Archived: Manchester Royal Infirmary

Manchester Royal Infirmary is a large teaching hospital that is part of Central Manchester University Hospitals NHS Foundation Trust. The hospital provides a full range of general and specialist services including emergency care, critical care, general medicine including elderly care, surgery and outpatient services. The hospital is also a specialist regional centre for kidney and pancreas transplants, haematology and sickle cell disease. The Heart Centre is a major provider of cardiac services in the region, specialising in cardiothoracic surgery and cardiology. Located on the same site as the Manchester Royal Infirmary are the following specialist hospitals:

St Mary’s Hospital - a specialist hospital for women, babies and families

Royal Manchester Children’s Hospital (RMCH) - provides specialist healthcare services for children and young people. With 371 beds it is the largest single-site children's hospital in the UK.

Manchester Royal Eye Hospital (MREH) - a large, specialist ophthalmic teaching hospital.

Each hospital is based on the trust’s main site along with the Manchester Royal Infirmary (MRI) but is a separate, purpose-built building with its own identity as a specialist hospital.

We carried out this inspection as part of our comprehensive inspection programme. We carried out an announced inspection of Manchester Royal Infirmary, Royal Manchester Children’s Hospital, St Mary’s Hospital and the Manchester Royal Eye Hospital between 3 and 6 November 2015. In addition an unannounced inspection was carried out between 3pm and 8pm on 23 November 2015 at Manchester Royal Infirmary, St Mary’s Hospital and Royal Manchester Children’s Hospital. As part of the unannounced visit we looked at triage and safeguarding processes in accident and emergency services and staffing levels in maternity services. We have reported our findings for all four hospitals within this report.

Overall we rated Manchester Royal Infirmary as ‘Good’. We have judged the service as ‘good’ for safe, caring, effective and well-led care and noted some outstanding practice and innovation. However improvements were needed to ensure that services were responsive to people’s needs.

Our key findings were as follows:

Cleanliness and infection control

• The areas we inspected were visibly clean and well maintained.
• Staff were aware of current infection prevention and control guidelines.
• We observed good practices in relation to hand hygiene, ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
• Cleaning schedules were in place, and there were clearly defined roles and responsibilities for cleaning the environment and cleaning and decontaminating equipment.

Nurse and midwifery staffing

• Care and treatment was delivered by committed and caring staff who worked hard to provide patients with good services.
• However nurse staffing levels, although improved, remained a challenge. There were still a high number of nursing vacancies across most services including midwifery, general medicine, A&E and surgery. The trust was actively recruiting nursing staff from overseas to try and improve staffing levels.
• Although we found staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased demand, or short notice sickness and absence.
• St Mary’s Hospital had implemented a number of initiatives to continually assess patient acuity and staffing levels using a designated co-ordinator. There was a commitment to increase the number of midwives available and recruitment was ongoing.
• Services tried to use the same bank and agency staff to ensure they had the required skills to work on the ward. Agency staff were given an induction before commencing work.
• The Intensive Care Society standard for nurse staffing states there should be a band 6 or 7 supernumerary clinical coordinator on duty 24 hours a day, seven days a week. At the time of inspection this was not always happening on the cardiac intensive care unit as there was not a supernumerary clinical coordinator on duty during the night shift.We were told of occasions when this supernumerary provision was met but a staff member may then be moved during the night to assist other areas within the hospital. We raised this matter with the directorate senior staff at the time of inspection. They responded promptly by immediately implementing an action plan which gave the cardiac intensive care unit their supernumerary clinical coordinator at night.
• Data showed there had been a 33% increase in the demand for end of life care services. The need for sufficient specialist palliative care staff to meet the demand for the service had been identified by the service and was on the end of life risk register. A business case had been submitted to seek investment in services to enable staff to respond in a timely manner and provide access seven days a week and out of hours.

Medical staffing

• Medical treatment was delivered by skilled and committed medical staff.
• There were sufficient numbers of consultants and medical staff to provide patients with safe care and treatment.
• Locum doctors were used to cover existing vacancies and for staff during leave. Where locum doctors were used, they underwent recruitment checks and induction training to ensure they understood the hospital’s policies and procedures.
• There was 168 hours of consultant presence on Maternity and NICU. The trust was one of only two in the country to implement this standard.
• For patients with palliative/end of life care needs, medical cover was provided on the general wards in MRI.
• Palliative care consultant cover was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland and the National Council for Palliative Care guidance.

