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The Royal Stoke University Hospital Good

Inspection Summary


Overall summary & rating

Good

Updated 2 February 2018

Our rating of services improved. We rated it them as good because:

  • We rated safe and responsive as requires improvement, effective and well-led as good, and caring as outstanding. All ratings improved, apart from safe which stayed the same.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • We saw the trust had taken steps to improve patient flow through both hospitals, including a range of initiatives in the Emergency Departments and in medicine.
  • Processes around the management of medicines had been improved in some areas.
  • Staff were very caring and compassionate, universally put the patient first despite facing huge pressure on capacity.
  • Staffing levels had improved and the trust had less reliance on temporary workers.
  • Services in critical care and end of life care had been transformed since our last inspection.
Inspection areas

Safe

Requires improvement

Updated 2 February 2018

Effective

Good

Updated 2 February 2018

Caring

Outstanding

Updated 2 February 2018

Responsive

Requires improvement

Updated 2 February 2018

Well-led

Good

Updated 2 February 2018

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 28 July 2015

Systems and processes were not always reliable or appropriate to keep people safe.

Cancer waiting times were constantly fluctuating and referral to treatment time targets were not being achieved. The diagnostic waiting times had been higher than the England average but were seen to be improving. A significant number of patients were waiting for follow up appointments.

The organisation of the outpatient services was not always responsive to patients' needs. There were numerous delays and clinics consistently over-ran.

Diagnostic imaging had nationally recognised accreditation in place.

Staff were suitably qualified and skilled to carry out their roles effectively, they were approachable, open and friendly. Patients’ needs were assessed and their care and treatment was delivered following local and national guidance for best practice.

There was a clear vision for the trust and the service. Staff in the outpatients department were engaged in developing services and staff in diagnostic imaging had a good understanding of the department’s vision and approach.

Maternity and gynaecology

Good

Updated 28 July 2015

Policies were based on national guidance, treatment was planned in line with current evidence-based guidance, standards and best practice.

Patients told us that they felt well informed and were able to ask staff if they were not sure about something. We saw a wealth of inpatient, day patient and outpatient’s information leaflets available.

There was an active maternity services liaison committee (MSLC), which met quarterly.

There were many good examples of the maternity unit being safe but the gynaecological service was not able to offer the same level of reassurance. Women waited for long periods in the emergency department or the surgical assessment unit for review and on-going treatment. Once on the wards, they were not cared for by nurses trained in gynaecological nursing.

Medical care

Requires improvement

Updated 28 July 2015

Medical care (including older people’s care)

Good

Updated 2 February 2018

  • There were still some resuscitation trolleys which had not had daily checks documented and two suction machines on two trolleys were out of their service renewal date.
  • There was still a lack of consistency around undertaking mental capacity and deprivation of liberty assessments.
  • There was still some COSHH products inappropriately stored which were in an open unlocked cupboard.

Urgent and emergency services (A&E)

Good

Updated 2 February 2018

Our rating of this service improved. We rated it as good because:

  • The department had introduced a number of initiatives which were designed primarily to increase flow through the department but had also increased patient safety whilst they were in the department.
  • We saw that initiatives had been trialled reviewed and were planned which improved how peoples medicines were checked and reviewed.
  • Previously poor engagement with National Audits had been identified and a consultant had been given responsibility for overseeing the process which meant that the department were engaging in current audits. We saw evidence of how the service had reviewed local audit results and implemented changes to improve performance.
  • The department had introduced a “Sepsis Bleep”. This enabled staff who were concerned that a patient may be suffering from sepsis to summon immediate assistance from medical staff.
  • Staff had maintained their caring and supportive approach when dealing with patients despite significant increasing pressure on the department in line with the increase in attendances.
  • The appointment of a senior matron/directorate chief nurse had improved liaison between the emergency department and medical wards. Resulting in specialist nurses reviewing patients in the emergency department and diverting them from the department to day-case services, increasing flow.
  • Managers, senior nursing staff and clinicians worked closely together to identify areas where the service and patient experience could improve.
  • The emergency department had achieved platinum accreditation with Excellence in Practice Accreditation Scheme (EPAS); demonstrating their commitment to training and developing staff. This was the first NHS emergency department to apply for accreditation.

However:

  • The department did not have a compliant mental health room, in line with guidance in the College of Emergency Medicine toolkit – Mental Health in Emergency Departments 2013.
  • Patients with physical injuries or illness received little or no investigation regarding their mental health and how this may have contributed to their physical condition. Similarly those presenting with a mental illness did not receive routine assessment of their physical health.
  • Pathways of care for patients transferred from County Hospital to speciality care at Royal Stoke or referred internally to surgery who were subsequently identified as unsuitable for surgery were poor, with patients being admitted or returned to the emergency department unnecessarily instead of direct transfer to the appropriate department.

Surgery

Good

Updated 2 February 2018

  • The service did not manage patient safety incidents well. While staff recognised incidents and reported them appropriately and managers investigated incidents, lessons learned were not shared effectively with the whole team and the wider service.
  • Not all areas of the service’s premises were suitable, and some equipment was stored inappropriately.
  • Managers were not achieving the trust’s target to appraise staff’s work performance through supervision meetings with them to provide support and monitor the effectiveness of the service.
  • People could not always access the service when they needed it. Waiting times for some kinds of treatment were worse than other, similar services in England. People whose operations were cancelled for non-clinical reasons did not always have them completed within 30 days of the cancellation.

