You are here

The Royal Stoke University Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 February 2020

Our rating of services went down. We rated them as Requires Improvement because:

  • Our rating of safe was Requires Improvement overall. Risks within the emergency department were not always identified and escalated appropriately. We were not assured that all patients allocated to wait on the corridor were safe. Not all staff had completed all of the required mandatory training. Not all staff had training on how to recognise and report abuse. However, despite the low training figures, staff we spoke with were knowledgeable on how to recognise and report abuse. Both nursing and medical staff throughout the core service did not meet the trusts targets for safeguarding training. The service did not always have enough nursing staff with the right qualifications, skills and experience to keep patient's safe from avoidable harm and to provide the right care and treatment on all wards. Staff did not always undertake observations of patients’ vital signs in a timely manner. Risk assessments relating to patient malnutrition were not undertaken in line with the trust target
  • Our rating of effective was Requires Improvement overall. The service did not always provide care and treatment based on national guidance and evidence of its effectiveness. The service did not always ensure staff were competent for their roles. Managers sometimes appraised staff’s work performance to provide support and monitor the effectiveness of the service. Staff did not always assess and monitor patients regularly to see if they were in pain. Staff did not always understand their roles and responsibilities under the Mental Capacity Act 2005. They did not always know how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Our rating of caring was good overall. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment. Staff cared for patients with compassion however, patient dignity was sometimes compromised.
  • Our rating of responsive was requires improvement overall. People could not always access services when they needed. The service treated concerns and complaints seriously however, complaints were not always responded to within appropriate time frames or learning effectively shared.
  • Our rating of well led was requires improvement overall. Not all managers had the right skills and abilities to run services providing high-quality sustainable care. Departments did not always have effective systems for identifying risks.
Inspection areas

Safe

Requires improvement

Updated 14 February 2020

Effective

Requires improvement

Updated 14 February 2020

Caring

Good

Updated 14 February 2020

Responsive

Requires improvement

Updated 14 February 2020

Well-led

Requires improvement

Updated 14 February 2020

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 14 February 2020

Our rating of this service went down. We rated it as requires improvement because:

  • Both nursing and medical staff showed poor compliance to the trust target for mandatory training. The 95% target was met for one of the 10 mandatory training modules for which qualified nursing staff were eligible. The 95% target was not met for any of the eight mandatory training modules for which medical staff were eligible. Neither medical or nursing staff had met their training targets on how to recognise and report abuse. The environment within elderly care wards was not always suitable to prevent the spread of infection due to a lack of side rooms. The service did not always have enough nursing staff with the right qualifications, skills and experience to keep patient's safe from avoidable harm and to provide the right care and treatment on all wards. Documentation demonstrating some environmental safety checks was not always present. Staff did not always undertake observations of patients’ vital signs in a timely manner. Records were kept in record trolleys which were not always locked whilst unattended on wards. We found that missed doses of medicines were not always coded appropriately; and at times antimicrobial medicines had not been administered in line with best practice guidance. Managers mostly ensured that actions from patient safety alerts were implemented and monitored; although evidence showed that this was not always effective to prevent recurrence of similar incidents.
  • Staff did not always protect the rights of patients who were subject to the Mental Health Act 1983. Nutritional risk assessments were not consistently undertaken. Staff gave patients enough food and drink to meet their needs and improve their health. However, this was not always done in a timely manner. Staff did not always know how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. Deprivation of Liberty Safeguards were found to be out of date and not applied as per the Mental Capacity Act (2005). Relevant staff had not met the trust target for training in this area.
  • Staff reported, and we saw, not always having time to do this consistently to manage patients’ emotional needs.
  • Not all staff received regular team meetings. We found that there was no policy regarding the management of detained patients during our inspection. Staff did not always feel engaged with organisational or local changes. Patients we spoke with had not been involved in the wider planning of care or involved in shaping or improving services.

However, we also found:

  • The service controlled infection risk well. Staff assessed some risks to patients, acted on them and kept reasonable care records. They mostly managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff mostly treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Local leaders ran services well. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt supported. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Staff were committed to improving services continually.

