A summary of services appears in the Overall summary section above.

People told us what it was like to be a patient in Salford Royal NHS Foundation Trust Hospital. We visited five wards, the

emergency assessment unit (EAU), two elderly care wards, a respiratory medical ward and an orthopaedic ward. We spoke with a number of patients, relatives and staff. We were told :

"Staff are very knowledgeable about the care I am receiving, they are kind and helpful."

“I feel that the staff have really communicated well”, and “You don’t have to ask, they explain everything to you”.

Patients told us they felt involved in making choices and decisions about their care. Patients felt that the hospital promoted the dignity of people. Patients had their treatment explained and were provided with information in relation to the proposed length of their stay at the hospital.

During the inspection we looked at the arrangements for the safeguarding of patients from abuse and staff training. We also looked at how the Trust monitored the safety and quality of the service.

We met with senior managers at the Trust who were able to demonstrate that the views of patients about their experiences were gathered, carefully considered and used to help shape the development of the service. The Trust had processes in place to monitor various aspects of patient safety and clinical outcomes and to improve patient experience overall.

We found evidence of compliance with all areas we inspected.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We spoke with six patients, one relative and eight members of staff and observed the care given to people during our visit to the hospital. We also used information provided by patients on NHS Choices website, complaints that we have been sent, Patient Environment Action Team assessments and patient survey results.

People we spoke to were very positive about their experiences of care and treatment. Many of the people we spoke told us that they trusted the doctors and nurses to make the right decisions about their care and treatment.

Others told us that the doctors and nurses were very good at making sure people understood everything about their illness and their treatments. People said they were kept informed, were involved in making decisions about treatment options and were given enough information both written and verbally to help with this process. Most patients also said that they had their care needs met and had been treated respectfully. The people we spoke to on our visit said that they did not have to wait when they called for staff assistance and all knew how to operate the nurse call system. No complaints were made to us about the time people had to wait for assistance.

The patients told us they were also involved in making decisions about their care. One patient told us that she had been able to discuss her future needs and options about where she should be discharged to had been explained to her.

All of the people we spoke to were aware of the reason for their admission to hospital, the likely length of stay and the treatment options available to them.

Example comments included staff described as being ‘excellent’,’ the care being very good’, ‘staff were kind and caring’.

Some people told us that they were happy with the care they received but felt at times more staff were needed to ensure that everyone received the individual care that they required. During our visit, we observed that, on one occasion, a patients’ dignity was being compromised.

Patients were very complimentary about their experiences of mealtimes. They commented that the staff made an effort to make it a pleasant experience. Patients also commented that they were well supported to eat and drink. Patients said that there was a good choice of food, including meal options that met different cultural requirements. These findings are supported by the trust’s inpatient survey (2010) results, which showed that:

• 5.4 out of 10 on how patients would rate hospital food

• 8.5 out of 10 on amount of choice of food

• 7.9 out of 10 on whether patients received enough help with eating

These results are about the same when compared to other similar trusts’.

Salford Royal NHS Foundation Trust provides both acute and community services to a population of 240,000 people across Salford and the surrounding areas of Greater Manchester. The trust serves a national population for people requiring some specialist care for the treatment of disease or disorders of the brain, skin, renal system, spine and those with intestinal failure conditions.

Salford Royal NHS Foundation Trust employs around 6,600 whole time equivalent staff across both the acute hospital and the community services. Of these staff, there are 730 medical staff, 2,200 nursing staff, 2,000 care support staff and 350 allied healthcare professionals.

We carried out this follow-up inspection in addition to the comprehensive inspection carried out in October 2013. This is because Salford Royal Hospital was inspected during a pilot period when shadow ratings were not published. In order to publish a rating, we needed to update our evidence and inspect all the core services that Salford Royal Hospital provides. At our earlier inspection in 2013, we had not inspected the community services provided by the trust. Our methodology included an unannounced visit to the hospital on the evening of 27 January 2015. We also held a public listening event, where we heard directly from approximately 60 people about their experiences of care.

