Royal Manchester Children's Hospital

Updated 19 March 2019

The Royal Manchester Children’s Hospital provides general, specialist and tertiary services for children from Manchester and beyond. The hospital has approximately 370 paediatric beds including 15 paediatric intensive care and 12 paediatric high dependency unit beds.

Between 1 October 2017 and 31 May 2018, a total of 61,469 children (aged 17 and under) attended the emergency departments at the trust, including the Royal Manchester Children’s Hospital. This is approximately 250 children a day.

The hospital was previously part of the Central Manchester University Hospital NHS Trust; on 1 October 2017 the trust merged with the University Hospital of South Manchester University NHS Trust to become a new organisation, Manchester University NHS Foundation Trust. Royal Manchester Children’s Hospital is one of the hospitals that is part of the new trust. It is co-located on the Oxford Road campus alongside the adult hospitals.

During our announced inspection we spoke with over 200 members of staff of all grades. We also spoke with 78 patients and their relatives about the care they received and observed direct care and treatment being delivered. We reviewed 79 sets of patient records. We reviewed information that was provided by the trust before and after the inspection.

Updated 19 March 2019

We had not previously rated this hospital. We rated it them as good because:

• The services mostly had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health.
• Staff cared for patients with compassion and provided emotional support to patients to minimise their distress. This was child- centred and age appropriate. There were some outstanding examples of caring provided at the hospital.
• There was a strategy and hospital-wide agreed framework for transition to adult services with aspirations for better coordination linked to the overarching “our family caring for yours” values approach. Some clinical areas, for example oncology, burns, diabetes and respiratory medicine, had already developed robust transition pathways.
• Staff understood their role in recognising and preventing potential abuse.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. All the areas we visited were clean and tidy.
• The service made the most of the premises available to them and all areas were bright and welcoming, with a variety of child-friendly decorations in every part of the hospital.
• The services had systems in place that ensured that medicines were administered and stored safely.
• The services took account of patient’s individual needs. Young people’s education was delivered at the well-equipped hospital school. There were play leaders and play specialists who worked alongside nurses, doctors and other members of the multi-disciplinary team to ensure that children received the interventions needed in the most appropriate and child-friendly way, whilst also being fully aware of the child’s needs.
• We saw examples where the service took a proactive approach to understanding the needs of patients’ individual needs. They treated all children in their care as individuals and adopted individualised plans of care and treatment using tailor made packages of care.
• The services had experienced leadership who ensured a quality service was delivered and was sustainable.

However;

• 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.
• The emergency department premises were not suitable for the number of patients attending the department. A plan to redesign and increase the size of the department had been agreed and was due to commence in 2019.
• We found that although staff could access other members of staff for advice or support, there was no regular, formal safeguarding supervision for staff at the hospital.
• The trust did not have a nurse on each shift on each medical ward that was APLS/EPLS trained, so this did not meet the standards set out by the Royal College of Nursing (2013). Plans were in place to address this.

Updated 19 March 2019

We had not previously rated this service. We rated it as good because: -

• Staff understood their role in recognising and preventing potential abuse. There were systems in place to ensure that patients were appropriately protected.
• The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. All the areas we visited were clean and tidy.
• The service had suitable premises and equipment and looked after them well. The service made the most of the premises available to them and all areas were bright and welcoming, with a variety of child-friendly decorations in every part of the hospital.
• Risks to patients were assessed, planned for and managed effectively and staff understood how to seek support from senior staff when the risks to patients changed.
• Staff kept detailed records of patient’s care and treatment.
• The service had systems in place that ensured that medicines were administered safely all of the time.
• The service managed patient safety incidents well. There was an incident reporting policy in place and staff knew how to access this.

However:

• We found that although staff could access other members of staff for advice or support, there was no regular, formal safeguarding supervision for all appropriate staff.
• There was no clearly identified area within the records for staff to immediately find information in relation to vulnerable children, or those with safeguarding concerns.
• Although the hospital had clinical co-ordinators with a minimum of one staff member on duty at all times who had been trained in advanced life support, the trust did not have a nurse on each shift on each ward that was APLS/EPLS trained, so this did not meet the standards set out by the Royal College of Nursing (2013). The hospital had plans in place to address this.
• Compliance with mandatory training was low in some areas.
• The nursing records were kept in folders, which were then stored in holders along the side of the main ward area, meaning they could potentially be picked up by someone other than a staff member.

Updated 19 March 2019

We had not previously rated this service. We rated it as good because:

• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. All nursing staff in critical care were trained in safeguarding and knew how to recognise and report abuse and they knew how to apply it.
• 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.
• Staff assessed and monitored patients regularly to see if they were in pain. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Patients were well supported during referral, transfer between services and discharge.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff were actively encouraged to participate in the annual paediatric intensive care society conference and were constantly thinking of new ways to communicate with staff.

Updated 19 March 2019

We had not previously rated this service. We rated it it as good because:

• Staff delivered end of life care in the hospital setting that was caring, compassionate and supportive of patients and their families.
• The end of life care team worked effectively and engaged with other professionals to ensure patients received the required level of care and support.

• When we talked with patients and staff and observed care, we found that staff were passionate and committed to providing good end of life care. All staff we spoke to across the hospital wanted to do the best they could for children and their families.
• Feedback from the parents we spoke with was very positive. They felt fully informed and involved in the care and decisions.
• We found that care and treatment was safe, evidenced based and followed accepted standards and professional guidance. There were clear care pathways for children being cared for in the hospital and community and all parties involved in the child’s care were included in these plans.
• There was excellent multidisciplinary team working in palliative and end of life care services which included chaplaincy, after death care by mortuary staff and dedicated psychological and social support teams.
• Children and their families were given the choice as to whether they wished to receive end of life care at the hospital, at home or in a hospice. The hospital considered individual circumstances and needs and supported them in their decisions without judgement.
• The trust had appointed a board member with a specific lead role for end of life care and staff were aware of whom this executive lead was.
• The team were passionate about continually improving the service, which included training programmes for nurses and other staff across the hospital.

