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Stepping Hill Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 October 2017

Stepping Hill Hospital is the main location providing inpatient care as part of Stockport NHS Foundation Trust In total Stepping Hill Hospital has 833 inpatient beds.

We carried out an unannounced focussed inspection of Stepping Hill Hospital on the 21, 22 and 28 March 2017. We carried out this inspection to particularly look at the care and treatment received by patients in the Urgent and Emergency care department and patients receiving care from the Medical services team at the hospital.

We inspected these areas because of concerns identified at our announced inspection of the Trust in January 2016 and information received from other agencies during that time that indicated a lack of improvement in some areas

Overall, we rated Stepping Hill Hospital as Requires Improvement. We found that staff treated patients with dignity and respect, however this was at times compromised due to a shortage of nursing staff and patient safety was compromised. We requested immediate assurance from the trust to address the lack of nursing staff in the areas identified during the inspection to assure patients safety. The trust did respond to this and put a number of measures in place to address this in the short term. However these would not be sustainable in the medium or long term. The shortage of nursing staff and poor record keeping were identified as breaches in regulation at the last inspection, these issues still persisted in areas on both the emergency department and medical division. Improvements were needed to ensure that all services were safe, effective, caring well-led and responsive to people’s needs.

We inspected the Urgent and Emergency care services and medical services in January 2016. Following this inspection we told the trust that they must take actions to make improvements to key areas including the safe delivery of care and treatment, nurse staffing, privacy and dignity, timely access to emergency and medical services and the management of patient records. When we returned for this inspection we found that the trust had not made sufficient or significant progress and improvement in a number of areas. Safety in the emergency department was still not a sufficient priority, nurse staffing was still a significant challenge and patients were still experiencing unacceptable delays in accessing care and treatment. In the medical services we found that access and flow remained a significant concern with the number of delayed transfers of care increasing by 30 per day since the last inspection.

We also found that in some areas the trust had deteriorated since our last inspection. In the emergency department we found that staff lacked an understanding of the Mental Capacity Act (2005) and consideration of this was evident in patient records. In the medical services we found that staff also lacked an understanding of the Mental Capacity Act (2005) and were not applying the deprivation if liberty safeguards appropriately. We also found that nurse staffing was below expected standards in the medical division and we observed occasions where this negatively impacted on patients safety.

Incidents

  • All staff had access to the trust wide electronic incident reporting system.
  • Staff were aware of what type of incidents they should report and were able to show us how they would report an incident.
  • Some incidents were not investigated appropriately and associated action plans were not always up to date and meaningful. We also found that duty of candour was not always considered in a timely way.
  • Staff told us that learning from incidents was disseminated through emails, communication files, newsletters and at daily meetings. However, a number of senior staff told us that when they incident reported staffing concerns they did not get feedback and the situation did not change.
  • We reviewed the summary of incidents for the 4916 incidents reported in the medical division. We noted inconsistency in the grading of incidents, for example a clostridium difficile (c.diff) infection was categorised as minor, moderate and major. We received the incident grading from the trust, which explained to all staff the appropriate grades for types of incident. However, we found several instances of deviation from this policy and no evidence of action taken as a result of this.
  • The trust’s incident grading criteria did not reflect across to general incident grading criteria used in other NHS organisations, for example the trust did not use no or low harm categorisation instead using ‘minor’ as a categorisation for low or no harm incidents. This left the trust open to mistakes in incident reporting categorisation particularly by bank and agency staff, which, at the time of our inspection, the trust heavily relied on.

