Source · CQC inspection
Manchester Royal Infirmary
Provider Central Manchester University Hospitals NHS Foundation Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 3 Nov 2015
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Requires Improvement
Well-led
Good
Earlier inspection findings
Must-do actions (2)
Must-do action 1 of 2
Must do
Safe
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.
Must-do action 2 of 2
Must do
Responsive
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.
Should-do actions (36)
Should-do action 1 of 36
Should do
Safe
Ensure checks of resuscitation equipment are carried out and recorded in line with trust policy and procedures.
Should-do action 2 of 36
Should do
Safe
Ensure medicine fridge temperatures are recorded daily and staff take appropriate action if and when a temperature is outside the recommended range.
Should-do action 3 of 36
Should do
Safe
Continue to improve the quality and storage of patient records to ensure they are fully completed and all contents are securely stored.
Should-do action 4 of 36
Should do
Well-led
Ensure that all staff receive appraisals and mandatory training to enable them to carry out their role and responsibilities.
Should-do action 5 of 36
Should do
Well-led
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.
Should-do action 6 of 36
Should do
Well-led
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.
Should-do action 7 of 36
Should do
Safe
Upgrade the mental health rooms as planned.
Should-do action 8 of 36
Should do
Safe
Ensure that there are established systems in place to effectively document adult safeguarding concerns.
Should-do action 9 of 36
Should do
Well-led
Ensure the risk register is regularly updated and clearly reflects actions taken to control and mitigate risks.
Should-do action 10 of 36
Should do
Safe
Consider how to prevent or manage the spread of infection on OMU.
Should-do action 11 of 36
Should do
Safe
Consider how side rooms without nurse call bells are used in ED.
Should-do action 12 of 36
Should do
Responsive
Consider how to make services in the WIC more child friendly.
Should-do action 13 of 36
Should do
Safe
Ensure staff in the children’s emergency department hand hygiene protocols to prevent the spread of infections.
Should-do action 14 of 36
Should do
Safe
Review safeguarding processes for triaging a patient and the electronic patient records 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.
Should-do action 15 of 36
Should do
Safe
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.
Should-do action 16 of 36
Should do
Effective
Ensure that all staff understand and follow the correct process when completing DoLS applications.
Should-do action 17 of 36
Should do
Safe
Ensure that all equipment has up to date electrical safety certificates and that oxygen cylinders are stored in line with guidelines.
Should-do action 18 of 36
Should do
Caring
Ensure that patients’ privacy and dignity is maintained at all times on the endoscopy unit.
Should-do action 19 of 36
Should do
Effective
Ensure that all staff seek consent for the use of bed rails and if patients lack capacity apply the Mental Capacity Act (2005) principles.
Should-do action 20 of 36
Should do
Effective
Improve availability of patient notes for patients admitted as part of the rapid access process.
Should-do action 21 of 36
Should do
Well-led
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-do action 22 of 36
Should do
Well-led
Should ensure there is a clear vision and strategic plan in place for the cardiac intensive care unit.
Should-do action 23 of 36
Should do
Safe
Ensure that all areas of the maternity services are clean and tidy at all times.
Should-do action 24 of 36
Should do
Safe
Ensure that personal protective clothing used in the operating theatres meets with current guidance.
Should-do action 25 of 36
Should do
Responsive
Ensure there is adequate seating made available for patients to wait in comfort in the day assessment unit and the maternity triage area.
Should-do action 26 of 36
Should do
Effective
Ensure their policy and procedures for the induction of labour meet with current guidance.
Should-do action 27 of 36
Should do
Safe
Take action to ensure that there is a robust system for protecting babies from abduction.
Should-do action 28 of 36
Should do
Well-led
Ensure there is a clear policy in place for transitions 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.
Should-do action 29 of 36
Should do
Safe
Ensure medicines are labelled with the date they are opened so that they are disposed of in a timely manner.
Should-do action 30 of 36
Should do
Safe
Consider having a designated isolation area, for patients that enter the children’s emergency department with infectious diseases.
Should-do action 31 of 36
Should do
Effective
Consider how blood sample tubes can be transported form ward 85 to the pathology laboratory in a timely manner.
Should-do action 32 of 36
Should do
Responsive
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.
Should-do action 33 of 36
Should do
Safe
Ensure staff have access to suitable and sufficient equipment, such as syringedrivers to deliver person centred care in a safe and effective way to meet people’s needs.
Should-do action 34 of 36
Should do
Responsive
Review its access to specialist palliative care over 24 hours (seven days) in line with national guidance for end of life care.
Should-do action 35 of 36
Should do
Effective
Ensure that it fully implements the national recommendations following the removal of the Liverpool Care Pathway.
Should-do action 36 of 36
Should do
Responsive
Reduce the frequency of delays above 60 minutes for patients attending appointments.