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Provider: Stockport NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 May 2020

  • We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good. We rated three of the trust’s 13 services as requires improvement, one as inadequate and nine as good. In rating the trust, we took into account the current ratings of the nine services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • We rated urgent and emergency care as inadequate. We rated medical care, maternity and children and young people’s services as requires improvement.
  • Within urgent and emergency care, people were not always kept safe and were at high risk of avoidable harm during periods of heavy demand on the service.
  • Risk assessments for patients with mental health needs were not being completed, meaning that opportunities to prevent or minimise harm were missed. We raised this with the trust and they took immediate action to address this.
  • There was a lack of consistency in the effectiveness of the care, treatment and support that people received in some areas.
  • There were significant issues with the flow of patients through the emergency department and the hospital so that patients were assessed, treated, admitted and discharged in a safe, timely manner. Emergency care was consistently unable to be provided in a timely way. Women could not always access the maternity service of their choice when they needed it. High numbers of patients were medically optimised and awaiting transfer or discharge.
  • Governance and risk management systems were not always effective. There was a lack of oversight of key performance areas in the services.

However:

  • There had been improvements, particularly within medical care, regarding staff knowing how to support patients who lacked capacity to make their own decisions or those who were experiencing mental ill health.
  • We rated caring as good in medical care, maternity and services for children and young people.
  • There was improved compliance with the Fit and Proper Persons Requirement (Regulation 5 of the Health and Social Care Act (Regulated Activities) Regulations 2014).

Inspection areas

Safe

Requires improvement

Updated 15 May 2020

  • We rated safe as requires improvement in medical care, maternity and children and young people’s services. We rated safe as inadequate in urgent and emergency care.
  • Within urgent and emergency care, people were not always kept safe and were at high risk of avoidable harm during periods of heavy demand on the service. Safety systems and processes were not consistently used or monitored by staff and the premises, equipment and facilities did not always support staff to keep people safe.
  • Within urgent and emergency care and the children’s and young people’s services, risk assessments for patients with mental health needs were not being completed, meaning that opportunities to prevent or minimise harm were missed. We raised this with the trust and they took immediate action to address this.
  • The provider did not ensure sufficient numbers of nursing and medical staff completed mandatory and safeguarding training.
  • Within urgent and emergency care, medical care and maternity, we found the trust did not have 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 at all times.
  • The trust did not consistently manage patient safety incidents well. Learning from incidents was not always shared across the trust.

Effective

Requires improvement

Updated 15 May 2020

  • We rated urgent and emergency care and children and young people’s services as requires improvement.
  • Within urgent and emergency care, patients were at risk of not receiving effective care or treatment. There was a lack of consistency in the effectiveness of the care, treatment and support that people received.
  • The trust did not always make sure staff were competent for their roles. Completion of appraisals was below trust targets across the services we inspected.
  • Within services for children and young people, staff did not always know how to support children, young people and their families who were experiencing mental ill health.
  • Key services were not always available seven days a week to support timely care for children, young people and their families.
  • Within urgent and emergency care, patient outcomes were not always positive or met expectations in line with national standards.

However:

  • We rated medical care and maternity as good for effective. These services provided care and treatment based on national guidance and evidence-based practice.
  • Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients in medical care.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients.
  • Staff supported patients to make informed decisions about their care and treatment. There had been improvements, particularly within medical care: staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures that limit patients' liberty appropriately.

Caring

Good

Updated 15 May 2020

  • We rated caring as good in medical care, maternity and services for children and young people.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, 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.
  • Staff supported patients, families and carers to understand their condition and make decisions about their care and treatment.

However:

  • We rated caring as requires improvement in urgent and emergency care. Staff were not always able to support, treat or care for patients with compassion and kindness during periods of heavy demand on the service. There were times when patients’ privacy and dignity was not always maintained.

Responsive

Requires improvement

Updated 15 May 2020

  • We rated responsive as requires improvement for medical care and maternity services. We rated urgent and emergency care as inadequate.
  • Urgent and emergency care services were not planned or delivered in a way that met people’s needs during periods of heavy demand, and the facilities and premises did not always meet people’s needs.
  • There were significant challenges to patient flow within the medical care service. High numbers of medically optimised patients were awaiting transfer or discharge.
  • People could not always access the service when they needed it during times of high demand in all medical specialities. People were frequently and consistently unable to access emergency treatment in a timely way and did not receive the right care promptly during periods of heavy demand. Waiting times from arrival to treatment and arrangements to admit, treat and discharge patients were consistently not in line with national standards. People experienced unacceptable waits for admission.
  • Women could not always access the maternity service of their choice when they needed it. Service closures had progressively increased over the last three years.