Intensive/critical care

Outstanding

Updated 2 February 2018

Our rating of this service improved. We rated it it as outstanding because:

  • Following their previous Care Quality Commission inspection, the leadership team, with the support of the trust, embarked on a transformation programme to address the issues highlighted in all domains.
  • Within the safe domain, there were improvements required to increase capacity for level 2 and level 3 patients. This had been achieved by introducing designated units and understanding patient complexity to inform the skills mix and determining nursing requirements. The number of agency staff had decreased and an effective outreach facility helped with access and flow of patients who required the service.
  • Local systems and processes reflected a culture of reducing harm and improving. For example, regular audits and reviews, local champions and the introduction of advanced skilled practitioners supported learning.
  • The trust had invested in a state of the art electronic patient record system. The technology supported safe management and care of patients. It meant staff could access and update patient information when needed.
  • At the last inspection the trust did not contribute cardiac critical care data to the Intensive Care National Audit Research Centre (ICNARC). It had since been introduced, which meant that the information could be used to identify areas for improvements.
  • Staff expertise and practical skills were strengthened by the support of a range of practice development nurses, advanced critical care practitioners and quality nurses. There were strong links with local universities and some of the advanced critical care practitioners were honorary lecturers.
  • Staff demonstrated compassionate and dignified care for all. We saw this in our observations, discussions with patients and those involved in their care. Patients’ and families religious, emotional, and social needs were considered and the resources provided.
  • Critical care was accessible, patients’ needs were catered for and they were also afforded a suitable space to make their experience in critical care comfortable and supportive. There was an access and flow co-ordinator who helped manage waiting times, discharges and to keep delays to a minimum and where possible avoid cancellations.
  • The leadership team demonstrated in their transformation work that they were effective and knew what was needed to deliver excellent and sustainable care. They reviewed and evidenced progress against the strategy and plans. This clearly demonstrated their commitment to improvements.
  • Excellence was at the heart their achievements. This was demonstrated in their evidenced based approach and research led culture. We saw lots of evidence of innovation and creativity and commitment to research in key areas relevant to critical care.
  • There was strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences. There was clear demonstration to commitment to best practice and use of a range of performance and risk management systems and processes. Staff told us that they felt proud to work for the trust and spoke highly of the organisation and culture.

Services for children & young people

Good

Updated 28 July 2015

There were effective procedures to support children and young people to have safe care. There was an open culture of reporting incidents. There was enough trained staff on duty to ensure that safe care was delivered. Although, not enough staff were trained in providing advanced paediatric life support and the trust had identified this on their risk register.

Parents commented that the facilities were very good and that there was plenty to occupy children. Although we found more space was required in the oncology day-case unit to provide care to children who were receiving care lying down and dedicated patient toilets.

Children and their families were treated with compassion, kindness, dignity and respect. Staff went that extra mile and involved children and their families in decisions about their care and treatment. We found extensive evidence that staff emotionally supported children and their parents. Many aspects of the service were very responsive to the needs of children and young people.

End of life care

Good

Updated 2 February 2018

Our rating of this service improved. We rated it as good because:

  • We saw staff were aware of how to report incidents and provided examples of incidents they would report. We saw changes to practice had occurred following incident investigations.
  • Documentation had improved since our previous inspection in 2015. We saw improvements with the recording of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions.
  • We saw improvements with the use of individualised care plans as these were used for all patients and were highlighted for staff with colour coded materials.
  • We saw that there had been improvements with the prescribing of anticipatory medicines for patients since the last inspection.
  • End of life care training formed part of staff mandatory training; ensuring staff were familiar with the processes to follow for the identification and care of patients at the end of life.
  • Specific equipment regularly used with patients at the end of life, such as syringe drivers, was readily available which was an improvement since the previous CQC inspection.
  • Staffing within the specialist palliative care team, mortuary team and bereavement teams was sufficient to meet the needs of patients.
  • We saw the trust had improved their results within the National Care of the Dying Audit for Hospitals; and had action plans to address areas where performance indicators had not been met.
  • The end of life care service followed guidelines set by the National Institute of Health and Care Excellence (NICE) regarding end of life care.
  • Staff were caring and compassionate in their approach to patients and relatives. Staff made effort to protect privacy and dignity, even when patients were located within a ward bay rather than a side room.
  • The purple bow scheme assisted staff to be responsive to patient and relative needs, and to provide a service over and above what is normally offered to patient visitors. This supported a positive experience for patients at the end of life, and their relatives.
  • The end of life care service was recognised at trust board level, and had a trust strategy to support its delivery. Staff were aware of the end of life care objectives and sought to achieve these within their day to day roles.

However:

  • We saw that staff did not undertake Mental Capacity Act assessments with patients who were identified as potentially lacking capacity when completing DNACPR forms.
  • We saw staff training in, and availability of, the end of life care specific individual care plans had been rolled out across Royal Stoke hospital during 2017 prior to our inspection. However, we saw that not all information was always completed such as sections covering the spirituality needs of patients.
  • We saw that the trust failed to meet four out of five clinical indicators as part of the ‘End of life care: Dying in hospital’ audit, 2016.
  • The trust did not monitor patients achieving their preferred place of care, or patients achieving rapid discharge.
  • There was no local risk register for the end of life care service; instead one risk was identified for the service on a corporate register.