We have rated this trust overall as outstanding. The Salford Royal Hospital was rated as outstanding and the community services were rated as good. Of the five key questions that CQC asks, we rated the trust as good for being safe and effective, and we rated it as outstanding for being caring, responsive and well-led. In relation to the core services, A&E, medical care and end of life care in the acute hospital and adult services and end of life care in the community were each rated as outstanding.

Throughout the reports for this trust, we refer to the Nursing Assessment and Accreditation System (NAAS) and the trustwide initiative to provide safe, clean and personal care every time (SCAPE). NAAS is a performance framework system designed to help nurses in practice by measuring the quality of nursing care that teams deliver. The NSSA performance assessment framework is based on the trust’s own SCAPE approach to service delivery and combines Key Performance Indicators and Essence of Care standards. The framework is designed around 13 standards with each standard subdivided into three elements: leadership, care and environment. The assessment consists of observations of care, asking relevant questions of patients and staff, observing how meals are delivered, and receiving feedback from patients. Wards and departments are rated from red (worst) to blue (SCAPE – best). Where we have reported that wards have attained SCAPE status, this indicates that the ward has been assessed over a period of at least 24 months, and during each assessment, had attained at least a green rating (good). Three consecutive green assessments result in SCAPE status being awarded.

For a ward to achieve SCAPE status, it must, as a minimum, have maintained NAAS (green) for 24 months. Further assessments are undertaken using a comprehensive set of standards for nursing care and the teams can then apply for SCAPE. A SCAPE panel (consists of board members, senior multi-professional staff and a member of the public) then reviews the teams and makes recommendations to trust board that will approve, defer or decline SCAPE status for the applying area.

We rated the leadership of the Salford Royal Hospital as good overall. Three core services each demonstrated outstanding leadership; two core services were rated as good and two core services required some improvements to be made. The leadership of the community services was rated as outstanding overall, and the trust-wide leadership was rated as outstanding. The aggregation of these judgements for assessing the well-led question at provider level is outstanding overall. When we combine the overall ratings of outstanding for being caring, responsive and well-led, it results in the overall trust being rated as outstanding.

Our key findings were as follows:

Safe:

• The concept of providing safe, harm-free care was considered as a priority by all members of staff. Through the use of quality improvement programmes, we found many examples of how staff had worked together to ensure they provided safe care.

• The use of internal governance systems to ensure safe care was well embedded. Nursing assessment and accreditation systems (NAAS) provided a high level of transparency to the trust's board and to patients in relation to clinical performance indicators and measures. This information was publicised throughout the wards and clinical areas for people to consider.

• In conjunction with the NAAS initiative, staff spoke positively about ensuring that patients received safe, clean and personal care every time (SCAPE). SCAPE was described as a process lasting 24 months and involving three separate assessments whereby staff delivered on a range of patient focused competencies and considered a range of performance indicators. Clinical leaders and ward-based staff considered the accolade of SCAPE as significant success.

• The hospital was visibly clean and staff were witnessed to follow appropriate infection control practices. Audits were routinely undertaken to ensure staff complied with local and national policies and action was taken if areas of concern were identified.

Effective:

• Staff based care on best practice guidance. A robust audit programme was in place to demonstrate that action was taken and outcomes monitored to determine effectiveness where improvements were needed. The trust benchmarked itself against a range of national comparators; this demonstrated that the trust generally performed the same as, or better than others in many areas.

• Multidisciplinary working was strongly embedded across the trust. The provision of integrated care through the development of Salford Health Care showed the trust's ability to provide care through multidisciplinary working.

Caring:

• There was a strong emphasis on providing caring, compassionate and dignified care to patients. Performance against national patient satisfaction surveys was consistently good across of all core services, with the exception of services for children and young people, which needed further work to gather feedback from children and their parents/carers.

