Salford Royal Hospital

Updated 22 December 2022

Northern Care Alliance NHS Foundation Trust was formed on 1 October 2021 when Salford Royal Hospital NHS Foundation Trust legally acquired Pennine Acute Hospitals NHS Foundation Trust.

The trust has four hospitals – Salford Royal Hospital, Royal Oldham Hospital, Fairfield General Hospital and Rochdale Infirmary which provide a full range of acute services, including acute medicine, urgent and emergency care, acute frailty units, rehabilitation services, dental services and surgical services, to a population of approximately 1 million people. The trusts had been working in partnership from 2016 until the acquisition. This included a shared executive leadership team.

When a trust acquires another trust in order to improve the quality and safety of care, we do not aggregate ratings from the previously separate trust at trust level for up to two years. The ratings for the trust in this report are therefore based only on the ratings for Salford Royal Hospital and our rating of leadership at the trust level.

Our normal practice following an acquisition would be to inspect all services run by the enlarged trust. However, our usual inspection work has been curtailed by the COVID-19 pandemic.

At Northern Care Alliance we inspected only those services where we were aware of current risks. We did not rate the hospital overall.

In our ratings tables starting on page 30 we show all ratings for services run by the trust, including those from earlier inspections and from those hospitals we did not inspect this time.

Medical Care

The medical care division provided medical care, consisting of general medicine and care of the elderly as well as specialities such as cardiology, endoscopy and stroke are delivered from Salford Royal Hospital.

During our visit our inspection team spoke with patients’ relatives and staff which included consultants, junior doctors, nurses, matrons, pharmacists, discharge coordinators, house keepers and nursing students. We also spoke with the associate director of nursing, the associate director of operations and the clinical director for the medicine care group.

We inspected the service between 8 and 9 August 2022. Our inspection was unannounced (staff did not know we were coming) to enable us to observe routine activity. As part of the inspection we reviewed information provided by the trust about staffing, training and monitoring of performance.

Since we last carried out a comprehensive inspection of this service, they have become part of a newly formed NHS trust. As such we cannot compare previous ratings.

We rated it as requires improvement because:

• The service did not have enough staff to care for patients and keep them safe. Staff did not always have training in key skills. The service was not meeting its mandatory training compliance target.
• The service did not always ensure that staff received appropriate support, training, professional development, supervision and appraisals. The service did not offer comprehensive training for staff to ensure they could support patients living with dementia, autism or a learning disability.
• People could not always access the service when they needed it or received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
• There was limited evidence that the medical division monitored the effectiveness of care and treatment and used the findings to make improvements and achieved good outcomes for patients. There were gaps in management and support arrangements for staff, such as staff appraisals.

However:

• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
• The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.

Surgery

The division of surgery provides a range of general and specialist surgical services, including trauma and orthopaedic surgery, urology and complex elective and emergency surgery. The surgery division has seven wards, a pre-operative assessment clinic, two surgical admission lounges and a day surgery unit. It includes an intestinal failure unit (IFU) which holds national reference centre status for the treatment of complex intestinal failure. 

There are 20 operating theatres on two levels and a day case theatre; wards and departments are spread throughout the hospital, including different buildings and on different floors.

Between October 2021 and July 2022, the hospital had a monthly average of 766 emergency admissions, 1134 day case admissions, 358 elective admissions and 1291 operations performed.

During the inspection, we visited seven wards, theatres, surgical admissions lounge, recovery areas, the surgical triage unit, and the pre-operative assessment clinic. Due to COVID-19 restrictions we visited wards identified as not having an outbreak at the time of inspection. We observed staff interactions with patients, safety huddles and handovers.

The inspection team spoke with 26 staff, five patients and three carers and relatives who were using the service. Staff we spoke with included senior leaders, consultants, matrons, sisters, registered nurses, junior doctors, health care assistants, porters, and housekeepers. We reviewed ten patient records and ten complaint files.

