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The Royal Stoke University Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 July 2015

The Royal Stoke Hospital is part of University Hospitals of North Midlands NHS Trust. The trust was created on 1 November 2014, following integration with Stafford Hospital from the Mid Staffordshire NHS Foundation Trust. The hospital is based in Stoke on Trent and provides general acute hospital services as well as some specialised services.

We recognise that the leadership of the new trust has had the significant task of bringing together two organisations at a challenging time. We have seen that progress has been made but there is still more to be achieved.

We inspected this service in April 2015 as part of the comprehensive inspection programme. We inspected all core services provided by the trust at both hospital sites.

We visited the hospital on 22, 23 and 24 April 2015 as part of our announced inspection. We also visited unannounced to the trust until Tuesday 5 May 2015. Our unannounced visit included A&E, Medical Care Services and Critical Care.

Overall we have rated this hospital as requiring improvement. We saw that services were caring and compassionate. We saw a number of areas that required improvement for them to be assessed as safe and effective. We saw that leadership of services also required improvement at both a local and an executive level. The responsiveness of services was assessed as inadequate.

Our key findings were as follows:

  • Staff were caring and compassionate towards patients and their relatives, we saw a number of outstanding examples of good care right across the hospital.
  • There was a strong culture of incident reporting and staff were encouraged and supported by their managers to engage in this. This made staff feel empowered.
  • Achieving safe staffing levels was a constant challenge for the organisation and there was a heavy reliance on agency and locum staff to support this.
  • Systems and processes did not support patients flow through the organisation.

We saw several areas of outstanding practice including:

  • A range of initiatives in services for children and young people to enhance their patient experience

  • Diagnostic imaging services had received accreditation from the Royal College of Radiologists through the imaging services accreditation scheme (ISAS).
  • The hospital Alcohol Liaison team had reduced hospital stay for patients with alcohol related issues by an average of 1 day per patient. This equated to 2762 hospital days saved during the last two years.
  • A specialist one stop clinic had been developed for women with substance misuse issues where they could obtain the script for their medicines and then see the consultant and specialised midwife for their antenatal care.

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

Importantly, the hospital must:

  • Review systems and processes to ensure patients flow through the organisation in a timely manner
  • Address high waiting times in the emergency department
  • Review the capacity and adequacy of the critical care services.
  • Review the sustained use of recovery to accommodate critically ill patients
  • The hospital should review staffing arrangements in medicine and the emergency department to ensure there are sufficient numbers of nurses and that the planned and actual staffing levels for each shift are displayed.
  • The hospital should ensure that resuscitation trolleys throughout the hospital are appropriately stocked and are checked as regular intervals
  • There must be sufficient and appropriately experienced staff to provide safe and effective patient care.
  • There must be appropriate systems in place and available to respond to deteriorating patients and the outreach team must be able to provide a service to all parts of the hospital.
  • Implement the individualised care plan as soon as possible so that patients who are actively dying are supported holistically.
  • Improve must be made to the discharge process for patients who wish to go home to die so that fast track discharges can be completed within 48hrs.
  • Patients preferred place of death should be recorded and monitored so that the hospital can meet patients’ choices.
  • The hospital must review the sustained use of recovery to accommodate critically ill patients
  • The hospital must review arrangements for gynaecology patients to ensure they are provided with a safe service and are cared for by staff with the relevant skills and expertise.
  • Out of hours medical cover and arrangements for emergencies in critical care must be reviewed.
  • Multi-disciplinary working in critical care must be reviewed to ensure that effective working arrangements are in place.
  • Patients who appear to lack capacity should be assessed appropriately when decisions about their care are being discussed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 28 July 2015

Effective

Requires improvement

Updated 28 July 2015

Caring

Good

Updated 28 July 2015

Responsive

Inadequate

Updated 28 July 2015

Well-led

Requires improvement

Updated 28 July 2015

Checks on specific services

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)

Updated 28 July 2015

Medical care services ensured that actual and potential patient harm incidents were reported and investigated promptly. Staff were told about the results of investigations so that patient safety could be improved. All of the wards had noticeboards displaying their performance against quality targets.

