Manchester Royal Infirmary

⚠ Nursing records within the children’s clinical decision unit were not completed in line with required standards. Risk assessments for child and adolescent mental health patients were not completed in line with the departments referral pathway.

⚠ Planned staffing levels were not consistently achieved. Staff reported concerns about staffing levels.

⚠ The trust consistently failed to meet the standards for waiting times from referral to treatment and arrangements to admit, treat and discharge patients within four hours and the trust’s monthly median total time in the department for all patients was consistently longer than the England average.

⚠ The service did not always have sufficiently robust procedures in place to meet the needs of patients with additional support needs. We saw examples of where staff were not responsive to ensuring the patients’ needs were documented and followed.

⚠ The five steps to safer surgery were not fully adhered to at Manchester Royal Infirmary and Trafford General Hospital.

⚠ Not all staff seeing children in the outpatients’ clinic had received level 3 safeguarding training, although plans were in place to address this.

⚠ We had concerns about the sexual health clinic held at the hospital. The department had limited space for patients which led to overcrowding.

⚠ In outpatients, there was a lack of overall leadership with no one person with oversight of the entire building and all risks.

⚠ There was overcrowding observed in the sexual health clinic and one patient voiced their concerns regarding confidentiality. Although most staff cared for patients with compassion, we witnessed a lack of care shown to a vulnerable patient in the sexual health clinic.

⚠ Although the service provided mandatory training in key skills to all staff, training compliance in some areas was low, particularly in safeguarding level three training for children.

⚠ People could not always access the service when they needed it. The service had consistently struggled to meet the four hour standard to admit, treat or discharge patients. In addition, there were several occasions when patients spent between 12 and 16 hours in the department.

⚠ The service did not always control infection risk well. We found several areas of the department, including some equipment to be visibly dirty. This meant that there was an increased risk that infection would be spread.

⚠ There had been eight occasions in October 2018 when emergency equipment had not been checked in the amber area of the department. This meant that there was an increased risk that the correct resuscitation equipment would not always be available in the event of an emergency.

⚠ Response to early warning scores was not always in line with the trust policy. This had been audited and recognised, but no clear actions were in place to improve performance.

⚠ Staff had not always completed patient risk assessments consistently. For example, there had been three out of five occasions when falls, bed rails and pressure ulcer risk assessments had not been fully completed. In addition, intentional rounding had not always been completed when required. Recent audits completed by the management …

⚠ The service had not always followed best practice when prescribing and recording medicines. There had been 10 out of 22 occasions when the administration of controlled drugs had not been recorded correctly.

⚠ Records indicated that on 24% of late shifts and 72% of night shifts the planned number of nursing staff had not been achieved. On these occasions the service was short by at least one nurse. This meant that there was a risk that there would not always be sufficient numbers …

⚠ The service had not monitored the effectiveness of the service that was provided in the walk-in centre. This meant that there was a risk that the service would not always recognise when improvements would be required in this area.

⚠ Although the emergency department used a triage system to prioritise patients, a triage system was not used in the walk-in centre. This was not in line with national guidance. Compliance with the time taken to complete a clinical assessment was not monitored, meaning that we were not assured that all …

⚠ The service was not consistently complying with the surgical safety checklist which meant that opportunities to minimise or prevent harm could be missed.

⚠ Staff did not always manage infection prevention risk well. There was poor compliance with hand hygiene practices on the wards, and inconsistent infection control practices in theatres. This included a blood-stained table prop, a lack of sterile keyboards, and equipment with visible dust.

⚠ The service did not look after its equipment well and its premises were not always suitable.

⚠ Medicines were not always stored safely or securely.

⚠ There was not a consistently positive culture and staff were not always open to change. There were low levels of staff satisfaction with some staff, and poor collaboration and cooperation between some teams. The management arrangements of the emergency surgery trauma unit were not clear and did not promote effective …

⚠ We observed patients that had waited in the main outpatient department, from time of booking to consultation for up to two hours.

⚠ Staff kept paper records of patients’ care and treatment, however; in the records we reviewed, they were not always clear or completed fully. Patient records were not always available to staff providing care. An audit of records availability showed that an average of 25% had not been available.

⚠ Confidential patient records were not securely stored, in the main outpatients, and observed to be easily accessible, to the public when not attended.