However:

  • We rated services for children and young people as good for responsive.
  • These services planned and provided care in a way that met the needs of local people and the communities served.
  • These services were inclusive and took account of patient’s individual needs and preferences.

Well-led

Requires improvement

Updated 15 May 2020

  • We rated well-led as requires improvement in medical care, services for children and young people and maternity. We rated urgent and emergency care as inadequate. All of these ratings had deteriorated since our last inspection.
  • Within urgent and emergency care, the delivery of high-quality care was not assured by the leadership, governance or culture. Leaders were not always in touch with the impact on patient care and staff morale as a result of continuing heavy demand and low staffing levels.
  • Services did not always have a vision for what it wanted to achieve or a strategy to turn it into action. The trust strategy had been in development and was not yet launched.
  • The culture in the services was mixed.
  • Governance systems and processes were identified, however there was a lack of oversight of key performance areas in the services.
  • Although leaders and teams had a system to identify risks, key risks were not always identified and actions to reduce the impact of risks were not always progressed.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 15 May 2020

Our rating of use of resources improved. We rated it as requires improvement because:

The trust is in deficit and has an inconsistent track record of managing spend within resources. Although the trust has agreed the control total for 2019/20, at the time of the assessment there remained a number of risks associated with the delivery of this plan. Since the previous Use of Resources assessment in September 2018, the trust has seen some improvements and was able to demonstrate a number of areas of good practice, particularly within Pharmacy. However, the trust has also seen a number of metrics deteriorate and has faced particular challenges regarding operational performance over the previous 12 months.

Please see the separate use of resources report for details of the assessment and the combined rating.

Combined rating

Combined rating summary

Requires improvement

Updated 15 May 2020

Our rating of combined quality and resources stayed the same. We rated it as requires improvement because:

  • We rated safe, effective, responsive and well led as requires improvement. We rated caring as good.
  • The overall trust quality rating was requires improvement.
  • The trust was rated requires improvement for use of resources.
  • This gives a combined quality and resource rating of requires improvement.
Checks on specific services

Community health inpatient services

Good

Updated 3 October 2017

We inspected the Community Unit at Stockport NHS Foundation Trust, which is located in the trust’s main site at Stepping Hill Hospital. The unit is a community facility based within Stepping Hill Hospital but managed through the trust’s community business group. The unit was operational 24 hours a day seven days a week. Service users were transferred to the unit seven days a week from within the trust. The unit has 16 beds and had been opened on 24 November 2016 as part of a health and social care system response to the urgent care situation in relation to Delayed Transfer of Care (DTOC) and decreased access to community capacity.

During our inspection we spoke with four residents and six members of staff. We observed a GP ward round and reviewed four sets of residents’ records.

We did not rate this service in view of the short period of time that the unit had been opened. However, our key findings were:

  • Staff were aware of how to report incidents and feedback from incidents was provided.
  • Lessons were learned from incidents and were distributed to facilitate learning.
  • Safety performance was being monitored. Care and treatment was provided in line with guidelines and the service was planning to participate in clinical audits where they were eligible to take part.
  • Residents told us there pain was effectively monitored and we saw evidence of this in their records.
  • Staff treated patients with kindness, dignity and respect.
  • Staff provided care to patients while maintaining their privacy, dignity and confidentiality.
  • Services were planned to meet the needs of the local population and included national initiatives and priorities.
  • Reasonable adjustments were routinely considered and made to meet the needs of patients living with a disability.
  • Staff felt supported and able to speak up if they had concerns.
  • All staff were committed to delivering good, compassionate care.
  • Staff who worked for the trust were aware of the trusts vision and values.
  • Staffing levels were not always sufficient and there was a high reliance on bank and agency staff members, however, the use of bank and agency staff ensure minimum staffing levels were maintained at all times. Recruitment was ongoing to fill current vacancies, but long-term plans for the unit had not been agreed upon.

Community health services for adults

Good

Updated 21 December 2018

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

  • There were high compliance rates of mandatory training and most mandatory training module targets had been met.
  • Services had suitable premises and equipment. They were kept clean to minimise the risk of infection.
  • There were enough staff, with the right qualifications, skills and training to meet key performance indicators so that patients were seen and assessed in a timely way and within the prescribed targets.
  • The service provided care and treatment based on national guidance. There were processes in place to ensure that guidance was promptly reviewed, disseminated and embedded.
  • The effectiveness of care and treatment was monitored regularly and reported to the trust board. Services were involved in the annual clinical audit programme. Audit results and patient outcome monitoring were used to drive improvements.
  • Staff received regular supervision and role-specific training. They were encouraged to take up external training courses that were relevant to their roles.
  • Staff worked collaboratively with the acute hospital, GPs and local authority to deliver effective care and treatment and support people to live healthier lives and manage their own conditions.
  • Staff cared for patients with compassion and respected their privacy and dignity. They offered adequate emotional support and involved patients and their carers in decisions about patients’ care and treatment.
  • Complaints and concerns were treated seriously and lessons were learned and shared with staff.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action. The views of staff and patients were used to drive improvements.
  • Staff were valued and supported by managers and a positive culture and the wellbeing of staff was promoted.