We had concerns about the management of some patient records and the storage and administration of medicines on some wards.

Many wards had staff vacancies and staff were working overtime shifts to cover these shortfalls. Not all shortfalls could be covered in this way and on occasions wards were short staffed as agency staff were not available to cover all shifts.

Staff told us that the ward management up to matron and consultant level was supportive, visible and approachable, however the executive team were not visible to ward staff and staff were not generally aware of the trust executives’ vision and plans.

Urgent and emergency services (A&E)

Requires improvement

Updated 28 July 2015

The trust has failed to meet the national standard of 95% of patients being seen within 4-hours of arrival for over two years and, over the winter period, has had unprecedented numbers of patients waiting more than 12-hours to be admitted to hospital.

Capacity issues across the hospital impacted on the department’s ability to transfer patients who required admission from being transferred to more appropriate locations within the hospital.

We did not see evidence that the department exerted sufficient pressure on other departments or senior managers to address the issues for patients who were in the department for unacceptable lengths of time.

Despite the pressures on capacity and flow, services were safe and we saw that staff were caring and compassionate in their dealings with patients. Patients felt well informed and engaged in their care.

Surgery

Requires improvement

Updated 28 July 2015

The national referral to treatment time target for 90% of patients to have surgery within 18 weeks was not met overall. The hospital had a high volume of elective surgery which was cancelled, including for those patients who were suffering from cancer.

High numbers of patients remained in the theatre recovery areas for post -operative care with inadequate facilities to promote privacy and dignity of these patients.

Essential and emergency equipment such as resuscitation trolleys were not managed safely and in some instance these were not fit for purpose. Medicines were managed safely most of the times. Although we found issues with safe keeping of some medicines not being maintained at the correct temperature.

Safety thermometer information was displayed on all the wards, the results showed variation in the quality of care provided. Where the compliance level was well below safety margins, this was not addressed.

Intensive/critical care

Requires improvement

Updated 28 July 2015

The capacity of the critical care services was insufficient at the time of our inspection and this had a wider impact on the safety of patients in the hospital. The consistent use of the recovery area of theatres for extended periods to accommodate critically ill patients was not good practice. The lack of availability of outreach staff whilst they provided care in recovery meant they were unable to respond to deteriorating patients on other wards.

Nursing staffing levels had improved in recent weeks but the adequacy and skill mix of staff remained inappropriate.

A failure of cardiac critical care to contribute data to the Intensive Care National Audit & Research Centre (ICNARC) meant that the effectiveness of the service could not be compared to other critical care units.

Multi-disciplinary working and collaborative care across critical care relied on individuals rather than suitable working arrangements in place and did not meet best practice guidelines.

The critical care managers were a newly appointed management team. They had identified that improvements were required and had a plan in place to address this; however this was work in progress.

There were systems in place to review critical care service delivery although timely actions were not consistently taken to address areas of concern and ensure that risks to patients were minimised.

Staff did not all feel that senior management were listening to or addressing their concerns.

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

Requires improvement

Updated 28 July 2015

The hospital did not have safe arrangements in place regarding Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR). The completion of the documentation was not always done as per trust policy.

Since the removal of the Liverpool Care Pathway, the hospital had failed to implement an individualised plan of care for the dying patient, with the trust still in the evaluation process of the new pathway.

The specialist palliative care team (SPCT) was adequately staffed, however it was not their responsibility to deliver care for all the palliative and end of life patients at the hospital; we saw that staffing challenges on the wards resulted in some people and families receiving care that was not optimum.

Caring within the service was good; staff were committed, compassionate and emotionally supportive. The SPCT team were expert communicators and demonstrated this during the inspection.

Outpatients

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.