Nurse Staffing

  • Across both the Emergency and Medical services divisions there were significant shortfalls in nursing staff.
  • During the inspection we saw examples of where this had impacted on the safety and quality of care patients received; for example
  • In the Emergency and Urgent care department early warning scores (EWS) designed to identify patient who were deteriorating, were not completed in line with the trusts protocol in all cases we reviewed.
  • We observed that trolleys and cubicles were not always cleaned between patients use and the sluice room was found in visibly soiled state.
  • In the medical department staff were frequently moved from their usual area of practice to fill gaps in rotas. This resulted in staff being placed in areas where they felt they did not have the necessary skills and competence to meet the needs of patients.
  • At the time of our inspection on ward A11, there were two nurses and three HCAs on duty, when there should have been three nurses and four HCAs. Two patients had left the ward without being observed, one of which was subject to a DoLs.
  • Ward staff had taken appropriate action once they discovered the patients had left but steps had not been put in place to address the staffing issue until we escalated this to the trust.
  • During our inspection, on all the wards that we visited there was one to two nurses less per shift than had been identified as required to meet patients’ needs. A number of senior nursing staff told us that patient care was compromised when staff were taken away from the wards to support other areas. . On one ward during our inspection there was one registered nurse to 10.5 patients. On another ward, there was one registered nurse to 13 patients. Staff told us the impact on patient care is that falls assessments and risk assessments are not completed, as priority has to be given to direct patient care and the provision of medication.
  • In the Emergency and Urgent care department shift fill rates varied across recent months but were consistently below 80%. In some cases the numbers of shifts unfilled by bank or agency staff exceeded 50%.
  • In the medical services some areas including the coronary care shift fill rates were consistently below expected standards and at times were below 50%.

Medical Staffing

  • There was a high rate of medical staff vacancies across the medical division and the turnover of medical staff was within the trust target.
  • There were rotas in place which included medical trainees. There was an on call rota which ensured there was consultant cover 24 hours a day seven days a week. This meant that senior advice was available at all times. Nursing staff told us that they were able to access medical assistance and advice easily
  • The number of consultants working at the trust was about the same as the England average but the number of junior doctors was lower than the England average.
  • Medical staff morale was low in the emergency department with medical staff telling us that they felt they could not provide the level of care they wanted to due to capacity issues.

  • The general medical council had implemented enhanced monitoring of the trust medical staffing due to safety concerns raised by junior doctors in the emergency department.
  • Medical staff told us that they felt the education program offered to them was not sufficient.

Mental capacity and deprivation of liberty safeguards (DoLS)

  • Across both the emergency and medical services department’s staff did not have a good understanding of the mental capacity act (2005) (MCA) and its application or the deprivation of liberty safeguards (DoLS).
  • When speaking to the staff there was a limited understanding of the trusts own policy regarding MCA and DoLS.
  • The application of both the MCA and DoLs at ward and department level was inconsistent and in the majority of cases we inspected records were unclear and incomplete.

Cleanliness, infection control and hygiene

  • Staff were observed using personal protective equipment, such as gloves and aprons and changing this equipment between patient contacts and we saw staff washing their hands using the appropriate techniques.
  • We saw that staff followed the 'bare arms below the elbow' guidance.
  • There was adequate access to hand washing sinks and hand gels.
  • Monthly infection control audits were undertaken across all wards and departments, which looked at standards such as the cleanliness of patient equipment and hand hygiene. We reviewed these infection prevention audits.
  • The hand hygiene audit findings were below the trust’s target of 90% compliance. These ranged from 68.8% to 79.4%
  • The audit which looked at how well the infection control and prevention measures in relation to indwelling devices was managed ranged between 80% and 52% these were below the trust’s target of 90% compliance
  • Infection prevention and control staff training figures were 90% for level one training and 87% for level two training, which were both below the trust’s target of 95%.
  • Staff training in infection control in the emergency department was above the trusts 90% target.

Records

  • The hospital used electronic and paper based patient records across the medicine division, only a very few paper records were used in the emergency department.
  • During our last inspection we identified that the records trolleys that were inspected were unlocked which meant they were potentially accessible by members of the public.
  • During this inspection across the emergency department electronic records were secure, restricted to authorised access and easily accessible to authorised staff. However paper records were not kept secure and were stored in pigeon holes which were accessible to members of the public.
  • Across the medical division in all areas we visited, except A11, records trolleys were unlocked. Whilst the records trolleys were located at the front of nursing stations, we observed that these areas were not always manned therefore representing the same risk.
  • Records audits were undertaken to review compliance with the trust’s record policy.
  • These audits showed a mixed rate of compliance across the six month period prior to our inspection.