Services for children & young people

Good

Updated 14 February 2020

  • The service had enough staff to care for children and young people and keep them safe. Staff knew how to protect children and young people from the risk of abuse. They managed infection prevention and control systems well and most medicines were managed safely. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff exceeded the expectations of children, young people and their families in their passion for patient care. There was a strong, visible person-centred culture where staff genuinely valued their relationships with children, young people and their families. They also extended their compassion towards others outside of their service. Staff recognised and respected the importance of the totality of people’s needs and used innovative methods to support family units during challenging times. Staff consistently supported and empowered children, young people and their families to understand their condition and make decisions about their care and treatment. Staff showed an excellent understanding and a non-judgmental attitude when caring for or discussing children and young people with mental health needs. They worked in a creative and innovative manner to provide exceptional, strong and caring emotional support to children, young people and their families to minimise their distress.
  • The service planned care to meet the needs of local people, took account of children and young peoples’ individual needs, and made it easy for them to give feedback. Children and young people could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of the children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However, we also found:

  • Staff were not always up to date with their mandatory training. Improvements were needed to ensure records relating to risk were kept and maintained. Some ligature points were present in the CAU which posed a potential risk to children and young people.
  • Assessments that identified if children and young people could consent to their care and treatment were not always clearly documented.
  • There was a risk that children and young people’s individual preferences and needs may not be consistently met as these preferences and needs were not always clearly recorded or accessible to staff.

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.

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.

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.

Urgent and emergency services

Requires improvement

Updated 14 February 2020

Our rating of this service went down. We rated it as requires improvement because:

  • Not all staff had completed all of the required training.
  • Staff did not always receive training in how to recognise and act on abuse. However, despite the low training figures, staff we spoke with were knowledgeable on how to recognise and report abuse.
  • Facilities were not designed to keep people safe.
  • Navigating in the department was not managed in a way to keep people safe.
  • Staff did not follow a consistent approach to monitoring and recording observations.
  • The service had enough nursing staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. However, during busy periods we were not assured of the levels of staff available to manage patients safely in the corridor. The service also had high sickness, vacancy rates and bank usage for their nursing staff.
  • Some patient outcomes were worse than national averages. However; staff monitored the effectiveness of care and treatment. They used the findings to make improvements to improve outcomes for patients.
  • Staff did not always support patients to make informed decisions about their care and treatment. They did not always follow national guidance to gain patients’ consent. They did not always support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Patients privacy and dignity was not always maintained.
  • Call bells were not always available for patients to enable them to alert staff if they were required.
  • The department lacked flow and patients were often waiting in corridors.
  • The service did not ensure patients did not stay longer than they needed to.
  • Staff told us that morale had been adversely affected due to the corridor care.
  • The department did not always identify and escalate relevant risks and issues.
  • The service did not always collect reliable data.
  • The service did not routinely engage with patients.

However

  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The service managed patient safety incidents well.
  • The service made sure staff were competent for their roles.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • Staff treated patients with compassion and kindness and took account of their individual needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patient's personal, cultural and religious needs.
  • The service was inclusive and took account of patients’ individual needs and preferences.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.
  • The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders.
  • Leaders operated effective governance processes, throughout the service and with partner organisations.
  • Following the 2018 CQC inspection visit there were nine areas for improvement identified, of which the service had shown improvement towards achieving eight of these.

Maternity

Good

Updated 14 February 2020

  • The service had enough staff to care for patients and keep them safe. Staff, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Not all staff had training in key skills.
  • Staff did not always manage medicines well.
  • Not all staff were up to date with their appraisals.
  • Staff did not always complete all crucial stages of the surgical safety checklist.

Outpatients

Requires improvement

Updated 14 February 2020

We rated it as requires improvement because:

  • People could not always access services when they needed it and receive the right care promptly. Waiting times from referral to treatment were not always in line with good practice for some clinics.
  • Systems to manage performance and risk were not always effective in identifying and escalating relevant risks and performance issues or in identifying actions to reduce their impact.
  • Although staff completed and updated risk assessments for each patient and removed or minimised risks. Staff were unaware of whether there was a policy to guide them in identifying and quickly acting upon patients at risk of deterioration.
  • There was a lack of effective monitoring of patient outcomes. This meant they could not be used to improve services.
  • The fracture clinic waiting room was not big enough for the amount of people attending clinics.

However;

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.