Our rating of this service went down. We rated it as requires improvement because:

• The service did not always have enough nursing staff to keep patients safe. Staff did not always complete mandatory training in key skills. Compliance for some risk assessments did not always meet hospital targets. Not all staff had completed training on how to recognise and report abuse.
• Whilst staff monitored the effectiveness of care and treatment, they did not consistently use the findings to make improvements. The service had a higher than expected risk of readmission for elective admissions for urology and general surgery patients when compared to the England average. Managers did not always appraise staff’s work performance or hold supervision meetings with them to provide support and development. Not all staff completed training in the Mental Capacity Act or Deprivation of Liberty Safeguards.
• The environment across the surgical wards and theatre areas was not always dementia friendly. People could not always access the service when they needed it or received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. Complaints were not always responded to within the timescales specified in the trust complaints policy.
• Senior leaders were not always visible and approachable in the service for all staff. Not all staff felt there was an open culture where they could raise concerns without fear. Not all staff were clear about their roles and accountabilities. Staff could not always find the data they needed in accessible formats to help them understand performance, make decisions, and drive improvements. Data was not recorded or presented uniformly across the trust and some important data was not captured. Senior leaders were not always actively and openly engaged with staff.

However:

• Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean. Staff managed clinical waste well. Staff identified and quickly acted upon patients at risk of deterioration. The service had enough medical staff and support staff to care for patients and provide the right care and treatment. Staff kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• The service provided care and treatment based on national guidance and evidence-based practice, gave patients enough food and drink, and gave them pain relief when they needed it. The service mainly achieved good outcomes for patients. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives and supported them to make decisions about their care. Most key services were available seven days a week to support timely patient care.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families, and carers.
• The service planned and provided care in a way that met the needs of local people, took account of patients’ individual needs and preferences, and made it easy for people to give feedback.
• Most staff spoke positively about the local leadership. Leaders had the skills and abilities to run the service, the service had a vision for what it wanted to achieve and a strategy to turn it into action. Leaders operated effective governance processes, throughout the service and with partner organisations. They identified and escalated relevant risks and issues and identified actions to reduce their impact. The service collected data and analysed it, leaders and staff actively and openly engaged with patients. Staff were committed to continually learning and improving services. Leaders encouraged innovation and participation in research.

Urgent and Emergency Care

Our rating of this location ​went down​. We rated it as ​requires improvement​ because:

• The service did not have enough staff to care for patients and keep them safe. Staff did not always have training in key skills and did not always manage safety well. Patients with suspected sepsis were not always escalated appropriately or treated in a timely manner. Not all staff completed training on how to recognise and report abuse. The service did not consistently control infection risk well. Staff did not consistently assess risks to patients, nor act on them. The management of controlled drugs in the Majors area was not effective.
• Staff did not always give patients enough to eat and drink, nor always give them pain relief when they needed it. Managers did not always make sure staff were competent for their roles. Overall compliance with annual appraisals was 56%, and due to staffing pressures, staff were not always released to carry out face to face training such as immediate life support. Staff did not always support patients to make informed decisions about their care.
• Due to staff shortages and overcrowding in the department, staff were not able to respect the privacy and dignity of patients. They were not able to take account of their individual needs, nor help them understand their conditions. They were not able to provide emotional support to patients, families and carers.
• People could not access the service when they needed it and had to wait too long for treatment. The service did not always take account of patients’ individual needs.
• Leaders did not consistently run services well and did not always use reliable information systems. Staff did not always understand the service’s vision and values, and how to apply them in their work. Staff did not always feel respected, supported and valued. Though staff were committed to improving services we did to see evidence of ongoing quality improvement work or innovation.

However:

• The service had enough medical staff to care for patients and keep them safe. Staff mostly understood how to protect patients from abuse. Staff kept good care records. The service managed safety incidents well and learned lessons from them.
• Staff mainly provided good care and treatment. Managers monitored the effectiveness of the service. Staff mostly worked well together for the benefit of patients, advised them on how to lead healthier lives. Key services were available seven days a week.
• Staff treated patients with compassion and kindness.
• The service planned care to meet the needs of local people and made it easy for people to give feedback.
• Leaders supported staff to develop their skills. Staff were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged with stakeholders to plan and manage services.

