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Stepping Hill Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 21 December 2018

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We rated safe, effective and responsive as requires improvement. We rated caring and well-led as good.
  • We noted improvements within the safe and well-led domains in medicine and urgent and emergency care. However, there were still patient safety concerns.
  • In maternity there was improvement in the effective and well-led domains. However, we had concerns regarding patient safety for different reasons than those outlined in our last inspection.
  • Staffing remained a challenge. Across maternity and medical services the hospital did not have sufficient numbers of trained staff, including support staff. Whilst this position had improved since our last inspection, the trust was still heavily reliant on the use of bank and agency staff.
  • Across the medicine business group, whilst care assessments generally considered the full range of people’s diverse needs, care provided did not consistently reflect the adjustments made particularly in relation to patients with learning disabilities.
  • Whilst most staff had the skills and competencies required to deliver their roles, the hospital did not have an effective system to record this. Due to staff moves, staff were not always placed in areas where their competencies could be best utilised.
  • In relation to Deprivation of Liberty Safeguards, records we reviewed did not consistently evidence that care was provided in line with patients’ ‘best interests’. The trust did not have an effective system in place to evidence that these patients were monitored to ensure care delivery was in their ‘best interests’. We continued to be concerned regarding capacity assessments and staff’s understanding around them.
  • In medicine, patients were moved to other beds and wards during the night to meet bed capacity demands.
  • The average length of stay for non-elective patients in geriatric medicine and cardiology was longer than the England average from April 2017 to March 2018. Work was on-going to improve patient length of stay through improvements in patient discharge processes.

However,

  • Most care was provided in line with best practice and current national guidance.
  • Patients were supported, treated with dignity and respect, and were involved as partners in their care.
  • There were changes in the leadership within the business groups, which were having a positive impact on service delivery and improvement.
  • The most recent Sentinel Stroke National Audit Programme (SSNAP) audit identified the stroke services at the hospital as the top performing unit nationally.

Inspection areas

Safe

Requires improvement

Updated 21 December 2018

Effective

Requires improvement

Updated 21 December 2018

Caring

Good

Updated 21 December 2018

Responsive

Requires improvement

Updated 21 December 2018

Well-led

Good

Updated 21 December 2018

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 21 December 2018

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

  • The medical wards did not have sufficient numbers of trained nursing staff. Staffing levels were maintained through the use of bank and agency staff, by increasing care staff numbers and by transferring staff to wards with nurse staffing shortfalls.
  • We did not see sufficient evidence in patient’s records to demonstrate that patients restricted under the Deprivation of Liberty Safeguards (DoLS) had an on-going review or assessment of their needs after the initial Deprivation of Liberty Safeguards application had been made. This meant there was a risk that patients could be deprived of their liberties unnecessarily for a prolonged period of time.
  • If patients lacked the capacity to make their own decisions, staff made decisions about care and treatment in the best interests of the patient. However, there was no standardised process for documenting best interest meeting discussions and decisions.
  • The trust carried out an analysis to measure compliance with the British Thoracic Society (BTS) Quality Standards for acute non-invasive ventilation in adults (April 2018). The analysis looked at 21 standards and identified the trust was compliant in eight standards (38%), partially compliant in eight standards (38%) and not compliant in five standards (24%). Actions were being taken to improve compliance where non-compliance was identified.
  • A non-invasive ventilation audit was carried out during 2017 to assess the quality of care and treatment against the British Thoracic Society quality standards. This identified areas of poor compliance such as only 53% of non-invasive ventilation patients were reviewed by a respiratory consultant within 14 hours of starting treatment, compared with the standard of 100%. An action plan was in place to improve compliance with the British Thoracic Society standards and a further audit was completed in 2018.
  • The majority of nursing and medical staff had completed their mandatory training. However, the 90% training completion target had not been achieved for a number of training topics.
  • The majority of nursing staff (91.5%) in the medical care services at the hospital had received an appraisal. However, this was below the trust target of 95%.
  • Staff had guidelines and care pathways in place for the management of patients with sepsis. However, an internal audit on the acute medical unit (AMU) in May 2018 identified poor staff adherence to the sepsis care bundle and none of the internal audit standards were met. Remedial actions were put in place to improve compliance.
  • Staff carried out an assessment of patients’ nutritional requirements. However, fluid balance monitoring audit (April 2018) highlighted areas for improvement. Actions such as updated guidelines were being implemented to improve compliance.
  • There was an inconsistent approach to storing paper-based staff competency assessment records.
  • Medicines were returned to pharmacy for disposal; however records were not kept of the medicines that were returned.
  • Patients were moved to other beds and wards during the night to meet bed capacity demands. The average length of stay for non-elective patients in geriatric medicine and cardiology was longer than the England average from April 2017 to March 2018. However, work was on-going to improve length of stay through improvements in patient discharge processes.
  • Nursing staff told us that being moved to other medical wards had a negative impact on staff morale.

However;

  • The services participated in national and local clinical audits. The most recent Sentinel Stroke National Audit Programme (SSNAP) audit identified the stroke services at the hospital as the top performing unit nationally. Where standards had not been achieved, actions had been taken to improve compliance in audits such as the national audit of inpatient falls 2017.

