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The County Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 February 2020

Our rating of services stayed the same. We rated it 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. Not all staff had completed all of the required mandatory training. Not all staff had training 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. Staff did not update all risk assessment documentation completely and consistently. There was not enough of all suitable equipment for resuscitation of children and did not have effective systems for identifying risks associated with out of date equipment. In outpatients the service did not always manage patient safety incidents well. Staff did not recognise incidents and report them appropriately. When things went wrong, staff apologised and gave patients honest information and suitable support. However, feedback to staff from managers was inconsistent and lessons learnt were not always shared with the whole team.

Our rating of effective was Requires Improvement overall. There was a lack of effective monitoring of patient outcomes and did not always provide care and treatment based on national guidance and evidence of its effectiveness.  Staff did not always assess and monitored 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. In outpatients 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. There were issues with the ‘choose and book’ system as it was not always reliable. Call centre staff booked patients first appointments and sometimes used incorrect codes. This meant there was a risk of patients not being identified on clinic lists, resulting in them being delayed in clinic or having to rebook their appointment. However, the service planned and provided care in a way that met the needs of local people and the communities served. It also worked with others in the wider system and local organisations to plan care. The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. 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 included patients in the investigation of their complaint.

Our rating of well led was requires improvement overall. In outpatients' 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. The service did not always have a systematic or consistent approach to improving the quality of its services. The governance structure for outpatients services at the fracture clinic was not always clear and consistent which meant that lines of accountability and management were not always clear. However, most managers had the right skills and abilities to run services providing high-quality sustainable care. Departments had 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 2 February 2018

  • Staff treated patients with kindness and compassion. Patients were involved in the care they received.
  • The service had improved how it stored medicines safely.
  • The service had stopped using agency staff which improved the continuity of care patients received.
  • There was good multidisciplinary working to treat the patient holistically.

Services for children & young people

Requires improvement

Updated 28 July 2015

Inpatient care for children transferred to the Royal Stoke site in May 2015. We saw robust plans in place to facilitate the move and staff were involved.

We found some parents were confused over the plans and did not know what services the hospital was planning to provide. Although, we noted there had been several efforts to engage with the public around the closure of the inpatient ward.

Care plans and risks assessments were not adequately maintained and contained insufficient detail to care for patients. Parents made comments that the medical staff did not always keep them informed but the nursing staff did. We saw there were a number of issues in maintaining patient and staff safety. There was a lack of correct storage of medicines and hazardous cleaning products were not safely stored.

We saw elements of compassionate care and were told staff had taken the children on days out. Parents told us they felt emotionally supported by staff. Staffing levels were found to be of a safe standard.

Critical care

Requires improvement

Updated 28 July 2015

The changes to critical care services had been in place for three weeks at the time of the inspection. As a result of this it was difficult to assess an accurate picture of the responsiveness of the service.

An intensive care consultant was on site Monday to Friday. Medical cover was mainly provided from early afternoon, evening and throughout the night by anaesthetic middle grade doctors with anaesthetic consultants on call from home. This does not meet intensive care core standards.

Staff morale was low and they were concerned about the future of the unit and their on-going employment.

Critical care staff were caring and compassionate. There were sufficient, highly experienced nursing staff available within the critical care unit and within the outreach team at the time of our inspection.

People received effective care, treatment and support that met their needs and achieved good outcomes, promoted a good quality of life and was based on the best available evidence.

End of life care

Good

Updated 2 February 2018

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

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

  • 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 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.
  • 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.
  • 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 (NCDHA); 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 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms.
  • 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.
  • We saw variable completion of individual care records for end of life patients.
  • 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.

Medical care (including older people’s care)

Requires improvement

Updated 28 July 2015

Surgery

Good

Updated 28 July 2015

Patients received compassionate care and staff were kind and caring. Patients’ privacy and dignity were respected and outcomes for patients were above the England national average. The standard of cleanliness was good and infection control procedures were followed. There were standardised protocols for elective surgery which were followed and included the five steps to safer surgery checklist. Incidents were reported and learning from these was shared with staff.

Access and flow was not well managed and resources at the County were not optimised. Beds and theatre were not being fully utilised.

Senior clinicians and nurses told us they had good multi- disciplinary working at the County and they felt supported in their roles. Staff did not feel part of the wider trust. They said senior trust management was not visible.

Urgent and emergency services

Requires improvement

Updated 14 February 2020

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

  • The service did not make sure all staff completed mandatory training in key skills. Staff did not update all risk assessment documentation completely and consistently. There was not enough of all suitable equipment for resuscitation of children.
  • There was a lack of effective monitoring of care and treatment. Staff did not consistently document capacity assessments or information relating to pain relief. Not all clinical staff completed training on the Mental Capacity Act and Deprivation of Liberty Safeguards. Data provided by the trust below showed low completion rates of staff appraisals.

However:

  • 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.

We rated safe and effective as requires improvement and caring, responsive and well-led as good.

Maternity

Good

Updated 14 February 2020

We rated this service as good because:

  • 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. Some 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.
  • Not all staff were up to date with their appraisals.

Outpatients

Requires improvement

Updated 14 February 2020

We previously inspected this service jointly with diagnostic imaging and are not therefore able to compare the ratings. 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.

  • There had been issues with chemotherapy treatments not being on transports from Stoke. This meant the trust could not be assured that patients’ medicines would be available in a timely way at all times.
  • Systems to manage performance and risk were not always effective. The risk register was not effective in identifying and mitigating risks to patient care and treatment. Therefore, we were not assured that all patient risks had been identified and acted upon.
  • Some incidents were not reported on the electronic incident reporting system. For example, staff requiring to stay beyond their working hours to ensure patients were chaperoned whilst waiting for transport. There were discrepancies in the recording of ‘near misses’ on the electronic incident reports, these are incidents which might have resulted in harm to a patient.
  • Although, staff told us how they would respond to an emergency involving a child or young person, there was no policy staff were aware of in regards to a deteriorating child in the main outpatients department. This meant staff did not have clear guidelines for managing a paediatric emergency.
  • There was a lack of records audits for County Hospital, this meant the trust could not be assured that patient records were full and complete. Staff in the outpatients ‘hub’ told said consultants occasionally omitted the time to next booking from patients paper based outcomes forms. Staff at the hub told us they had been advised to put these patients on the six week waiting list. This meant administrative staff were making decisions about when some patients should attend their next appointment.
  • Not all leaders were visible and approachable for staff. Most staff we spoke with described local leaders as present and approachable. Local managers told us senior managers were accessible and visible. However, some staff told us it was difficult for staff based in County Hospital to access senior managers that were based at Royal Stoke Hospital
  • There was a lack of effective monitoring of patient outcomes at County Hospital. This meant audit findings could not be used to improve services. The outpatients’ dashboard did not gather information on patient outcomes.
  • The governance structure for all outpatients services was not always clear and consistent. Governance was devolved to divisions and each care division operated independently. County Hospital was under represented at some governance meetings
  • Although staff said the trust promoted a culture of outpatients across sites being ‘one team,’ this was not fully embedded. Some staff told us there was a ‘them and us’ culture between Royal Stoke Hospital and County Hospital. Although most staff said this was improving.

However:

  • The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
  • The service provided mandatory training in key skills to all staff and made sure staff completed it.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service controlled infection risk well.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service made sure staff were competent for their roles.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff cared for patients with compassion. Staff were mindful of the emotional wellbeing of patients and took steps to support patients and families where necessary.
  • 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.
  • Staff were committed to continually learning and improving services.