Updated 22 December 2022

Updated 27 March 2015

Overall, we have rated this service to be good. The service was delivering care that was safe, effective, caring and responsive to the needs of children and their families. There was, however ,some disparity between the overall strategy and vision with regards to the provision of care to children at Salford Royal Hospital, and further work was necessary to strengthen this to ensure the service remained viable for the future. The disparity was in part, due to the existing clinical and operational structures of the hospital. We found that where services routinely treated children, such as the PANDA unit, which was managed by the children’s services directorate within the Salford Health Care division, the governance arrangements, risk management and the measurement of performance was suitably robust.  But this was not necessarily the case for the relatively low number of children who attended the hospital annually to undergo routine day surgery. While a senior clinician was accountable for overseeing the delivery of care to all children, this oversight was not sufficiently apparent for children requiring surgery.

The low number of children who underwent general anaesthetic at the hospital meant that anaesthetists and other staff in the operating theatres were at risk of not having the necessary regular and relevant paediatric practice sufficient to maintain their core competencies. The trust had acknowledged this as an area of concern in 2013, and had instigated a range of initiatives to reduce the potential risk to children. This included commencement of scenario-based training, as well as ensuring that two qualified anaesthetists were present for any child undergoing a general anaesthetic. The service had good incident reporting systems, which staff were able to describe in detail. Staff were aware of their responsibilities to report incidents. Lessons were learned where incidents had taken place. The department was visibly clean. There were systems in place to ensure that patients were protected from the risk of harm associated with hospital acquired infections. Staff undertook regular training to ensure they could recognise and respond to the needs of vulnerable patients.

There was evidence that staff used a range of local and national clinical guidelines to assist in delivering evidence-based care. The service was recognised as being a leader in the provision of diabetes care to children and young people. Patient outcomes and clinical practice were audited to ensure that practice was consistent. Where there had been deviations from clinical guidelines, or where auditing had identified variations in clinical practice, action plans were utilised to ensure a more standardised approach to care delivery. Within the Salford Health Care children’s services directorate, we observed strong and effective multi-disciplinary team working among those involved in providing both acute and community-based care to children and their families.

We observed children being looked after in a caring and compassionate manner. Parents and some children spoke about their care and how involved they were with planning it, and how information was shared with them so they could be fully informed about what would happen to them. Parental involvement was encouraged where children were under16 years of age, in line with national recommendations; this reduced the impact of hospitalisation on younger children.

The commissioning arrangements of children’s services at Salford Royal Hospital meant that there were no inpatient facilities. Where children required hospital care lasting more than 24 hours, there were arrangements in place to ensure that they were transferred to an appropriate facility. There were arrangements in place to ensure that when young people required hospital care or admission, this was done in line with local hospital policy and only where the requirement to provide care had been appropriately risk-assessed. Some improvements were required to ensure that there was age-appropriate information available for children scheduled to undergo surgery.

Staff reported that leadership at a local, ward-based level was good; managers were reported to be supportive of their staff and people spoke positively about working at Salford Royal Hospital. Staff visions and behaviours were aligned to the trust-wide vision of ensuring that patients received safe, clean and personal care every time. A small minority of staff who worked within the day surgery unit reported that improvements could be made to ensure that they received the necessary amount of sustained and consistent support from managers.

Updated 24 August 2018

Our rating of this service stayed the same. We rated it as good because:

• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• Completion rates for mandatory and safeguarding training were high across the service. Staff were able to identify and knew how to report safeguarding concerns and incidents, which were appropriately investigated. There was governance oversight of incidents and complaints. Learning from these was shared with staff and teams across the service.
• The service’s environment, layout and facilities supported the delivery of good quality care and helped staff to maintain appropriate levels of cleanliness and hygiene. Hospital acquired infection risks were appropriately managed.
• Patients received comprehensive risk assessments and were closely monitored for signs of deterioration. Staff escalated care to medics appropriately and quickly.
• Care and treatment was evidence based. The was effective multidisciplinary working within the teams that took account and assessed patients’ capacity to consent to treatment.
• The service collected data across a range of patient outcome measures, and benchmarked itself against similar units.
• Staff were kind and compassionate in the care and treatment provided to their patients. Staff involved people in decisions and ensured people understood the care and treatment provided to them, and supported people emotionally when appropriate.
• The service worked with local commissioners in planning the services offered to people, and took into account individuals’ needs. People could access the service when they needed to and there were sufficient staff and resources to provide care 24 hours a day, seven days a week.
• The leaders of the service understood the challenges the service faced, and had a vision and plans for development to achieve full compliance with national and local policy and guidance.
• A positive and supportive culture was evident within the service which encouraged engagement with staff, patients and the public.

