The Care Quality Commission
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Stockport NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider
Important: Services have been transferred to this provider from another provider
Important: We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

All Inspections

28 Jan to 27 Feb 2020

During a routine inspection

  • 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).

11 Sep to 4 Oct

During a routine inspection

  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating. In rating the trust, we took into account the current ratings of the seven services not inspected this time.
  • We rated safe, effective and responsive as requires improvement. We rated caring as good. In terms of well-led, although we rated leadership at service level as good, the overall trust rating is determined by our trust-wide assessment of well led, which we rated as requires improvement.
  • We rated Stepping Hill Hospital as requires improvement. Whilst the overall rating was the same as at the last inspection, there was notable improvement in the safe and well-led domains.
  • We rated the Devonshire Centre for Neuro-rehabilitation overall as good. However, in terms of being effective we rated the centre as requires improvement.
  • We rated Bluebell Ward - The Meadows as good across all domains.
  • The trust had made changes following our comprehensive inspection in 2016 and our responsive inspections in 2017. Most services showed improvements, but further work was still required in urgent and emergency care, medicine and maternity services.
  • The trust had experienced staff turnover in the board since our last inspection. This included within key roles. However, substantive appointments had been made to most roles. At the time of our inspection the board were working together to improve services.
  • Significant changes had been made below board since our last inspection in 2017. The trust had established new management groups (an associate medical director, associate nursing director and Business Group Director) to manage business groups within the trust. Further development work was required, but clear positive changes were evident, as outlined in the service’s well-led sections of this report.
  • In medicine and maternity services we still had concerns regarding patient safety. However, in urgent and emergency care and medicine there had been improvements since our last inspection.
  • We were concerned regarding some of the systems and processes within the trust. These included the process for assessing whether directors were fit and proper, parts of the governance and risk management systems. We also had some concerns regarding learning from serious incidents, although this had improved since our 2017 inspections.
  • Across the trust there were no facilities for room temperature monitoring in locations we inspected where medicines were stored.
  • The Sentinel Stroke National Audit Programme (SSNAP) audit identified the stroke services at the hospital as the top performing unit nationally. Stroke patients received care in a dedicated unit from a highly motivated and effective multidisciplinary team. We identified this as an area of outstanding practice.

11 Sep to 4 Oct

During an inspection of Community health services for adults

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.

Date of inspection visit: 21, 22 and 28 March 2017

During an inspection looking at part of the service

Stepping Hill Hospital is the main location providing inpatient care as part of Stockport NHS Foundation Trust In total Stepping Hill Hospital has 833 inpatient beds.

We carried out an unannounced focussed inspection of Stepping Hill Hospital on the 21, 22 and 28 March 2017. We carried out this inspection to particularly look at the care and treatment received by patients in the Urgent and Emergency care department and patients receiving care from the Medical services team at the hospital.

We inspected these areas because of concerns identified at our announced inspection of the Trust in January 2016 and information received from other agencies during that time that indicated a lack of improvement in some areas

Overall, we rated Stepping Hill Hospital as Requires Improvement. We found that staff treated patients with dignity and respect, however this was at times compromised due to a shortage of nursing staff and patient safety was compromised. We requested immediate assurance from the trust to address the lack of nursing staff in the areas identified during the inspection to assure patients safety. The trust did respond to this and put a number of measures in place to address this in the short term. However these would not be sustainable in the medium or long term. The shortage of nursing staff and poor record keeping were identified as breaches in regulation at the last inspection, these issues still persisted in areas on both the emergency department and medical division. Improvements were needed to ensure that all services were safe, effective, caring well-led and responsive to people’s needs.

We inspected the Urgent and Emergency care services and medical services in January 2016. Following this inspection we told the trust that they must take actions to make improvements to key areas including the safe delivery of care and treatment, nurse staffing, privacy and dignity, timely access to emergency and medical services and the management of patient records. When we returned for this inspection we found that the trust had not made sufficient or significant progress and improvement in a number of areas. Safety in the emergency department was still not a sufficient priority, nurse staffing was still a significant challenge and patients were still experiencing unacceptable delays in accessing care and treatment. In the medical services we found that access and flow remained a significant concern with the number of delayed transfers of care increasing by 30 per day since the last inspection.

We also found that in some areas the trust had deteriorated since our last inspection. In the emergency department we found that staff lacked an understanding of the Mental Capacity Act (2005) and consideration of this was evident in patient records. In the medical services we found that staff also lacked an understanding of the Mental Capacity Act (2005) and were not applying the deprivation if liberty safeguards appropriately. We also found that nurse staffing was below expected standards in the medical division and we observed occasions where this negatively impacted on patients safety.

