24/7 clinical coordinator nurse and a backup nurse 81% and 97.5% of the time, respectively. When patient numbers increased, a supernumerary nurse changed role to support patient care.

We observed a safe staffing meeting where leaders ensured that staffing met recommended levels across the directorate. On Fridays, leaders assessed staffing for the next 72 hours over the weekend.

Medical cover was provided by 1 registrar at night. Leaders stated they would like to increase Advanced Critical Care Practitioner presence to 24 hour, 7 days a week to ensure more support on the ICU at night. Staff agreed that registrar night shifts often felt busy and pressurised but felt able to call consultants for support. The unit supported 1 specialist intensive care medicine trainee per year.

New nursing staff were given a minimum of 6 weeks supernumerary period, though this could be extended, and initial competency books to complete within 3 months of starting. Prior to being included in staffing numbers, new staff had to complete mandatory parts of the competency book and have them signed off by signatories who had themselves completed the national Step 1 Critical Care National Nurse Network competencies or an ICU nursing course. We viewed a sample of workbooks and found them to be correctly completed. New clinical support workers also completed a competency book before going on to complete the Care Certificate qualification.

The service employed 2 part-time professional development nurses (PDNs). They told us they facilitated learning events including monthly simulation sessions for nursing staff, bi-monthly simulations for the whole critical care team, as well as study days. We viewed the agenda of a recent study day which included training on a piece of equipment, manual handling training and a talk from a tissue viability nurse. They told us staff who did not attend study days were sent emails with information, and items were added to the unit newsletter. Staff told us due to time constraints, PDNs were not often able to work clinically with staff.

We reviewed data in relation to critical care course completion. At the time of the assessment, 42% of ICU staff had undertaken the course. This was just below the GPICS recommendation of a minimum of 50%. The SORT team had 100% completion rates. Leaders told us that they had received health education funding, and 8 registered nurses were completing the course at university. The predicted completion rate for ICU by September 2025 was 52.6%.

Mandatory training records showed an overall compliance rate of 89.9% for nursing staff and 92.8% for clerical staff. We looked at individual mandatory training compliance and found that staff did not meet the trust target rates in hand hygiene (85.5%), fire local arrangements (88.2%) and infection prevention control (84%). At the time of the assessment compliance with adult basic life support was 68%, however following the assessment this increased to 88%. Compliance with advanced life support (ALS) for the critical care outreach team was 100%, as was the critical care workforce who required it. Leaders told us there was always a senior nurse band 7/8 trained in ALS scheduled on each shift. We found most staff completed appraisals with an overall compliance rate of 86.4%. Compliance rate for medical staff was lower overall at 86.3%. Staff told us that their appraisals were good opportunities to discuss their development and goals with managers. Information provided by the hospital showed that 16 out of 27 consultants did not meet the overall mandatory training compliance rates, with 9 consultants being red, amber, green rated as red. Mandatory training compliance levels for medical staff were below the trust target on 7 of the 10 mandatory training modules on our previous inspection. Staff told us they could generally complete training within work hours. All of the intensive care consultants were fully airway trained.

We saw a set of slides for an ICU rehab study day, the slides had information for staff around psychological health during and after ICU, as well as information on delirium.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading.

There was a policy for hand hygiene and personal protective equipment (PPE), this was in date. Leaders completed hand hygiene audits, results for December 2024 and February 2025 showed 100% compliance. They also monitored infection rates, and over the last 6 months there had been 2 cases of Escherichia a coli, 1 case of klebsiella pneumoniae and 1 case of methicillin resistant staphylococcus aureus. We observed that patients who had, or had been in contact with, an infection were being cared for in side rooms. Staff placed signs on side room doors to advise what PPE was required when treating the patient inside. However, staff did not always wear PPE when entering side rooms.

There was also a droplet airborne report from an audit in February 2025 which scored 100% compliance. The report covered areas of audit such as infection prevention risk, hand hygiene, and equipment cleanliness.

We reviewed the December 2024 and February 2025 papers for submission to the Infection Prevention and Control Committee. The papers reported on Intensive Care National Audit and Research Centre data for Q2 which showed all areas being within the 95% green range for the first time, including unit acquired infections in blood. A cannula audit completed in 2024/2025 showed ICU as consistently meeting target rates most months. The papers also included how the department had prepared to respond to potential new infections.

Environmental and infection control was on the agenda of the critical care ward meeting and actions had been identified and recorded, for example using green stickers when equipment had been cleaned and keeping sluices clean.

We viewed a sample of cleaning rosters. Staff completed and recorded most tasks daily. Patients said staff always washed or sanitised their hands before treating them. Staff thoroughly cleaned a bedspace after a patient was transferred to a ward. However, we observed that not all staff were bare below the elbow on the first day of the assessment. Some soft furnishing in the relatives’ room showed significant signs of wear, with a large split in the seat of a sofa which could pose an infection control risk. Leaders told us that they were intending to use charitable funds to refurbish the relatives’ room.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Emergency medicines were stored securely next to bedsides but there was no list of what medicines or quantities should be stocked. This meant stock levels would be difficult to maintain and monitor consistently. In the clean utility, medicines were stored securely in lockable cupboards. However, we found an emergency drug kit that contained an expired medicine. The emergency drugs kit contained a list of medicines that should be in the box however the contents did not match the list. There were gaps in the medicine expiry checklist folder, where staff had not signed to show if the medicines dates had been checked. A syringe of medicine that was expiring at the end of the month in a bedside cupboard. It had no markings to show it was short-dated. This meant we could not be assured that all medicines would be fit for use when needed.

Records showed that the medicine fridges had been above 8 degrees on consecutive days with no action taken. We cannot therefore be assured medicines were always stored at the correct temperatures and fit for use when needed.

Controlled drug (CD) stock balances were checked and logged. We found a patient’s own CD in the cupboard a week after the patient left the unit which had not been transferred with the patient. This meant that protocol was not always followed.

Policies provided to us by the Trust were out of date, with some due to be reviewed in 2021. Policies and procedures relating to medicines that were kept in folders next to patient beds were also out of date. A medicine compatibility chart in use was dated from 2011. This meant that newer medicines and the most up-to-date information would be missing and not available to staff if required. Staff also found it challenging to locate policies in the Trust intranet. The trust had a policy for the IV administration of potassium but none of the staff we spoke with were aware of the policy.

Staff told us total parenteral training (TPN) was delivered via peer learning with no clear formal training. This could lead to different standards of knowledge.

Prescription charts were completed with allergies, assessments for venous thromboembolism (VTE) and medicines including oxygen were prescribed appropriately. A patient with a known drug allergy was wearing a red wristband as required.

The pharmacy service did not meet GPICS guidelines at the time of the assessment. The pharmacist supporting the service was a trainee in critical care. Leaders told us that they got support from a partner trust whilst in training. The pharmacy service provided to ICU was not a 7-day service but half days Monday to Friday, with the ICU pharmacist being available by bleep in the afternoon. On weekends the service was covered by the dispensary and the pharmacist on call, not a specific ICU pharmacist.

Leaders told us that because of medicines incidents in the service, staff education in this area was prioritised. On one of the assessment days, we observed a medicines management learning session taking place.