However,

• We were not assured there were sufficient staff trained in safeguarding vulnerable children level three to support those occasions when older teenagers were cared for on the unit.
• The service did not have sufficient numbers of allied health professional staff to provide dedicated dietetic or speech and language therapy support for pods A to C.
• We were not assured that staff practices in relation to recording the decision to discharge a patient to the ward only when a bed was available for imminent transfer, or the service’s mixed sex accommodation escalation policy within the unit was in line with national guidance. As such, we were not assured that single-sex breaches were being appropriately reported internally and externally.

Updated 27 March 2015

The hospital's Specialist Palliative Care(HSPC) team provided face-to-face support seven days a week, with the hospice providing out-of-hours cover. There was strong clinical leadership of the HSPC team resulting in a well-developed, strong, motivated team. A strong bereavement team was available to support carers and families following the death of their relative. The teams worked well together to ensure that end of life policies were based on individual need and that all people were fully involved in every part of the end of life pathway.

Relatives of patients receiving end of life care were provided with free car parking and open visiting hours. Families were offered ‘keepsakes’ including fingerprints, photographs and locks of hair. Families were given the choice of how their relative was moved to the mortuary. Relatives received their family member's belongings in canvas bag with a ‘swan logo’, which highlighted to staff that people carrying the bag may need extra support. There was excellent spiritual/religious awareness across the hospital and facilities were in place to support the different cultures and religions of the people of Salford.

End of life care was embedded in all the clinical areas and staff we spoke to were passionate about end of life care and the need to ensure that the wishes and preferences  of their patients and families were met as they entered the last stage of their life. Palliative care link nurses were introduced onto the wards to champion good end of life care.

There was a multidisciplinary team (MDT) approach to facilitate the rapid discharge of patients to their Preferred Place of care(PPC) or Preferred Place of Death(PPD). Patients were discharged within a six-hour window.

Patients were cared for with dignity and respect and received compassionate care.

Medicines were provided in line with guidelines for end of life care.

Updated 24 August 2018

• Environmental concerns raised at the previous inspection had been addressed at the time of this inspection.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The department had plans for dealing with major incidents and staff understood their roles.
• The service provided mandatory training in key skills to all staff and made sure everyone completed it.
• The service prescribed, gave, recorded and stored medicines well.
• The service provided care and treatment based on national guidance.
• Patients had access to food and drinks whilst waiting for their appointment.
• Pain was assessed and managed by staff caring for patients.
• Doctors, nurses and healthcare professionals from different specialities supported and worked together as a team to improve patient care.
• The service supported patients by promoting healthier lifestyles.
• Care was delivered in a compassionate way and staff provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Feedback from patients confirmed that staff treated them well and with kindness.
• Patients could access the service in the way they needed it.
• The service had managers at all levels with the right skills and abilities to run the service, providing high-quality sustainable care. Specialist clinics were well-led, organised and responsive.
• Individual clinics used a systematic approach to continually improve the quality of its services to create a service in which clinical care would flourish.

However:

• Some staff raised concerns about bank staff being left to run clinics alone without working there before.
• All staff had received safeguarding training but some staff lacked understanding of how to escalate or follow-up safeguarding concerns.
• The main outpatient area was less responsive to meeting the needs of patients.
• Because of a management vacancy in the main outpatient’s department the leadership team needed to ensure it had the capacity to deliver the quality of its service.
• Senior managers acknowledged there were staff satisfaction issues in the main outpatient’s department. We heard some staff describe the culture in the department as an ‘us and them’ culture and felt that staff morale was low.

Updated 22 December 2022

Updated 22 December 2022