Incidents

  • All staff had access to the trust wide electronic incident reporting system.
  • Staff were aware of what type of incidents they should report and were able to show us how they would report an incident.
  • Some incidents were not investigated appropriately and associated action plans were not always up to date and meaningful. We also found that duty of candour was not always considered in a timely way.
  • Staff told us that learning from incidents was disseminated through emails, communication files, newsletters and at daily meetings. However, a number of senior staff told us that when they incident reported staffing concerns they did not get feedback and the situation did not change.
  • We reviewed the summary of incidents for the 4916 incidents reported in the medical division. We noted inconsistency in the grading of incidents, for example a clostridium difficile (c.diff) infection was categorised as minor, moderate and major. We received the incident grading from the trust, which explained to all staff the appropriate grades for types of incident. However, we found several instances of deviation from this policy and no evidence of action taken as a result of this.
  • The trust’s incident grading criteria did not reflect across to general incident grading criteria used in other NHS organisations, for example the trust did not use no or low harm categorisation instead using ‘minor’ as a categorisation for low or no harm incidents. This left the trust open to mistakes in incident reporting categorisation particularly by bank and agency staff, which, at the time of our inspection, the trust heavily relied on.

Nurse Staffing

  • Across both the Emergency and Medical services divisions there were significant shortfalls in nursing staff.
  • During the inspection we saw examples of where this had impacted on the safety and quality of care patients received; for example
  • In the Emergency and Urgent care department early warning scores (EWS) designed to identify patient who were deteriorating, were not completed in line with the trusts protocol in all cases we reviewed.
  • We observed that trolleys and cubicles were not always cleaned between patients use and the sluice room was found in visibly soiled state.
  • In the medical department staff were frequently moved from their usual area of practice to fill gaps in rotas. This resulted in staff being placed in areas where they felt they did not have the necessary skills and competence to meet the needs of patients.
  • At the time of our inspection on ward A11, there were two nurses and three HCAs on duty, when there should have been three nurses and four HCAs. Two patients had left the ward without being observed, one of which was subject to a DoLs.
  • Ward staff had taken appropriate action once they discovered the patients had left but steps had not been put in place to address the staffing issue until we escalated this to the trust.
  • During our inspection, on all the wards that we visited there was one to two nurses less per shift than had been identified as required to meet patients’ needs. A number of senior nursing staff told us that patient care was compromised when staff were taken away from the wards to support other areas. . On one ward during our inspection there was one registered nurse to 10.5 patients. On another ward, there was one registered nurse to 13 patients. Staff told us the impact on patient care is that falls assessments and risk assessments are not completed, as priority has to be given to direct patient care and the provision of medication.
  • In the Emergency and Urgent care department shift fill rates varied across recent months but were consistently below 80%. In some cases the numbers of shifts unfilled by bank or agency staff exceeded 50%.
  • In the medical services some areas including the coronary care shift fill rates were consistently below expected standards and at times were below 50%.

Medical Staffing

  • There was a high rate of medical staff vacancies across the medical division and the turnover of medical staff was within the trust target.
  • There were rotas in place which included medical trainees. There was an on call rota which ensured there was consultant cover 24 hours a day seven days a week. This meant that senior advice was available at all times. Nursing staff told us that they were able to access medical assistance and advice easily
  • The number of consultants working at the trust was about the same as the England average but the number of junior doctors was lower than the England average.
  • Medical staff morale was low in the emergency department with medical staff telling us that they felt they could not provide the level of care they wanted to due to capacity issues.
  • The general medical council had implemented enhanced monitoring of the trust medical staffing due to safety concerns raised by junior doctors in the emergency department.
  • Medical staff told us that they felt the education program offered to them was not sufficient.

Mental capacity and deprivation of liberty safeguards (DoLS)

  • Across both the emergency and medical services department’s staff did not have a good understanding of the mental capacity act (2005) (MCA) and its application or the deprivation of liberty safeguards (DoLS).
  • When speaking to the staff there was a limited understanding of the trusts own policy regarding MCA and DoLS.
  • The application of both the MCA and DoLs at ward and department level was inconsistent and in the majority of cases we inspected records were unclear and incomplete.

Cleanliness, infection control and hygiene

  • Staff were observed using personal protective equipment, such as gloves and aprons and changing this equipment between patient contacts and we saw staff washing their hands using the appropriate techniques.
  • We saw that staff followed the 'bare arms below the elbow' guidance.
  • There was adequate access to hand washing sinks and hand gels.
  • Monthly infection control audits were undertaken across all wards and departments, which looked at standards such as the cleanliness of patient equipment and hand hygiene. We reviewed these infection prevention audits.
  • The hand hygiene audit findings were below the trust’s target of 90% compliance. These ranged from 68.8% to 79.4%
  • The audit which looked at how well the infection control and prevention measures in relation to indwelling devices was managed ranged between 80% and 52% these were below the trust’s target of 90% compliance
  • Infection prevention and control staff training figures were 90% for level one training and 87% for level two training, which were both below the trust’s target of 95%.
  • Staff training in infection control in the emergency department was above the trusts 90% target.