However:

  • The crisis response team was not carrying out the expected nursing assessments required for patients which was particularly important given their role as the first response. We found that records were incomplete.
  • The crisis response team were not operating in line with their terms of reference and did not have a clear exclusion policy. They were not measuring expected key performance indicators such as bed days saved due to the intervention of the team and whether patients were admitted to hospital when patients were discharged from the service.
  • The security arrangements in Kingsgate House could be improved with addition of secure doors between patient waiting areas and clinic room corridors.
  • The arrangements for meeting individual patient needs and access to information could be improved. For example, it was difficult to establish from the trust website what community services were offered, where those services were and a choice of methods to contact the services.
  • Most services did not have information leaflets printed in different languages, easy read or pictorial versions.

Community health services for children, young people and families

Outstanding

Updated 11 August 2016

We gave an overall rating of outstanding to the community children’s, young people and families service. Services were safe and lessons were learned from incidents. Staff were aware of the duty of candour. Safeguarding processes were robust and there was effective leadership and partnership working in this service. There was one to one safeguarding supervision for staff. Records were securely stored and were comprehensive, accurate and complete.

Staffing was adequate and there had been an increase in staffing establishment in a number of areas. Recruitment was in progress to address the vacancies and there was good skill mix in teams.

There was an audit programme and the results of the audits were used to change and improve services. Services were evidence based and outcome focused. Staff worked with different agencies and other health professionals to improve health and social care outcomes for children, young people and families.

There was a focus on positive mental health and well-being and a preventative approach to services that required a high level of input for children in their pre-school years. The most vulnerable children and young people were intensively supported to help them to achieve their outcomes.

Services were caring and children with complex health needs were supported from birth through their school years and work was ongoing to support young people through transition. The trust worked with children and their families to develop and improve services.

Targets were met by the trust and the relationships with other agencies, including commissioners was positive. This partnership working supported children and young people in their development.

The leadership at all levels of the trust was effective and robust. Governance, quality and risk management structures were in place and there was two way communication between the senior management team and the staff in community clinics. Staff enjoyed working at the trust and felt that they did a good job.

Community end of life care

Good

Updated 11 August 2016

Overall rating for this core service GOOD O

The specialist palliative care team worked as part of a multidisciplinary team covering the acute and community based services, with specific team members dedicated to providing the community element of specialist care. Their role was to assess, support, deliver, monitor and evaluate end of life and palliative care provided by the trust within Stockport, Tameside and Glossop.

The specialist palliative care team provided safe, co-ordinated care and had patients as the focus of their work. Patients were discharged quickly from hospital and equipment and services were put in place within the community to meet their needs.

There was excellent team working between the trust and other services to provide holistic patient care. General Practitioners, social services and community district nurse services all worked alongside the specialist team ensuring patients were a priority. The trust worked to national standards such as the Gold Standards Framework, and were working towards accreditation, and provided excellent educational programmes[DW1] for specialist staff and other clinical staff that may participate in end of life care as part of their role.

In twelve months between 31st March 2014 and 1st April 2015, 918 people had been referred to the community specialist palliative care team. This was less than the previous year. Of those patients 92% (844) had a cancer diagnosis.

Implementation of alternative documentation for the Liverpool Care Pathway[DW2] 2014 (LCP) had been slow. The service had used guidance and key action documents in the interim, to ensure individualised care planning had taken place and the introduction of the Individualised Plan of Care was still being rolled out at the time of inspection.

Patients and relatives we spoke with told us the care they received was delivered with an attentive and considerate manner. They felt involved in their treatment and felt their wishes were followed Patients were treated with dignity and respect.

There was good communication between the specialist palliative care management team and the executive team. Senior staff told us they felt supported and there was non-executive director representation on the trust board. Communication through the community teams, however, could be improved. Some staff told us they felt disconnected from the community and hospital senior leadership teams.

Plans were in place to merge services as part of the Healthier Together and Greater Manchester devolution programmes which would enhance service provision in the area.

Training took place at local level and the business group managed the outcomes from the two areas separately. Separate MDT meetings took place weekly in each area and although the trust had a specialist palliative care consultant in the community, they were only responsible for patients in the Stockport area. Patients in Tameside and Glossop were treated by their GP and any clinical advice was obtained from the local hospice.