Access and Flow

  • There were high numbers of delayed transfers of care (patients who were medically fit to be discharged but remained in hospital) and these had increased significantly since the last inspection in January 2016. This was having an adverse impact on the medical division’s ability to accommodate and care for patients safely and effectively.
  • There had been a significant increase in the number of’ black breaches’ (Black breaches occur when the time from an ambulance’s arrival to the patient being handed over to the department staff is greater than 60 minutes). Since the last inspection. During the last inspection we found that from November 2014 to October 2015 there were 199. During this inspection we found that in one month alone this figure had been exceeded and there were no months between January 2016 and January 2017 where less than 20 black breaches occurred.
  • We observed the department lacked capacity to accommodate patients and patients were routinely treated and accommodated in the corridor areas.
  • There is a Department of Health standard for emergency departments to admit, transfer or discharge 95% of patients within four hours of arrival. From January 2016 to January 2017 the hospital did not meet this standard for all 12 months and the average percentage of patients admitted and transferred or discharged was 77.4%.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In urgent and emergency services

  • Ensure that all medications in the emergency department are securely stored at all times.
  • Ensure that patients received their medications in timely manner and ensure that any necessary checks are completed in line with local and national guidance and policy in the emergency department.
  • Ensure that patient records are accurate, up to date and reflect the care the patient receives in the emergency department.
  • Ensure that all staff are up to date with their mandatory training in the emergency department. Specifically in relation to life support and safeguarding.
  • Ensure that patients are protected from infections by isolating patients with suspected infections and cleaning areas where patients receive care in line with their infection control policies and procedures in the emergency department.
  • Ensure that staff follow clinical guideline sand provide evidence based care.
  • Ensure that patients risk is appropriately identified and all possible measures are taken to minimise risks to patients safety are in place. Specifically in relation to patients being accommodated in areas not designed for clinical care such as corridor areas.
  • Ensure that patients are treated with dignity and compassion and that their dignity and privacy is maintained at all times while they are in the emergency department.
  • Ensure that patients can access emergency care and treatment in a timely way.
  • Ensure that all risks identified in relation to the emergency department are appropriately risk assessed and appropriate control measures are in place.

In medical services

  • The trust must ensure that records are securely stored.
  • The trust must ensure that patient risk assessments are completed and updated at regular intervals.
  • The trust must ensure that it is compliant with the Mental Capacity Act and that all staff have the required level of training in this area.
  • The trust must ensure that its mandatory training reporting systems are accurate and reflective of the training needs and requirements of all staff.
  • The trust must ensure all staff are up to date with their mandatory training.
  • The trust must ensure that at all times there is a suitably trained member of staff on each medical ward and unit that has current adult life support training.
  • The trust must ensure there is consistent categorisation of the same type of incident in the trust’s incident reporting system.
  • The trust must ensure safeguarding training levels for staff are in accordance with the trust’s own policy and best practice guidance.
  • The trust must ensure there is an adequate skills mix on all medical wards and that staff have the right level of competence to effectively nurse the patients they are asked to care for.
  • The trust must do all that is reasonably practicable to ensure there is safe staffing on the medical wards.
  • The trust must address the delayed transfers of care and formulate an action plan outlining how it will address this issue within a reasonable time period.
  • The trust must ensure nursing intervention records are consistently completed.
  • The trust must ensure that thickening powder is securely stored.
  • The trust must ensure that patient’s dignity is preserved at all times across the medicine division.

In addition the trust should:

  • The trust should consider implementing clear guidance for senior staff to use when making judgments about staff moves.
  • The trust should ensure that where audit findings fall below the trust’s expected standards, action plans to address this are created and monitored.
  • The trust should improve the appraisal rate for the medicine division.
  • The trust should ensure the proportion of patients seen by a cancer nurse specialist is above audit minimum standard of 80% for lung cancer.
  • The trust should ensure that patients’ discharge summaries are published within 48 hours.

Professor Ted Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 11 August 2016

Effective

Good

Updated 11 August 2016

Caring

Good

Updated 11 August 2016

Responsive

Requires improvement

Updated 11 August 2016

Well-led

Requires improvement

Updated 11 August 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 11 August 2016

Maternity and Gynaecology services at Stepping Hill Hospital were rated as requires improvement overall There was a lack of learning and feedback from incidents to ensure necessary changes were made to prevent recurrence. Not all medicine administration practices met with best practice guidance and some steps in the safer surgery checklist were not completed during surgical procedures. Half of the staff in maternity and gynaecology were not up to date with adult basic life support training and the systems for checking emergency equipment such as those used for resuscitation did not provide assurance that it would be in full working order. There were around one quarter of midwives who were not up to date with their maternity specific training and annual appraisals and their competence to carry out some practices had not been assessed. Midwifery staff shortages meant some shifts had staff numbers below those set by the trust. Some actions had been taken to improve this. Medical staffing was sufficient on the wards; however there was a shortage of consultant cover in the ante-natal clinics.