• People who used the services were actively involved in developing improvements in their care to ensure their care was personal. In January 2013, the trust launched a project aimed at improving the experience of patients, families and carers, as part of the patient experience strategy. This resulted in the concept of ‘always events’, which were things that patients should always expect to happen to them when receiving care from the trust.

Responsive:

• Services were able to assess and respond to the needs of the population they served. Feedback was gathered from patients and relevant stakeholders to enhance services.

• Provision of religious and spiritual support, and the support of patients during the end stages of life, was noted as being particularly outstanding.

• The critical care department provides a combination of ward, telephone and outpatient multidisciplinary follow-up service. The department contributed to the development of NICE guidelines (2009) on critical care rehabilitation. It proactively gathers feedback on the service for evaluation.

• The hospital had a multi-faith centre that catered for the religious needs of the local population, including a non-denominational ‘Oasis’ room.

• A blue butterfly symbol was introduced within the trust to identify people with cognitive impairment. Patients identified as such, were visited by dementia specialist nurses who also co-ordinated training for staff on dementia awareness. All wards had a dementia champion.

• Patient passports were in use across the trust, including passports in different languages.

• The trust had a rigorous complaints answering process to address both formal and informal complaints. Each department had a lead nurse in charge of reviewing and acting on complaints and disseminating the learning from the complaints through safety huddles and newsletters.

Well-led:

• Quality improvement was a clear focus for the trust through collaboration across all staff groups in quality improvement methods to reduce patient harm, and improve outcomes and patient experience. One ‘collaborative’ focused on gathering patients' views across the whole pathway of care from before admission to the community, to make improvements

• Members of the senior management team were fully engaged with ‘front-line’ staff. Strong working relationships had been developed between the trust's executive team and the Foundation Trust Governors. Governors were clear about their roles and purpose, which enabled them to contribute to the success of the trust.

• The ambition and vision of the trust to be the safest trust in the National Health Service was understood and embedded in the practices of staff across all professions and at all levels of seniority.

• Staff spoke positively about the engagement of the management team, which enhanced a culture of innovation. High staff satisfaction rates were representative of the positive feedback we received from staff during the inspection.

• The trust had a clear vision and strategy for quality improvement, both within the trust and for working with partners across Wigan, Bolton and Salford and more widely.

• The trust has some of the best scores in the country on the staff survey, reflecting the positive culture in the organisation.

We saw several areas of outstanding practice including:

• Nursing assessment and accreditation systems (NAAS) provided a high level of transparency to the trust's board and to patients in relation to clinical performance indicators and measures. This information was publicised throughout the wards and clinical areas for people to consider and scrutinise.

• In conjunction with the NAAS initiative, staff spoke positively about ensuring that patients received safe, clean and personal care every time (SCAPE). SCAPE was described as a process lasting 24 months and involving three separate assessments whereby staff delivered on a range of patient focused competencies and considered a range of performance indicators. The accolade of SCAPE was seen as significant success by clinical leaders and ward-based staff.

• There was clear evidence that the development of the 'emergency village' with its integrated care pathway approach, including medical in-reach, continued to deliver improved outcomes for people.

• Quality improvement initiatives had successfully led to a reduction in the number of hospital acquired pressure ulcers.

• Staff were encouraged to undertake research. For example, we reviewed a paper published in respect of improving patient care in a national intestinal failure unit.

• The surgical division celebrated its positive arrangement for moving elective orthopaedic work off site, and anticipated that this would improve patient throughput, standardise use of prosthetics and develop a centre of excellence.

• The surgical division indicated it had established a link with Central Manchester NHS Foundation Trust, which it anticipated could lead to future partnership working in the developed Manchester Orthopaedic Centre. This was expected to lead to increased pooled volumes of specialist activity with standardised practice leading to improved patient outcomes.

• The surgical division's annual plan described the development of a service model for emergency and complex surgery with two other NHS providers.

