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 the assessment we found that not all policies were in date. Documents stored on the intranet were also past their review dates. This was a breach of Regulation 17, Good Governance. Staff did not always find it easy to locate documents on the intranet. Leaders did not always follow their own policy relating to auditing working time compliance. This was a breach of Regulation 17, Good Governance. Funded provision did not meet GPICS standards.

Staff were aware of the Freedom to Speak Up (FTSU) service through posters and a mandatory training module but were not aware of any FTSU champions or ambassadors. Freedom to speak up guardians did not complete walkarounds of the critical care unit. Staff could not recall any diversity networks in the trust.

However;

Staff and leaders recognised there were some difficult interpersonal relationships in the service which had affected the culture but told us it was generally a good place to work. Leaders completed various leadership courses. Staff felt able to raise concerns to their managers, who they felt were visible and approachable.

Various critical care team meetings took place. Meetings reported on quality issues such as medicine management and standard operating procedures.

This service scored 61 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Critical care leaders said there was not a specific vision and strategy for the service, but this was being formulated. However, the trust had a strategy dated 2022-2027. The strategy included a vision, strategic aims and objectives, and the trust set of values which were Respect, Compassion, Professionalism and Teamwork.

The latest staff survey dated 2023 identified actions such as leading by putting people first, ensuring equality, diversity and inclusion, being a safe and healthy place to work and retaining and developing the workforce of today for the future; however, this was not critical care specific. No further surveys had been published at the time of our data request.

Staff and leaders recognised there were some difficult interpersonal relationships in the service which had affected the culture but told us it was generally a good place to work. A staff member stated that there had been division in the team since the pandemic, but this was improving. A staff member disclosed that they had experienced bullying and harassment while working in the service. Another had previously encountered issues as a member of a minority group, but felt that things had much improved, with a greater level of diversity in the team. Staff anonymously fed back feelings of anxiety and stress as a result of being redeployed to cover other areas of work.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders completed various leadership courses such as a clinical leadership programme, advanced clinical practice –leadership and management pillar, Leadership Role in Quality, Innovation and Change and the Mary Seacole NHS Leadership programme.

Staff felt able to raise concerns to their managers, who they felt were visible and approachable. However, 1 member of staff felt that issues raised through their managers were not always resolved. Leaders who undertook clinical duties said they were often visibly working on the unit. Leaders who were not clinical said they regularly visited the unit for meetings and walkarounds known as ‘Back to the Floor Fridays’. There were numerous channels for communication and engagement, from formal meetings to email and mobile app group chats. Nursing staff were placed in mentor groups led by band 7 nurses, and staff fed back that they found these groups supportive. Leaders said staff were able to move to groups if requested.

People were not always aware of Freedom to Speak Up, and the service did not have a visible presence on the unit.

Staff were aware of the Freedom to Speak Up (FTSU) service through posters and a mandatory training module but were not aware of any FTSU champions or ambassadors. We spoke with members of the Freedom to Speak Up team who said that they had had no concerns raised regarding the critical care service. However, while they undertook regular ‘walkarounds’ in other clinical areas, they said this did not happen in critical care.

Freedom to Speak Up guardians completed a FTSU report which was trust wide. We reviewed the report and noted it contained information such as key issues, an executive summary, considered themes, as well as the ethnicity profile of individuals raising concerns.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The hospital monitored gender pay gap, however the information was trust wide, so we have not added any specific information in the report. There was an Equality Diversity and Inclusion policy with the purpose of ensuring fairness for all in addition to an Equality Impact Assessment policy whose purpose was to help to evidence and understand the differential impact that a decision may have on different groups of people covered under the Equality Act 2010; however these were both due to be reviewed in 2023 so were not in date. Staff could not recall any diversity networks in the trust.

Good governance procedures were not always in place regarding policies and procedures. However, the service had clear responsibilities, roles and systems of accountability.

There was an information governance and data protection policy. However, during the assessment we found that not all policies were in date. We viewed the paper critical care guidelines folder and found 19 documents were out of date, with review dates ranging from August 2015 to May 2018. Documents stored on the intranet were also past their review dates. Staff did not always find it easy to locate documents on the intranet. We asked the divisional triumvirate what the barriers were to ensuring policies were reviewed and updated. They stated the process relied on staff manually checking when documents were due for review as there was not a system to flag approaching expiration, and this was a pressure on individuals’ time. Other leaders cited a protracted governance process and a lack of administrative support to format and upload documents onto the intranet. We had found some policies and procedures were out of date when we last inspected the service in 2019 and advised they should consider updating all polices to ensure they were up to date.

Leaders did not follow policy when auditing working time directive compliance. Monitoring was stood down in April 2024 due to no recorded compliance. Audits were restarted after the on-site assessment. However, leaders reviewed 2 weeks’ previous and 4 weeks’ future rosters, while trust policy states that working hours should be calculated over an of average 17 weeks.

Mandatory training levels for medical staff remained poor despite it being highlighted in our previous inspection in 2019.

The critical care service sat within the surgery division and had a triumvirate in place. There was an intensive care unit risk register which had 11 risks. The risk register was red, amber, green rated and contained controls as well as a risk review date. The risks at the time of the assessment included risks around equipment, limited availability to admit and in relation to falling below guidelines for the Provision of Intensive Care Services with the ICU course as the standard was 50% of nursing staff on ICU to have ICU course qualification and staffing.

Various critical care team meetings took place. Meetings reported on quality issues such as medicine management and standard operating procedures. The division of surgery also held its own meetings which included theatres, anaesthetics and critical care services. The meeting looked at areas such as governance reports and performance reports, finances and IT systems. Band 7 meetings included areas such as complaints, compliments, incidents and Martha's rule.

The surgical division had compiled a Theatres, Anaesthetics and Critical Care (TACC) Group Performance Review Division of Surgery December 2024. Within the report was key information relevant to critical care including ICNARC data, key risks, workforce, performance and mandatory training compliance.

The department also held Metric Review Meetings where key achievements and red and amber ratings were discussed. We reviewed the meeting notes from November, December 2024 as well as January 2025. The notes contained action plans where improvements had been identified. For example, in January 2025 actions identified were to raise awareness with staff in relation to poor compliance in relation to tissue viability and to e-mail the medical lead in relation to poor compliance in completing medical section of ICU 7-day document.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

Although funded provision did not meet GPICS standards, we observed physiotherapists working with patients during our assessment. Leaders told us there was collaborative working in place between the service and NHS England to provide additional physiotherapy support to critical care patients prior to tertiary transfer or step down to rehab care. A patient said they had been assessed by a dietician and given a diet plan. However, allied health professionals did not attend ward rounds. We saw evidence of specialty review in patient records.

A system partner we spoke with was positive about the working relationship they had with the service. They had recently worked collaboratively around ‘Martha’s Rule’. They considered leaders open and said that they would approach partners when issues arose. They felt a particular strength of the service was having strong, visible leaders.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe and effective practice.

The service had participated in a number of research trials including a study of the genetics of susceptibility and mortality in critical care, a COVID-19 recovery trial, and a study on critical illness related cardiac arrest. They were recruiting to an airway devices trial at the time of the assessment.

Staff told us about a multidisciplinary quality improvement project which had increased staff awareness on the detection and management of delirium. They said that new delirium guidelines were being created.

A Sepsis Outreach Response Team had been formed which had made a positive impact/improvement on sepsis figures. A post ICU rehabilitation class delivered virtual classes online once a week. An advice sheet had been created advising patients about the class including what exercise to complete between classes and when not to exercise.

We saw a set of slides that had been developed to share information on psychology and dreams. It included information around hallucinations, delirium and vivid dreams.