Audits took place to monitor the quality of the service provided; however there was a lack of clarity about how any areas for improvement identified were monitored. There was no system for monitoring patient outcomes in maternity services to assess the quality of service delivered. Areas of potential concern we found had not been identified by the trust. Information gathered was not used to benchmark performance against other trusts or national targets There was no date of entry or review for risks on the divisional risk register. Not all risks that had been identified were recorded

Medical care (including older people’s care)

Requires improvement

Updated 3 October 2017

We rated this service as requires improvement because:

  • The trust had not responded appropriately to the risk expressed to them at our last inspection regarding the security of patients’ records.
  • The trust regularly moved their own staff and had a heavy reliance on agency and bank staff, resulting in inappropriate skills mix and staff feeling they were nursing in wards where they did not have the required competence to care for patients.
  • Decisions to move nursing staff were made on clinical judgment without a clear guidance document or minimum set standards.
  • Records completion was not in accordance with best practice guidance.
  • Incident reports did not have consistent categorisation for the same type of incident.
  • Infection protection audits showed low levels of compliance with the trust’s policy. At the time of reporting action plans to address this were not provided.
  • Safeguarding training levels for staff were not in accordance with the trust’s own policy or best practice guidance.
  • There was a lack of consistency in how people’s mental capacity was assessed and not all decision-making was informed or in line with guidance and legislation. Decision-makers did not always make decisions in the best interests of people who lack the mental capacity to make decisions for themselves, in accordance with legislation. Restraint and deprivation of liberty were not always recognised or less restrictive options used where possible. Applications to authorise a deprivation of liberty were not always made appropriately or in a timely manner to the Court of Protection or by using the Deprivation of Liberty Safeguards.
  • Due to staffing pressures, patients’ dignity was not consistently maintained.
  • The arrangements for governance and performance management did not always operate effectively.
  • Risks, issues and poor performance were not always dealt with appropriately or in a timely way. The risks and issues described by staff do not consistently correspond to those reported to and understood by leaders.
  • In view of the expenditure for agency staffing, the sustainable delivery of quality care was put at risk by the financial challenge.

However:

  • Staff understood their responsibility to report incidents.
  • Staff were aware of the duty of candour and their obligations regarding this.
  • All areas we inspected were visibly clean and tidy.
  • Throughout our inspection, in most wards we visited, we did not identify any major environmental risks or hazards.
  • Safeguarding policies and procedures were in place and staff knew how to refer a safeguarding issue to protect adults and children from abuse.
  • Medicine storage was secure and accurate logs and records maintained.
  • Since the last inspection, the service had achieved JAG Accreditation for their endoscopy services.
  • Patients’ nutritional status and dietary needs were assessed using a recognised assessment tool.
  • Multidisciplinary team (MDT) working was established on the medical wards. We saw good examples of MDT working on all of the wards and units we visited.
  • Staff offered kind and considerate care to patients and those close to them. We saw that for most patients, privacy and dignity was maintained and that most patients’ needs were appropriately met. Patients and those close to them understood their treatment and the choices available to them.
  • Meeting people’s emotional needs was recognised as important by all staff disciplines, and staff were sensitive and compassionate in supporting patients and those close to them during difficult and stressful periods.
  • .In geriatric medicine, the service was above the England average for admitted RTT (percentage within 18 weeks).
  • There was a clear statement of vision and values, driven by quality and safety. It had been translated into a credible strategy with well-defined objectives that were regularly reviewed to ensure that they remain achievable and relevant.
  • The vision, values and strategy had been developed through a structured planning process with regular engagement from internal and external stakeholders, including people who use the service, staff, commissioners and others
  • The trust’s staff in all areas knew and understood the vision, values and strategic goals.

