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The Trust Quality Reviews – Assessing the Quality of Care

Central Manchester University Hospitals NHS Foundation Trust aims to continually improve the quality of the services it provides and seeks to provide the best care possible to the people who use our services.  One of the ways in which we do this is to gather information generated by a number of different methods which provides us with a comprehensive view of the quality of our services and helps us to identify where improvements need to be made.

In support of our approach to continuous improvement the Trust tracks a number of clinical measures, undertakes a comprehensive programme of Ward As well as regular senior leadership walk rounds. These are just a few examples of how we collect information on the quality of our services using, information, drawing on clinical outcomes and patient feedback and by talking to staff and patients about their experiences. Finally and probably most importantly getting out and about and making sure we can see how all of this comes together across our hospitals and community services. Together all of this enables us to form a view on quality. We are also working closely with external partners and regulatory bodies such as the Commissioners and CQC in order that we gain an independent view of our services too.

There are two key groups of people in the hospitals and services who can tell us about quality of care;

  • patients (including their families and carers)
  • and staff (of all disciplines and levels)

The Trust works hard to seek and act upon the views of patients and has made significant changes to practice and service delivery models on the basis of that information.

The Quality Review

The purpose of the Quality Review was to ensure that the organisation could be assured of the quality of care being delivered and that we could quickly identify and respond when we recognise that improvement is required. The aim of the reviews is to use the findings and resulting response to uphold public trust and confidence for patients and families in the services we provide and for them to be assured that they will receive the best possible experience and the best care at the right time.

This year the Trust was notified in the summer that the CQC would be undertaking their comprehensive review of our services in November 2015. For this reason it was decided that whilst the internal Quality Review should still go ahead, the exercise would be scaled down in order that the organisation was not going through two full assessments in one year. The teams were smaller and the reviews undertaken over a shorter timescale.

Staff and patient representatives were invited to take part in the annual Quality Reviews in 2015.  Approximately 100 members of staff expressed an interest in taking part. The teams were selected from the applicants ensuring staff were allocated to areas other than their own and were representative of all staff groups and all levels of experience.

Each team has been led by a Director in the organisation.  No team member was involved in a review of their own Division. This provided a mix of expertise and experience as well as an independence from the Division being reviewed.

The visits were all completed by October 2015. The teams used a number of methodologies including interviews, meeting attendance, observation in clinical areas and patient conversations. All teams received training and preparation to undertake the reviews.

We would like to thank all of the patients, staff, students and governors that contributed to the 2015 quality review.

Review Outcomes

The headline findings for the organisation were:

Celebrating success

  • Positive and professional attitude of staff throughout the organisation and pride in what they do
  • Commitment to learning and making improvements
  • High levels of incident reporting and 'being open'
  • Good awareness of Safeguarding requirements
  • Improvements in some Community facilities and premises
  • Patient safety seen as a priority in all areas
  • Improvements in checks prior to surgery and interventional procedures
  • Awareness of Equality Diversity & Inclusion requirements
  • Good use of Audit and Clinical Effectiveness (ACE) Days to improve outcomes
  • Evidence of good infection control practice
  • Training of a good standard
  • Excellence in Child and Adolescent Mental Health Services
  • Good evidence of use of Clinical Audit

Improvements required

  • Information Technology infrastructure requires improvement - in Community Services in particular.
  • Environmental improvements required - Radiology, Adult Emergency Department in MRI and Community premises.
  • Timeliness of reporting on radiological tests.
  • Noise at night on wards.
  • Patient records - storage and protection of confidential data.
  • Staffing numbers and the ability to release staff for training.
  • Medical devices - checking, maintenance and training.
  • Communication and feedback.
  • Variability of cleanliness and tidiness.
  • Never events.
  • Timeliness of preparation and delivery of take home medications.


The findings for each Division are available at the links on the right of this page. The reports will be reviewed with the pending CQC Comprehensive Inspection report (expected February / March 2016) and an action plan in response will be published her in the coming months.

The 2016 Quality Reviews will take place in Autumn 2016.

Professor Robert Pearson - Medical Director

Mrs Cheryl Lenney - Chief Nurse

Mrs Sarah Corcoran - Director of Clinical Governance