Records

  • The hospital used electronic and paper based patient records across the medicine division, only a very few paper records were used in the emergency department.
  • During our last inspection we identified that the records trolleys that were inspected were unlocked which meant they were potentially accessible by members of the public.
  • During this inspection across the emergency department electronic records were secure, restricted to authorised access and easily accessible to authorised staff. However paper records were not kept secure and were stored in pigeon holes which were accessible to members of the public.
  • Across the medical division in all areas we visited, except A11, records trolleys were unlocked. Whilst the records trolleys were located at the front of nursing stations, we observed that these areas were not always manned therefore representing the same risk.
  • Records audits were undertaken to review compliance with the trust’s record policy.
  • These audits showed a mixed rate of compliance across the six month period prior to our inspection.

Access and Flow

  • There were high numbers of delayed transfers of care (patients who were medically fit to be discharged but remained in hospital) and these had increased significantly since the last inspection in January 2016. This was having an adverse impact on the medical division’s ability to accommodate and care for patients safely and effectively.
  • There had been a significant increase in the number of’ black breaches’ (Black breaches occur when the time from an ambulance’s arrival to the patient being handed over to the department staff is greater than 60 minutes). Since the last inspection. During the last inspection we found that from November 2014 to October 2015 there were 199. During this inspection we found that in one month alone this figure had been exceeded and there were no months between January 2016 and January 2017 where less than 20 black breaches occurred.
  • We observed the department lacked capacity to accommodate patients and patients were routinely treated and accommodated in the corridor areas.
  • There is a Department of Health standard for emergency departments to admit, transfer or discharge 95% of patients within four hours of arrival. From January 2016 to January 2017 the hospital did not meet this standard for all 12 months and the average percentage of patients admitted and transferred or discharged was 77.4%.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

In urgent and emergency services

  • Ensure that all medications in the emergency department are securely stored at all times.
  • Ensure that patients received their medications in timely manner and ensure that any necessary checks are completed in line with local and national guidance and policy in the emergency department.
  • Ensure that patient records are accurate, up to date and reflect the care the patient receives in the emergency department.
  • Ensure that all staff are up to date with their mandatory training in the emergency department. Specifically in relation to life support and safeguarding.
  • Ensure that patients are protected from infections by isolating patients with suspected infections and cleaning areas where patients receive care in line with their infection control policies and procedures in the emergency department.
  • Ensure that staff follow clinical guideline sand provide evidence based care.
  • Ensure that patients risk is appropriately identified and all possible measures are taken to minimise risks to patients safety are in place. Specifically in relation to patients being accommodated in areas not designed for clinical care such as corridor areas.
  • Ensure that patients are treated with dignity and compassion and that their dignity and privacy is maintained at all times while they are in the emergency department.
  • Ensure that patients can access emergency care and treatment in a timely way.
  • Ensure that all risks identified in relation to the emergency department are appropriately risk assessed and appropriate control measures are in place.

In medical services (including older people's care)

  • The trust must ensure that records are securely stored.
  • The trust must ensure that patient risk assessments are completed and updated at regular intervals.
  • The trust must ensure that it is compliant with the Mental Capacity Act and that all staff have the required level of training in this area.
  • The trust must ensure that its mandatory training reporting systems are accurate and reflective of the training needs and requirements of all staff.
  • The trust must ensure all staff are up to date with their mandatory training.
  • The trust must ensure that at all times there is a suitably trained member of staff on each medical ward and unit that has current adult life support training.
  • The trust must ensure there is consistent categorisation of the same type of incident in the trust’s incident reporting system.
  • The trust must ensure safeguarding training levels for staff are in accordance with the trust’s own policy and best practice guidance.
  • The trust must ensure there is an adequate skills mix on all medical wards and that staff have the right level of competence to effectively nurse the patients they are asked to care for.
  • The trust must do all that is reasonably practicable to ensure there is safe staffing on the medical wards.
  • The trust must address the delayed transfers of care and formulate an action plan outlining how it will address this issue within a reasonable time period.
  • The trust must ensure nursing intervention records are consistently completed.
  • The trust must ensure that thickening powder is securely stored.
  • The trust must ensure that patient’s dignity is preserved at all times across the medicine division.

In addition the trust should:

  • The trust should consider implementing clear guidance for senior staff to use when making judgments about staff moves.
  • The trust should ensure that where audit findings fall below the trust’s expected standards, action plans to address this are created and monitored.
  • The trust should improve the appraisal rate for the medicine division.
  • The trust should ensure the proportion of patients seen by a cancer nurse specialist is above audit minimum standard of 80% for lung cancer.
  • The trust should ensure that patients’ discharge summaries are published within 48 hours.