• We saw in the theatre staff newsletter for December 2014 an introduction to the forthcoming ‘Theatre Improvement Programme’. We were told this was due to start at the end of January 2015, with the aim of ensuring that theatres could provide safe and reliable care, provide value and efficiency and deliver a high team performance with high team morale and wellbeing. This work was being co-ordinated and delivered through a Quality Improvement methodology, led by a steering group headed by the Director of Organisational Development and Corporate Affairs. We saw from information provided to us that the programme was based around the Productive Operating Theatre model, developed by the NHS Institute for Innovation and Improvement.

• The senior managers within the surgical directorate recognised the areas for further focus, which included interventional radiology, middle grade recruitment to medical staff, the delivery of complex emergency care and making improvements to the discharge process, by reviewing and enhancing the patient pathway.

• There was an incentive for staff who wished to be involved in helping the trust to make financial savings to the service. If an idea was adopted, the staff member received 10% of the overall savings as a reward for their innovation.

• Junior staff were rotated to other areas across the critical and high dependency care units to facilitate personal progression and encourage staff retention.

• Bleeps were provided to relatives so that staff could contact them quickly if they were away from the CCU.

• The diabetes outpatient service demonstrated good practice where children in transition from young people to adulthood were seen in a clinic attended by an adult physician and adult specialist nurses, giving dietetic and psychological support. This ensured a continuous and consistent pathway of care through to adulthood.

• We were told the trust was actively engaged in the NHS Improving Quality ‘Transform Programme’ (Phase 2).This programme aims to encourage hospitals to develop a strategic approach to improving the quality of end of life care. The trust had piloted the use of AMBER (Assessment Management Best practice Engagement Recovery uncertain) Care Bundles (ACB), which were used to support patients that are assessed as acutely unwell deteriorating, with limited reversibility and where recovery is uncertain. However, it was decided not to continue to implement the ACB after the pilot.

• Other improvement areas include Advance Care Planning (ACP), EPaCCS, rapid discharge pathway, meeting the priorities for care of the dying person and effective care after death, including bereavement and mortuary service.

• Innovative work undertaken included the access to seven-day Specialist Palliative Care for SRFT since 2009 (only 21% of trusts deliver this nationally). The trust has participated in all four rounds of the NCDAH and was described as above the national average for nine out of 10 Clinical KPIs. The bereavement care delivered across the trust and the trust's awareness around the cultural needs of the population were well met by the HSPC, bereavement and the chaplaincy teams.

• The system of daily safety huddles, and intra-team situation reports ensured that important information was passed between teams and shifts.

However, there were also areas of poor practice where the trust needs to make improvements.

Action the hospital MUST take to improve

• The trust must take action to ensure that WHO safety checks (or equivalent) are conducted on all patients going through operating theatres and it must take action to ensure that monitoring of WHO safety checks are carried out.

• The trust must ensure that the environment is appropriately maintained and fit for purpose; the main outpatient department experienced a regular leaking roof in several areas, and sewage leaks through the ceiling.

Action the hospital SHOULD take to improve

• The trust should ensure that safety checks on technical equipment used in the delivery of treatment and care to patients are carried out routinely. This is something that is required as part of Regulation 16, safety, availability and suitability of equipment. It was considered that the omissions related to the checking of anaesthetic machines by theatre staff were not proportionate to support a judgement of a breach of the regulation.

• The trust should ensure that the knowledge and application of the Mental Capacity Act and the Deprivation of Liberty Safeguards is consistently applied across all services.

• The trust should consider prioritising the improvement of the discharge process for patients from beyond the local area to the wider geographical area.

• Whilst we acknowledge that the trust has embarked on a programme of quality improvement within theatres to improve the culture and morale of the department, the trust should ensure that this initiative is both effective and sustainable so that changes are fully embedded for the future. 

• The trust should consider ways of reducing the rate of surgical procedure cancellations.

• The trust should consider a unified strategy for the delivery of children’s services, both medical and surgical. Governance systems, risk management and performance measurement processes should be standardised to ensure that children receive quality, evidence-based care.

Professor Sir Mike Richards

Chief Inspector of Hospitals