Urgent and emergency services (A&E)

Inadequate

Updated 3 October 2017

We rated urgent care services as inadequate because:

  • Although we noted an improvement in the senior nurse leadership in the service and found a more open and positive culture there were still significant issues which persisted from the last inspection.
  • There was poor infection control compliance including patients not being isolated appropriately, visibly soiled equipment and less that 60% compliance with key audits.
  • Duty of candour was delayed in some cases.
  • There were low nurse staffing levels and low shift fill rates of less than 50% at times. This also included very high use of agency staff.
  • There was a low compliance with the early warning score system and poor management and recognition of sepsis.
  • Medicine management issues persisted which included lack of security and delayed administration.
  • We found poor compliance with risk assessment processes and patients were being held in corridors on routine basis. There had been no improvement to the arrangements to manage the patients held in the corridor area. We found that very unwell patients were being held there with very little or no supervision this included patients with cardiac issues and sepsis.
  • The performance in relation to the 15 minute face to face assessment, four hour standard and ambulance handovers remained very poor and had deteriorated since the last inspection. Black breaches had increased fivefold from 199 in 12 months in the last inspection to 218 in one month during this inspection.
  • Clinical guidelines were not always followed and we found occasions when this had negatively impacted on patient outcomes.
  • The department had undertaken one national audit since the last inspection and this showed that they were not complaint with all four standards looked at.
  • Audit findings were not always actioned and action plans were not always monitored.
  • Patients were left in an undignified manner in the corridor areas including having physical examination in the corridor areas. Some patients told us that they were humiliated by their treatment.
  • Medical staff did not always feel supported and felt that their education and development program was not sufficient.
  • The viewing room for deceased patients had not improved since the last inspection and remained visibly soiled and clinical.
  • We found that deceased patient’s property was not treated in a sensitive manner and we found bags of unlabelled property stacked up on the floor in the viewing room.
  • We observed very poor record keeping which we saw negatively impact on patient care and safety, including staff being unaware that a patient had left the department until three hours later when inspection team noted this.
  • There was routine overcrowding and the department consistently failed to meet the department of health standard of seeing, treating and discharging or transferring patients within four hours.
  • Some risks were not identified or mitigated appropriately.
  • Medical staff told us that concerns they raised were not listened to or acted on.

However:

  • Staff were knowledgeable about how to manage safeguarding issues and we observed them acting on safeguarding concerns appropriately.
  • Equipment was checked regularly and appeared to be in good working order.
  • The paediatric department had improved their safety since the last inspection.
  • Staff told us that since the new matron and nurse consultant had been appointed, safety was more of a priority and focus.
  • Staff spoke positively about the newly appointed matron and the changes she had implemented.
  • Staff sought appropriate consent from patients before delivering treatment and care.
  • The department had a team of highly skilled and competent nurse and medical staff.
  • Appraisal rates were much improved from the last inspection.
  • Staff were observed to be treating patients with compassion and dignity in their one to one interactions with patients.
  • Some patients spoke positively about the way staff treated them.
  • Staff were caring and compassionate in their approach to patient care.

Surgery

Good

Updated 11 August 2016

Surgery services at Stepping Hill Hospital were rated as good overall because during our visit we found services generally to be safe, effective, caring, responsive and well-led. Those patients who we spoke with who used the service felt satisfied with their care and treatment and they reported a positive experience.

Services were deemed safe as there was a good culture of reporting incidents and safety issues. Investigations into incidents were thorough and there was evidence of learning and implementation of measures to improve quality and safety. There were sufficient staff to maintain patient care and safety and staff had received the appropriate training to enable them to keep people safe. We found surgery services to be compliant with the World Health Organisation (WHO) checklist and National Patient Safety Agency (NPSA) ‘five step to safer surgery’ operating procedures. The identification of patient risk and the provision of care for the deteriorating patient were found to be good. The environment was clean and hygienic with low levels of healthcare associated infections.

Care was effective as it was planned and delivered in line with evidence based guidance and best practice. Patient outcomes were satisfactory with performance similar to other trusts and England averages. Multidisciplinary team working was good with satisfactory access to a range of specialities. Staff were experienced, competent and enthusiastic; they were knowledgeable and were supported to improve their capability. There was effective assessment of mental capacity and consent to treatment and where applicable deprivation of liberty safeguards were applied appropriately.