  • Services were planned and delivered to meet the needs of local people. The number of delayed discharges had improved since our last inspection in March 2017 and the services performed better than the England average for patient referral to treatment within 18 weeks between June 2017 and April 2018.
  • Patient safety was monitored and incidents were investigated to assist learning and improve care. There were systems in place to support vulnerable patients, such as patients living with dementia or a learning disability.
  • Patients spoke positively about their care and treatment and they were treated with dignity and compassion. Staff kept patients and their relatives involved in their care and supported their emotional needs.
  • There was effective teamwork and visible local leadership within the services and staff worked well as part of a multidisciplinary team. Staff were positive about the leadership changes and felt there was a clear focus on quality and meeting performance objectives. There was routine public and staff engagement.

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.

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.

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 and diagnostic imaging

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.

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.

Urgent and emergency services

Requires improvement

Updated 21 December 2018

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

  • The trust did not meet their national performance targets for patients admitted, transferred or discharged within four hours of arrival at the department.
  • The service did not always follow pathways when delivering care and treatment which consequently led to incidents. We saw evidence through four reported incidents in July 2018 that staff requested x-rays of the wrong site and this was recognised as a theme across the emergency department. Through discussions with clinicians on site we heard that this led to care and treatment not being delivered in line with best practice. However, work was being done to address this at the time of inspection.
  • Whilst the trust had improved their mandatory training levels since our last inspection, there was still further work to do. Data received from the trust indicated that training compliance rates for nursing staff did not meet the trust’s target in six areas. For medical staff they did not meet the trust’s target in 15 out of 17 areas.
  • Not all staff had completed safeguarding training required for their roles. Records indicated that compliance with level two training for nursing staff and levels two and three for medical staff were low.
  • Although the service demonstrated nurse staffing fill rates of 94% between April and August 2018, on all the four days of inspection the service reported a 75% fill rate .
  • The service did not always have sufficient paediatric trained nursing staff to meet national recommendations for a minimum of two paediatric staff during opening hours. However, staffing was aligned to the activity in the department. Senior managers recognised a review of the nursing workforce across the emergency department was needed and were redesigning their staffing model to implement the Royal College of Paediatric and Children’s Health standards.
  • The service did not conduct hourly intentional rounding in line with national guidelines so that aspects of care such as pain, personal needs and positioning could be regularly checked.
  • There was an inconsistent approach to storing paper-based staff competency assessment records.
  • Staff did not always have an appraisal. Data showing the percentage of nursing and medical staff who were appraised was lower than the trust target and had deteriorated since our last inspection.

However;

  • Staff were compassionate, approachable and kept patients informed of their treatment plans.
  • Staff from different specialties worked together as a team to benefit patients presenting the emergency department. We observed positive examples of staff working well together.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The trust took action to improve services by learning from when things go well and when they go wrong.
  • The leadership team was visible and proactive in making improvements to the service. We saw through data and observations that qualitative improvements had been made since the last inspection.

Maternity

Good

Updated 21 December 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our ratings directly with previous ratings. We rated it as good because:

  • Records were kept contemporaneously and securely.
  • There was a good process for incident reporting and feeding back to all staff.
  • Guidelines were up to date.
  • Food and drink was available to women and their partners at all times.
  • Women were offered a variety of conventional and non-conventional forms of pain relief and were able to self-medicate where appropriate.
  • The department had been working with external bodies on safety initiatives and as a result their stillbirth rates were low.
  • Staff were competent to carry their roles appropriately and there was sufficient training opportunities for staff to access above their mandatory training.
  • There was good multi-disciplinary working both within the department and with wider community.
  • There was good health promotion in the unit with regards to vaccines uptake, smoking cessation screening and breastfeeding support and we observed appropriate consent being obtained and recorded.
  • We found the department to be caring as they provided compassionate care to women and their partners, women were encouraged to ask questions and to be involved in their care planning and women privacy and dignity were respected whilst in the unit.
  • We found that the service was responsive to the needs and wishes of the service users. The department employed specialist midwives who could co-ordinate care for women with specific needs and women with anxiety disorders were offered a listening service if they wished.
  • The department had a visible leadership team and we were told on several occasions during our inspection how visible and approachable the head of midwifery was and there was a good vision with a robust strategy. We found no evidence of any cultural issues and there was good engagement with staff and service users. There was a good governance structure and continual engagement with the service users.

However,

  • Within the birth centre none of the birthing rooms we visited had a facility to resuscitate a baby next to its mother and father, meaning they would have to be separated in such conditions. Furthermore, if a lone midwife had to take the baby for resuscitation this meant that the mother may be left alone in the immediate postnatal period with either a member of staff not qualified to deal with an obstetric emergency, or no member of staff.
  • Midwifery staffing was below establishment meaning that woman’s access to maternity care was adversely affected at times. Labour ward co-ordinators were not supernumerary.
  • Whilst medicines within the hospital were managed well, we had concerns regarding the way community midwives carried medication to home births. The method used did not provide assurance that either the wrong medication would be used in an emergency or that the glass vials that medicines were stored in would not be broken when in transit.
Other CQC inspections of services

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