Updated 19 March 2019

We had not previously rated this service. We rated it as good because:

• The outpatients department was clean, tidy and well-maintained. We saw evidence of regular quality care rounds undertaken by the manager to assess the environment, patient privacy and cleanliness.
• Safeguarding policies and procedures were in place. These were available electronically for staff to refer to. Staff were aware of their roles and responsibilities and knew how to raise matters of concern appropriately.
• We saw evidence of evidence-based treatment practice and staff told us of examples where they used guidelines approved by the National Institute for Health and Care Excellence (NICE).
• The feedback we received for outpatients was excellent. Children, parents and carers were continually positive about the care that the services provided and the way that staff treated them. They were involved in discussions about treatment and care options and able to make decisions. There was strong patient-centred culture.
• Staff members had developed a ‘social story’ leaflet to explain the clinics and procedures in a child-friendly way.
• The ward manager and matron had a good knowledge about the service and understood the risks and challenges to the service.
• There were opportunities for leadership development and managers felt supported in being able to carry out their roles effectively.

However:

• Staffing did not always meet the planned levels for the department. The manager and matron tried to address this with cover by bank and agency staff, but this did not always reach the planned level of staff.
• Most of the clinics ran late and the waiting times for patients were often over 30 minutes. The management team were aware of the issue and had tried to reduce waiting times by moving busy clinics to quieter weekdays.
• Systems were in place to aid communication with patients however, not all of these were working effectively.

Updated 19 March 2019

We have not previously inspected this service. We rated it as outstanding because:

• Staff within the service demonstrated outstanding levels of commitment to patient care and the adopted holistic patient and family centred care. Patients and families believed the care provided was excellent. Feedback was consistently positive.
• The service took a proactive approach to understanding the needs of patients’ individual needs. They treated all children in their care as individuals and adopted individualised plans of care and treatment using tailor made packages of care.
• The service had effective strategies for identifying, managing and reducing risk, learning and improving when things went wrong.
• There were sufficient numbers of competent and experienced staff to reduce the risk of harm to patients. They controlled infection and maintained equipment and premises well
• The service used best practice guidance to inform the delivery of care and ensured treatment was based on evidence based practice. Nutrition and pain was managed well.
• The service was well led by effective and enthusiastic managers, who were aware of risks to the service and were capable of tackling difficult issues head on, of making advancements and gaining staff commitment to improvement.

However:

• The wards did not always have a nurse on each shift on each ward that was trained in advanced paediatric life support, so this did not meet the standards set out by the Royal College of Nursing (2013). There was a plan in place to ensure one nurse per shift in each surgical ward would be trained in advanced paediatric life support by the end of December 2019.

Updated 19 March 2019

We had not previously rated this service. We rated it as good because:

• There was a newly established, but stable leadership team for transition. Appropriate leaders were involved in the development of transition pathways including child and adolescent mental health services leadership.
• There was a strategy and hospital-wide agreed framework for transition with aspirations for better coordination linked to the overarching “our family caring for yours” values approach.
• Although the pan hospital transition strategy was still in the early stages of development, some clinical areas, for example oncology, burns, diabetes and respiratory medicine, had developed robust transition pathways.
• The care of young people transitioning to adult services was assessed and delivered in line with legislation, standards and evidence-based guidance. A transition board and group had been developed to roll out improved transition services for young people in the hospital.
• Privacy and dignity were seen as very important to the lives of young people in hospital and the staff we spoke with were very aware of the specific needs of this group of patients.
• Young people were provided with a range of emotional support. We saw that throughout the hospital that staff had adopted a patient-centred approach which encouraged the young person and family members to take an active role in their and their child’s healthcare.
• The service, facilities and premises were designed to meet the needs of young people, including their social and emotional needs.

However:

• There was no ‘flag’ on the records system to identify young people on a transition pathway. This meant there was a risk that young people on the pathways would not be immediately identified.
• Transition to adult services was identified as a risk on the children’s hospital risk register. It was recognised that whist there were good areas of practice in transition, this was not consistent across the specialities. Actions had been identified to mitigate the risk; we saw some of the actions had been put into place and others were planned.

Updated 19 March 2019

We had not previously rated this hospital. We rated it as good because:

• The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
• The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.
• Staff gave patients enough food and drink to meet their needs and improve their health.
• Staff cared for patients with compassion and provided emotional support to patients to minimise their distress.
• The service took account of patient’s individual needs, wherever possible. Individual care plans were completed for those with complex needs and a play specialist was available to help children to understand the process of their visit to the department.
• The hospital performed consistently well for admissions, discharges and transfers within four hours against the England average for accident and emergency services, although they were below the 95% standard.
• The service had experienced leadership who ensured a quality service was delivered and was sustainable. There was a vision for the service and an improvement plan. There was a clear governance structure and risks were managed.

However;

• 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.
• The premises were not suitable for the number of patients attending the department and there were no isolation facilities within the department. A plan to redesign and increase the size of the department had been agreed and was due to commence in 2019.
• The room used for child and adolescent mental health patients was unsuitable and had a high number of ligature points. This had been risk assessed and was being addressed.