Staff showed kindness and compassion to their patients and protected their privacy and dignity when providing care and treatment. Patients told us staff were caring and respectful and that they were kept informed and involved in the they treatment received. This was reflected in good friends and family test results, which were better than the England average.

Surgical services were responsive. The hospital met the national target time of 18 weeks between referral and treatment targets overall, though they did fail to meet these for some individual specialities. There was evidence to show attention to individual patient needs and support for those with complex needs. Complaints were handled and responded to appropriately and the feedback was used to improve services for patients. Theatre utilisation was efficient which enabled better use of resources and there were no issues identified with access to treatment and flow through the service. Discharges were considered to be well organised and appropriate.

Surgical services were well-led both on a ward level and at clinical service level. Managers were enthusiastic and passionate about their service and there appeared to be a positive supportive culture throughout the surgical care group. Staff felt there was good team working and support at all levels.

Intensive/critical care

Good

Updated 11 August 2016

We have judged that overall, the critical care services provided at Stepping Hill Hospital were good.

There were sufficient numbers of suitably skilled nursing and medical staff to care for the patients. We found a culture where incident reporting and learning was embedded and used by staff.

There was strong clinical and managerial leadership at unit and business group level. The unit had a vision and strategy for the coming years developed in accordance with the ‘Healthier Together’ proposals for Greater Manchester.

There was an effective governance structure in place which ensured that all risks to the service were captured and discussed. The framework also enabled the dissemination of shared learning and service improvements and a pathway for reporting and escalation to the trust board.

Patients and their relatives were cared for in a supportive and sympathetic manner and were treated with dignity and respect.

Services for children & young people

Good

Updated 11 August 2016

We judged that though providing a good service overall services for Children and Young people at Stepping Hill hospital were outstanding in terms of being caring.

The service provided an integrated approach to acute and community services, both services operating from the Tree house unit. This approach ensured that children were seen by the same group of staff in hospital and the community. Family centred care was the prevailing philosophy in children and young people’s services. Children were involved with and positioned at the centre of their care.

We found a positive culture where incident reporting and learning was embedded and used by staff. There was strong clinical and managerial leadership within the units and at business group level.

There was an effective governance structure in place which ensured that all risks to the service were captured and discussed. The framework also enabled the dissemination of shared learning and service improvements and a pathway for reporting and escalation to the trust board. Patients and their relatives were cared for in a supportive and sympathetic manner and were treated with dignity and respect.

Though overall we rated the service as good there were some issues especially in the safe domain that required improvement. Nurse staffing on the paediatric unit is not in line with the RCN guidance on safe staffing (2013). The trust did not have a band six staff member on 37 of 93 shifts from 14 December 2015 to 13 January 2016. In a further six shifts the trust did not a band six staff member on for half of the shifts. From 14 December 2015 to 13 January 2016 the trust did not ensure there was a nursing staff member with APLS on 12 of 93 shifts. From 14 December 2015 to 13 January 2016 the trust did not ensure there was a nursing staff member with HDU training on 14 of 93 shifts. Whilst there have not been any patient safety incidents as a result of this, it is recommended by the Royal College of Nursing that the trust should have at least one APLS trained staff member on each nursing shift along with a staff member who is band six or above.

The security system that was in place on the neonatal unit and paediatric unit used an intercom system for visitors entering the ward and a swipe card system for staff. However, for exiting the ward, there was a push button allowing visitors to leave without being supervised. This meant there was a risk that children could leave the paediatric ward unsupervised and also raised a concern in relation to child abduction.

As part of our unannounced inspection on the paediatric assessment unit, staff medications were stored within a cupboard with patient medication. On examination of the cupboard, codeine phosphate belonging to the trust was found in with staff’s own medications. This gave us concern that trust medications may be being taken for staff members’ personal use. Additionally this medication should have been securely stored. We told the sister on the ward about this at the time of inspection.

Drugs requiring storage below certain temperatures were stored in fridges and most checks were in place to monitor fridge temperatures. On the paediatric unit, not all entries were complete on one of the fridges. This issue was discussed with the ward manager who escalated this to the safety huddle meeting. On our unannounced inspection, the high-dependency unit fridge was running with a high temperature (15 degrees C) and had not been checked that day. This meant medications may not have been as effective. We told the ward staff about this.

