The Manor Hospital

• There were systems in place to keep patients safe, including the reporting and investigation of incidents. Learning from incidents was cascaded to all staff.

• Staffing levels were sufficient to meet the needs of patients and there was an effective multidisciplinary approach to care and treatment. Staff worked well together to benefit patients.

• Staff were proud of the hospital and were committed to providing the best possible care for their patients. We observed positive interactions between staff and patients. All patients spoke highly of the care they had received.

• The hospital was focused on providing quality care and had a defined strategy, which was aligned to its vision. Staff were committed to providing a positive patient experience.

• The executive director was well respected, visible and supportive. Staff felt valued by their departmental managers and confident to report concerns.

• There were effective governance structures in place to ensure that risk and quality were regularly reviewed and actions were taken to address performance issues, where indicated.

• There was a comprehensive complaints management process with a culture of being open and honest with patients. There was a complaints policy and complaints were taken seriously, investigated and learning was shared with staff.

• When things went wrong, staff apologised and gave patients honest information and suitable support.

• There were effective arrangements in place for the management of medicines.

• Patients’ views and experiences were gathered and acted on to shape and improve the services and culture.

• Staff ensured that patients’ privacy and dignity was maintained at all times. Chaperones were available for patients during procedures as required.

However

• There was a lack of consistency with the consent process, with some patients being consented when they were admitted for treatment. This was not in line with national guidance. We raised this issue with the senior management team, and immediate action was taken to address our concerns.

• Mandatory and training completion rates were below those expected by the organisation.

• Some corporate policies and local standard operating procedures had expired their review date. This meant there was a risk that staff may not be following the latest evidence based guidance.

• Local risk registers lacked details and we were not assured they were regularly reviewed. However, we found the hospital risk register was detailed and included actions taken to minimise the risks identified.

• Not all staff had received an annual appraisal.

We found areas of good practice in relation to surgery:

• Patients had access to care and treatment in a timely way and cancellations to surgery were minimal.

• Patients were appropriately assessed prior to surgery and there were processes in place to transfer patients should they require a higher level of care.

• Audits were completed in line with the corporate audit programme and actions were taken to improve outcomes where indicated.

And some areas for improvement:

• Some competency frameworks were out of date and the assessment process was not robust in all areas.

• Not all staff were aware of feedback from audits.

• Some departmental managers did not always feel sufficiently supported and one-to-one sessions, which they found beneficial, were often cancelled.

We found areas of good practice in relation to outpatient care:

• There were robust systems in place to ensure that patients and staff were protected by adherence to national guidelines relating to ionising radiation and diagnostic imaging.

• Patient care and treatment was delivered in line with national guidance.

• There was bespoke written information provided to patients in the physiotherapy department.

And some areas for improvement:

• The outpatient risk register did not include all risks identified within the department and staff were referring to an out of date paper version.

Following this inspection, we told the provider that it should make some improvements, even though a regulation had not been breached, to help the service improve. Details are at the end of the report.