Stepping Hill Hospital

Updated 12 January 2022

We only inspected urgent and emergency care during this inspection and we re-rated this core service.

As a result of re-rating this core service, the ratings for the hospital location changed slightly with the effective domain changing from requires improvement to good. The overall ratings for the hospital location and the trust overall remained the same at requires improvement.

We inspected the urgent and emergency care service on site at Stepping Hill Hospital on 1 and 2 November 2021 and we interviewed departmental leads on 4 November 2021.

This was an unannounced inspection (the trust did not know that we were coming) in order to re-rate the service following all action plans from a previous inspection being completed.

During the inspection we spoke to 33 staff members, three people who worked for other organisations, three patients, attended two meetings and checked 14 sets of patient records.

Updated 15 May 2020

Our rating of this service stayed the same. We rated it as requires improvement because:

• The service had not improved in all areas identified from our last inspection. Staff did not have training in key skills and the oversight of mandatory training and staff competency was unclear.
• Although staff understood how to protect patients from abuse, there was low compliance for completion of the required level of safeguarding training.
• Leaders did not always manage the priorities of the service. The service had a system to identify risks but actions to reduce and mitigate risks were not always progressed in a timely manner.
• There were significant challenges to patient flow within the service. High numbers of medically optimised patients were awaiting transfer or discharge.
• Escalation wards and medical outlier’s clinical pharmacy service was not equitable with other medical wards.
• The service reported safety incidents but opportunities for shared learning were limited.

However:

• Staff treated patients with compassion, kindness, respected their privacy and dignity and provided emotional support to patients and their families and carers.
• The service provided care and treatment based on national guidance and evidence-based practice. The service was focused on the needs of the patients and gave practical advice to lead healthier lives.
• Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patient’s consent. They knew how to support patients who lacked capacity to make their own decisions and reviewed patient’s needs.

Updated 15 May 2020

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

• Staff did not always assess risks to patients and act on them. They did not always record environmental risk assessments for children and young people with mental health needs.
• The service did not always have enough staff to care for patients and keep them safe. Staff had not always completed training in key skills.
• Although staff understood how to protect patients from abuse, there was low compliance for completion of the required level of children’s safeguarding training.
• The service reported safety incidents but opportunities for shared learning were limited.
• Managers did not always make sure staff were competent. Whilst staff said they felt supported, there was a mixed culture with many staff sharing anxieties about feeling ill equipped to meet the demands in the service.
• Staff did not always complete accurate records of fluid intake for children.
• Key services were not always available seven days a week.
• Leaders did not always manage the priorities in the service. The service did not have a vision for what it wanted to achieve. The service had a system to identify risks but actions to reduce and mitigate risks were not always progressed in a timely way.

However

• The service controlled infection risk well. and kept good care records. They managed medicines well.
• 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. Staff worked well together for the benefit of children and young people, advised them and their families on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated children and young people 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 children and young people, families and carers.
• The service planned care to meet the needs of local people, took account of children and young people’s 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.
• Staff were focused on the needs of children and young people receiving care and were clear about their roles and accountabilities. The service engaged well with children, young people and the community to plan and manage services and all staff were committed to improving services continually.

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.

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.

Updated 15 May 2020

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

• The service did not have enough midwifery staff to care for women and babies. Staffing levels were not in line with national recommendations for safe maternity care provision.
• Women could not always access the service when they needed it. At other times, services such as the birth centre were not available due to staff being redeployed. The number of times that the service had closed to admissions had progressively increased.
• The midwife to birth ratio had fallen and the provision of 1:1 care of women in labour had decreased.
• Maternity staff compliance with mandatory training in key skills was below local and national targets.
• Compliance with safeguarding children level three was below local and national recommendations.
• Although we observed the World Health Organisation Five Steps to Safer Surgery carried out correctly during a caesarean section birth that we observed, the service had not completed any audits to ensure these were completed at other times in both maternity theatres and birthing rooms.
• Managers did not monitor the effectiveness of the service with local audits to make sure staff were competent.
• Only 75% of midwives in the department had had an appraisal in the 12 months immediately preceding the inspection against the trust target of 95%.
• Following our last inspection, we gave the service actions that it should take to improve. These had not all been addressed.

However:

• The service-controlled infection risk well.
• Staff gave women enough to eat and drink and gave them pain relief when they needed it.
• Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated women 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 women, families and carers.
• The service planned care to meet the needs of local people, took account of women’s individual needs, and made it easy for people to give feedback.

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.

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.

Updated 12 January 2022