End of life care

Good

Updated 11 August 2016

End of Life services at Stepping Hill Hospital were rated as good overall because during our visit we found services generally to be safe, effective, caring, responsive and well-led.

Incident reporting systems were in place and actions were followed up at ward level via handover and within the divisions at business group meetings. There was good knowledge of anticipatory EOL care medication within the SPC team which was clinically led by a consultant in palliative medicine. Mandatory training for EOL was excellent and staff knew how to access the SPC team and the safeguarding team when needed.

There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) document which facilitated support for the dying person in the last days and hours of life. There was an audit programme in place for EOLC and the service had taken action to address targets not met in the 2014 National care of the dying audit for hospitals audit.

There was a microsite on the trust intranet where information about palliative and EOLC could be accessed. This included links to the hospice, leaflets, care plans, standard operating procedures and policies and staff said they used it regularly. We saw good evidence of multi-disciplinary and team working, including in the mortuary where staff were working well together in the absence of a manager. There was one nurse from the SPC team on call at weekends but no EOLC medical cover. Access to information was good with a new system (EPAC) in place which allowed different EOLC care providers access to up to date information about their patients.

EOL care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill patients. The SPC team saw most patients within 24 hours of referral. Patients at the end of life were allocated a side room where possible. There was a rapid discharge process in place and this was being audited with actions identified and monitored to address areas where improvement was required. There was evidence that concerns and complaints were addressed at all levels, and that learning from surveys, audits, complaints and incidents was disseminated to staff.

Several of the systems and processes in place around EOL care were very new at the time of our inspection. The individual plan of care (IPOC) which had replaced the Liverpool Care Pathway (LCP) was new and had not yet been rolled out to all staff. Staff said that the safeguarding paperwork was new and they were still getting used to it. The EOL mandatory training was new and had not yet been delivered to all staff. The electronic care portal for anticipatory care (EPAC) was in its infancy. While all of these improvements to EOLC were positive and appropriate, they were not yet fully established which meant it was not possible to fully assess their impact on the patients and the service.

Similarly there were several further developments in the pipeline, including a new forum which would include discussion around EOLC governance including the use of a uDNACPR across all EOL services which was another new development being planned. A performance dashboard to provide an overview of how EOL services were performing against their agreed targets was in draft format. The SPC team was due to be fully integrated between the hospital and the community in March 2016 which will involve further changes. However, the EOLC leads we spoke with had a clear vision of the direction the service was moving in and were working towards it. They were conversant with the latest guidance and had registered for the Transform programme which was developed to provide hospitals with a comprehensive service improvement framework for EOLC.

Outpatients

Good

Updated 11 August 2016

Outpatient and Diagnostic imagaing services at Stepping Hill Hospital were rated as good overall because during our visit we found services generally to be safe, effective, caring, responsive and well-led. Staff were encouraged to report incidents. Lessons were learnt from incidents and these were shared openly with different staff groups. Duty of candour was understood and applied when necessary. Outpatient and diagnostic imaging areas were clean and tidy. An ‘I am clean’ labelling system was in use. Regular audits were carried out to review infection prevention and control and handwashing. PCR testing had been introduced to speed up time from suspected clostridium difficile to test results. Equipment was checked and maintained correctly on most areas we visited

Medicines were stored correctly and only designated staff had access to medicines. Stock was checked weekly and replenished by the pharmacy team. Fridge temperatures were recorded, although minimum and maximum temperatures were not logged. Prescription pads and medical gases were stored safely.

Records were a mixture of electronic and paper notes. Paper notes were stored securely. Staff logged off computer systems when not in use ensuring information security.

Responsibilities and procedures in relation to adult and children’s safeguarding were understood by staff.

Nursing staffing was organised to provide appropriate skill mix and numbers of staff. Bank workers received inductions which were documented. Radiology medical cover was provided 24 hours a day, supported by outsourcing of reporting at evenings and weekends. Locum consultants were used to supplement the current establishment. There were five consultant vacancies at the time of our inspection and work was ongoing to fill these posts.

Business continuity plans were in place to support staff in times of equipment failure, staffing shortages or major incidents.