Access and flow

• Due to the number of emergency admissions and increased demand for services there was continual pressure on the availability of beds across the hospitals, particularly the MRI and RMCH. As a result the management of patient access and flow across the hospitals remained a significant challenge for managers. There were sound arrangements to ensure the timely medical review of patients.
• The trust’s performance for patients being seen within 4 hours was similar to the England average and the trust exceeded the 95% target between March and May 2015. However, the adult emergency department at MRI consistently failed to meet national targets for time to treatment, time to discharge and ambulance handovers.
• Both the adult’s and children’s departments were often overcrowded. At the time of our visit, the children’s emergency department reached full capacity and we saw the matron and the clinical lead contact operational managers across the hospital to increase the flow of patients. Records showed that between April and September 2015, 15% of patients waiting in the adult emergency department to be admitted to the MRI were waiting on a trolley for between four and 12 hours. This was worse than the England average of around 2%.
• In MRI and RMCH, patients were sometimes placed on wards that were not best suited to meet their needs (also known as outliers).However, there were good systems in place for the management of these patients to ensure they received a regular medical review.
• The hospital held bed management meetings regularly throughout the day during the week to review and plan bed capacity and respond to acute bed availability pressures.
• There was a clear focus on discharge planning although there were a number of patients experiencing delayed discharge because they were waiting for packages of care.
• Adult surgery services achieved the 18 week referral to treatment standards across all specialties. Elective operations were frequently cancelled due to a lack of available beds and theatre lists running late. The rate of cancelled elective operations had been higher than the England average since July 2014. However, the division of surgery transformation plan included actions to improve theatre efficiency and reduce cancelled operations.
• At RMCH surgery services faced ongoing challenges in meeting the 18 week referral to treatment time standards, with some specialist services experiencing waiting list pressures.
• There had been significant improvements in adult critical care services in reducing the number of patients discharged out of hours. However, challenges with access and flow within the wider hospital impacted on patients’ discharge from the critical care units. Similarly capacity issues in the cardiac intensive care unit (and wider cardiac wards) meant beds were not always available to allow patients to be discharged onto a ward.
• Bed occupancy rates in maternity services were 25% higher than the England average throughout April, May and June 2015. This meant there was insufficient capacity for the numbers of patients attending the maternity unit. A policy to divert patients to other units in the area was in place however, the threshold for the use of this policy was not clearly defined and there was no risk assessment to support the process.
• The system at St Mary’s Hospital was to plan eight inductions per day, however due to bed capacity and staffing, these were often not completed on the day. This led to some patients being admitted to wait for induction and others being sent home to wait.

Mortality rates

• Mortality and morbidity meetings were held monthly and were attended by representatives from all teams within the relevant divisions. As part of these meetings, attendees reviewed the notes for every patient who had died in the hospital within the previous week. Any learning identified was shared and applied.
• The trust had previously been identified as an outlier for puerperal sepsis and other infections as part of the CQC intelligent monitoring programme. On request, the trust had provided the CQC’s maternity outliers panel with the requested information and could evidence that a full investigation had taken place to understand the data and identify areas for improvement. As a result the service had an action plan in place and this had reduced the rate of infection from 6.8% to 4% between April 2015 and July 2015.

Nutrition and hydration

• Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.
• A coloured tray and jug system was in place to highlight which patients needed assistance with eating and drinking.
• Some wards had ‘protected mealtimes’ in place when all other activities on the wards stopped, if it was safe for them to do so. This meant staff were available to help serve food and assist those patients who needed help.
• The food and drink provision had been reviewed since the last inspection in 2013, which highlighted that the choice of food across the hospital was limited. As a result, actions had been taken to improve food provision. Work however, across the trust was ongoing. The standard of food was an identified risk on the trust’s risk register and a programme of work was being undertaken to understand where and what improvements were required.

We saw several areas of outstanding practice including:

• Staff monitored patients by using an electronic early warning score system that automatically notified medical staff and some non-medical staff (such as the surgical lead pharmacist) if there was deterioration in a patient’s medical condition. This process was fully embedded across the main site and all the staff we spoke with were positive about using this system.
• The diagnostic imaging department used innovative new technology for assessing coronary artery disease which was available in only two centres in the UK. This meant that patients only required a single one hour visit rather than two visits and three hour appointments. It also meant lower radiation doses were administered to both staff and patient when compared with conventional technology.
• The neonatal unit used video technology to support women who were not well enough to visit their baby, and a bleep system for parents so that they were involved when decisions were being made by medical teams.
• The gynaecology emergency unit was locally unique in that it allowed patients to refer themselves to a specific unit for assessment and treatment of gynaecological emergencies and problems in early pregnancy.
• The development of a nationally unique service relating to developmental sexual dysfunction. This specialist clinic met the very specific needs of patients suffering a variety of sexual development issues. Patients who attended this clinic had the opportunity to be seen by consultant gynaecologists, endrocinologists and psychologists. Counselling services specific to the patients who attended the clinic was also available.
• Staff at St Mary’s hospital participated in an extensive programme of local, national and internationally recognised research. In areas such as female genital mutilation (FGM), senior staff within St Marys were participating in the development and implementation of national guidelines.
• The adult rheumatology ward had really thought about the feelings of young people transitioning into their department. They considered how young people would feel sitting in waiting rooms predominately designed for older patients and had developed a separate young person clinic, which was due to start in January 2016. They had involved young people in the re-design of the waiting room, using a mural of photographs of the young patients. The ward had set up a youth group who communicated via social media, which the staff monitored. They had developed their own education sessions for young people, in particular a session called ‘Sex, drugs, rock and roll’, to inform the young people of their condition and the impact of their life style choices.
• The baby hip clinic was the first example of a one stop assessment and treatment service for children with developmental dysplasia of the hip to be a collaboration between all consultants, rotating through the clinic, with agreed protocols and pathways, allowing standardisation of care and facilitating audit and research. This innovation placed the clinical needs of children and ease of accessing assessment and treatment for parents at the forefront of service redesign.
• Trained nurses were able to undertake eye screening for retinopathy of prematurity (ROP) using a web cam for babies in the neo-natal unit and were able to get immediate clinical review by ophthalmology consultants. The service had been evaluated as successful and was provided in other units as a result.
• The MREH was identified as a NICE exemplar (best practice) service for the management of glaucoma.

