Manor Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We only assessed 1 quality statement from the responsive key question and found areas of good practice. Staff and leaders had a good understanding of the complaints processes and worked together well. Complaints contained relevant information, contacts and offered people the opportunity to provide feedback on the complaints process. Staff recognised the importance of compassion and reflection when dealing with complaints and learning from complaints. The hospitals complaints handling procedure was based on "My expectations for raising concerns and complaints " (Parliamentary and Health Service Ombudsman).There were policies and processes in place for handling complaints and themes and trends were identified and reported on. We heard examples of learning from complaints and saw complaints were discussed during relevant meetings. However, the department recognised they had further work to do in relation to communication with patients who were vulnerable or who had a learning disability and were looking to make this a main focus.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Person-centred Care during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Care provision, Integration and continuity during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Providing Information during this assessment. The score for this quality statement is based on the previous rating for Responsive.

Each complainant received a complaint satisfaction survey which was analysed and reported in the trust Patient Voice Annual Report. We reviewed the April 2022 to March 2023 report and found it contained information from a trust wide perspective on areas such as activity, timeframes for responding, trend analysis and Parliamentary Health Service Ombudsman referrals. The report showed that the highest number of complaints (within the division) related to clinical care/assessment and treatment. The majority of contacts were in relation to treatment /advice. Overall, the Emergency Department received the majority of the contacts in relation to clinical care/assessment/treatment with 107 contacts received. Information was collected as part of the Friends and Family Test (FFT). Results from the FFT from February 2024 to April 2024 showed the Emergency Department scored between 79% and 81%. Results from the Urgent and Emergency Care survey (2023) showed that the trust scored the best nationally for arrival at A & E and patients being given enough privacy when discussing conditions with the receptionist, they also scored amongst the top 5 for waiting. Information was available to patients on how to make a complaint which included an easy-to-read complaints leaflet. Additionally, there was a patient information leaflet Welcome to the Emergency Department which including information on the Emergency Department pathway. The department displayed QR codes to participate in mystery patient feedback and the FFT; we saw there was also information for children, parents and carers on raising a concern. Patient stories were shared in the divisional quality board meetings. We noted a patient had shared their experience in relation to an attendance at the Emergency Department in the January 2024 meeting.

As part of the assessment, we spoke with staff and leaders involved in the complaints process; they explained how they worked together well in relation to complaints. This including agreeing timescales, management support/governance and oversight. They also spoke of the importance of compassion when looking at complaints and of the importance of reflection for staff involved. Leaders and staff were able to describe how complaints were handled within the organisation, the scrutiny of complaints as well as how complaints interacted with safeguarding. Staff spoke of working towards offering a mediation service and how advocacy was always promoted; however, was not always utilised as well as they would like. They spoke of the investigation toolkit that was available to guide staff and how they worked with other organisations when complaints involved more than one service. Staff and leaders recognised they needed to do more work in relation to communication with patients who had a learning disability or who were vulnerable and were looking to make this a main focus. Staff and leaders were able to give examples of change that had occurred due to complaints. They told us how on receipt of a complaint or concern the process was that an initial review was undertaken by the patient relations team. This ensured that the concerns or complaint was logged against the correct department and shared with the correct people. During this review the team determined if the patient or complainant had any learning difficulties or learning disabilities or if there was any cognitive impairments, for example dementia. There were processes in place around gaining consent. For example, if a relative was complaining on the patient’s behalf, and if the patient did not have capacity around the complaints process which included contacting the patients listed Power of Attorney or an Independent Mental Capacity Advocate.

From December 2023 to May 2024 the Emergency Department received 31 formal complaints and 54 informal concerns. All complaints were shared with the care group team which consisted of a clinical lead, matron and care group manager. Complaints were also shared with the Emergency Department governance team and the divisional director, divisional director of nursing and divisional director of operations for medicine and long-term conditions as well as the divisional assurance team. Complaint handlers received 1 to 1 training on allocation of their first complaint which was provided by the patient relations team. This included a walk-through of the formal complaints’ investigation toolkit. The patient relations team also provided any additional support during the initial investigation and provided any feedback as and when it was required. Of the 25 complaints responses due within the last 6 months 24 were completed within the agreed timescales with an average response time of 29.5 days. We reviewed 4 completed complaints responses. We found these to contain details of findings, an apology, timescales, offers of further meetings when needed, contact details of the NHS Complaints Advocacy service and the Parliamentary and Health Service Ombudsman. We also found people making the complaint were provided with a barcode to provide feedback on the complaints process. The patient relations and experience team produced monthly complaints updates for the division which included the emergency department, this included the number of complaints and an overall summery of themes and trends within the division. Between January 2024 and March 2024, the emergency department received a total of 22 formal complaints. There were separate patient voice reports which were compiled monthly.

We did not look at Equity in access during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Equity in experiences and outcomes during this assessment. The score for this quality statement is based on the previous rating for Responsive.

We did not look at Planning for the future during this assessment. The score for this quality statement is based on the previous rating for Responsive.