Evidence-based care and treatment was provided in line with national and local guidance. Services were audited locally and benchmarked against other local services. Staff were supported to maintain and develop skills and knowledge. Extended roles were encouraged and valued for both qualified and unqualified staff groups. Appraisal rates were generally more than 90% with some services achieving 100%. Teams worked well together to deliver effective patient care. Diagnostic imaging was available seven days a week

Only two percent of patients were seen in outpatients without their full medical record. Diagnostic images were stored electronically and images from other hospital sites could be viewed via this system. Staff understood the principles of consent and obtained consent correctly when required. Mental Capacity Act training had been received by over 90% of staff in Diagnostic and Clinical Services.

Staff were kind, caring and compassionate in outpatients and diagnostic imaging. They were sensitive in their communications with patients and understood and respected individual needs. Privacy and dignity was maintained at all times in the clinical environment. Patients were involved in making decisions about their care and treatment. They were given information and time to ask questions. Ninety percent of patients would recommend outpatients to their friends and family. In the Laurel suite this rose to 100%. Care in the Laurel suite and Bobby Moore Unit was outstanding. Patients we spoke with were very complimentary about the care and support they received.

We rated outpatients and diagnostic imaging as good for the responsive domain. Services had been planned and developed to meet the needs of local people and access to care was managed to take account of people’s needs including urgent needs. There were a number of rapid access and drop in clinics. The Bobby Moore Unit ran a one-stop breast clinic service. Waiting times for diagnostic imaging and urgent cancer services were consistently below (better than) the national average and there were rapid access and drop in sessions five days a week in radiologyThere was a transition clinic for young people with diabetes to support their move from childrens to adult services. In outpatients, patients were kept informed of any delays. They were able to leave the department and return later if delays were significant. Start times of clinics were monitored and incident reports were submitted if delays were long. There was flexilibility within the appointment booking service to change appointments to more suitable times when needed. In pathology, electronic reporting of results was available within 45 minutes within the trust and within half a day for primary care testing. Specialist advice was provided from pathology to other teams within one working day of the request.

Individual needs were understood and considered when delivering services including dementia, learning disabilities, bariatric patients and the needs of children. Adjustments were made to enable these patients to access services.Staff received training in dementia awareness and there were three dementia champions in outpatients. Translation services were available face to face or via telephone, including the facility to translate written information leaflets. Staff from the mammography team had carried out work to increase the uptake of mammography for patients with a learning disability or mobility difficulties. Waiting areas in children’s outpatients offered outstanding play facilities and equipment.

Information about how to complain was available in the areas we inspected. Staff were able to give examples of complaints and how lessons had been learnt and changes made to working practices. There had been a high number of complaints about outpatients A and B and changes had been made in response to this.

There were four specialities within the trust with high numbers of patients overdue a follow up outpatient appointment. These were ophthalmology, gastroenterology, respiratory medicine and cardiology. There were plans to reduce the wait times for these patients but three of the specialities were behind the target set by the trust. In October 2015, 16.52% of patients waited for over 30 minutes before they saw a clinician. This rose to over 20% for some specialities.

Staff were aware of the vision and strategy for the service. They understood and demonstrated the trust’s values. Objectives were set in line with the trust’s strategic aims and outcomes. Monthly and quarterly performance meetings were held. Radiology reviewed 10% of outsourced reporting to monitor quality. Audits were completed regularly in diagnostic imaging. The risk register was up to date and actions were taken to mitigate risks and reviewed regularly.

Leaders ensured staff were informed and up to date through regular staff meetings. Staff at all levels told us that leaders were approachable and listened to suggestions or concerns. The culture was open and honest. Staff felt proud to work within outpatients and diagnostic imaging.

Diagnostic imaging and outpatient therapies used patient satisfaction surveys and used information from these to improve services. Outpatients had not completed a survey recently. There was evidence of planning to ensure sustainability of services including applications for investment in equipment. The diagnostic imaging service was taking positive steps to recruit radiologists and radiographers. The introduction of electronic clinic room booking had improved clinic utilisation in outpatients.

Other CQC inspections of services

Community & mental health inspection reports for Stepping Hill Hospital can be found at Stockport NHS Foundation Trust.