However, there were also areas where the trust needs to make improvements.

Importantly, the trust must:

• Ensure that sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed in all services, particularly urgent and emergency services, medical care, surgery services and end of life care. This also includes midwives in all areas of the maternity services and sufficient doctors to provide timely review of patients when requested.
• Improve patient flow through the Manchester Royal Infirmary, St Mary’s Hospital and Royal Manchester Children’s Hospital, particularly in maternity services, medical care, surgery services and A&E.

In addition the trust should:

• Ensure checks of resuscitation equipment are carried out and recorded in line with trust policy and procedures.
• Ensure medicine fridge temperatures are recorded daily and staff take appropriate action if and when a temperature is outside the recommended range.
• Continue to improve the quality and storage of patient records to ensure they are fully completed and all contents are securely stored.
• Ensure that all staff receive appraisals and mandatory training to enable them to carry out their role and responsibilities.
• Have a vision and strategy in place for end of life care for adults, children and young people. The trust should review the leadership for palliative care across the service to ensure it reflects the needs of patients.
• The trust should ensure that appropriate systems are in place to assess, monitor and improve the quality of end of life care provision for patients and their families.

In urgent & emergency services

• Upgrade the mental health rooms as planned.
• Ensure that there are established systems in place to effectively document adult safeguarding concerns.
• Ensure the risk register is regularly updated and clearly reflects actions taken to control and mitigate risks.
• Consider how to prevent or manage the spread of infection on OMU.
• Consider how side rooms without nurse call bells are used in ED.
• Consider how to make services in the WIC more child friendly.
• Ensure staff in the children’s emergency department hand hygiene protocols to prevent the spread of infections.
• Review safeguarding processes for triaging a patient and the electronic patient record system to ensure that every opportunity is taken to identify and make staff aware of safeguarding or child protection concerns when a child or young person presents at the children’s emergency department or walk in centre.

In medical care services

• Consider the review of training around the medicines policy in relation to the administration of patients own medication and the administration of when required medication.
• Ensure that all staff understand and follow the correct process when completing DoLS applications.
• Ensure that all equipment has up to date electrical safety certificates and that oxygen cylinders are stored in line with guidelines.
• Ensure that patients’ privacy and dignity is maintained at all times on the endoscopy unit.
• Ensure that all staff seek consent for the use of bedrails and if patients lack capacity apply the Mental Capacity Act (2005) principles.

In surgery services

• Improve availability of patient notes for patients admitted as part of the rapid access process.

In critical care services

• Should review the medical staffing model operated in the paediatric high dependency unit (PHDU) to ensure that it fully supports effective care for children on the unit.
• Should ensure there is a clear vision and strategic plan in place for the cardiac intensive care unit.

In maternity and gynaecology services

• Ensure that all areas of the maternity services are clean and tidy at all times.
• Ensure that personal protective clothing used in the operating theatres meets with current guidance.
• Ensure there is adequate seating made available for patients to wait in comfort in the day assessment unit and the maternity triage area.
• Ensure their policy and procedures for the induction of labour meet with current guidance.
• Take action to ensure that there is a robust system for protecting babies from abduction.

In children and young people’s services

• Ensure there is a clear policy in place for transition services based on current guidelines and relevant legislation that considers how services can work in a joined up way to provide a person centred approach across children and adult services.
• Ensure medicines are labelled with the date they are opened so that they are disposed of in a timely manner.
• Consider having a designated isolation area, for patients that enter the children’s emergency department with infectious diseases.
• Consider how blood sample tubes can be transported form ward 85 to the pathology laboratory in a timely manner.
• Continue to work with children, young people and their families to ensure that food and menu options are child friendly and appeal to patients using the service.

In end of life care services

• Ensure staff have access to suitable and sufficient equipment, such as syringe drivers to deliver person centred care in a safe and effective way to meet people’s needs.
• Review its access to specialist palliative care over 24 hours (seven days) in line with national guidance for end of life care.
• Ensure that it fully implements the national recommendations following the removal of the Liverpool Care Pathway.
• Reduce the frequency of delays above 60 minutes for patients attending appointments.

Professor Sir Mike Richards

Chief Inspector of Hospitals