Professor Ted Baker

Chief Inspector of Hospitals

21, 22 and 28 March 2017

During an inspection of Community health inpatient services

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.

19 to 22 January 2016

During a routine inspection

Stockport Foundation Trust provides services for around 350,000 people in and around the Stockport area with approximately 912 inpatient beds provided in both acute and community services. We carried out our comprehensive Inspection of Stockport NHS Foundation Trust on 19–22 January 2016.

We inspected and rated the following locations and services

  • Stepping Hill Hospital is a busy general hospital that provided 833 inpatient beds and a full range of services including urgent care, maternity and children’s services. We found that services were provided by dedicated, caring staff, and patients were treated with dignity and respect. However, improvements were needed to ensure that all services were safe, effective, well led and responsive to people’s needs.

    We rated the hospital as Requires Improvement overall.

  • Community Services for Inpatients (Shire Hill Intermediate Care Unit and the Devonshire Unit).Adults, Children and young People and End of Life Services .

  • We rated the Community Service for Adults as Requires Improvement and the Inpatient services, Children and young People and End of Life Services as Good overall.

We collated all the ratings and rated the trust as Requires Improvement overall.

Our key findings were as follows:

Key Question - Well Led

Leadership and Culture

Staff in hospital based services confirmed that the executive team and board members were accessible and responsive. Staff, in the main, felt well supported by their line managers and senior management as a whole. Staff felt positive and valued by the organisation.

There was an open culture that supported the reporting of incidents to improve care and create opportunities for learning.

Staff felt encouraged to raise issues and concerns and were confident in doing so.

However, in Community Services for Adults, we found that there was a disconnect between staff above Band 7 and staff below. Locally staff were well supported however, staff reported that they never saw the Senior Team and did not feel part of the trust but rather part of an individual Community Healthcare Service. Staff in this service felt that the communication with the Executive Team was poor and infrequent.

In Community End of Life Services Staff we found that locally there was clear leadership for end of life care within the specialist community services. However, the team felt remote from the day-to-day activities of the trust. When we asked if staff felt supported by managers there were mixed responses. There had recently been changes to the middle management structure within the Stockport team and staff felt that they would benefit from better communication from senior leaders to support this change.

Macmillan nurses in Tameside and Glossop felt that the support network within their team was excellent.

Community staff were familiar with the Chief Executive ‘Choc and Chat’ meetings and other staff engagement opportunities but stated that due to work pressures they found it difficult to attend.

Overall, we found that Staff employed by the trust were proud of the work they did and demonstrated a commitment to providing patients with high quality services. Although there was an improving culture in most areas, there were still some staff groups that felt the trust still had work to do to address their concerns and improve engagement. This was particularly evident in community services.

Vision and values

The trust's vision was to be nationally recognised for specialism in the care of older people and as an organisation that provides excellent cancer care. The vision was underpinned by the trust's ‘Your Health. Our Priority’ promise and a range of values and value based behaviours that included;

Quality & Safety

  • Safe, high quality and compassionate care.

  • Clean and safe environment for better care.

Communication

  • To treat patients, their families and our staff with dignity and respect.

  • To communicate with everyone in a clear and open way.

Service

  • To provide effective, efficient and innovative care.

  • To work in partnership with others, to deliver improved care, in the right place at the right time.

Strategy

The trust had developed a strategy for the future provision of services with specialist Health Economists over an 18 month period accounting for demand, the health needs of the population served and future growth.

The Strategy had been developed into a delivery plan and included an innovation programme focused on improving quality, a focus on caring for older people and providing cancer care out of hospital. The plans were being implemented at the time of our inspection and included a capital development of £20m in a new Surgical Centre scheduled for September 2016 that would significantly improve the trusts estate and enhance patient experience.

Governance and risk management

The trust’s governance and risk management arrangements had been externally reviewed against Monitor’s “Well led Framework” in 2014- 15. ( Monitor was the former regulator for NHS Foundation Trusts) (Since April 2016 Monitor has become part of NHS Improvement a new body that is responsible for overseeing foundation trusts and NHS trusts, as well as independent providers that provide NHS-funded care. The organisation offers support to providers to give patients consistently safe, high quality, compassionate care within local health systems that are financially sustainable).

In July 2015 Monitor determined that it was satisfied that the trust had complied with the actions in relation to board effectiveness and governance of the discretionary requirements it had imposed in August 2014.

It was evident that since the imposition of the requirements the trust had strengthened its governance systems and processes. There was an improved assurance meetings structure for the Board, Council of Governors and Business Groups, as well as an improved Board Assurance Framework and Board reporting of performance through the development of the Integrated Performance Report (IPR). The Board Assurance Framework (BAF) was better aligned to the trust vision and priorities. The BAF was linked appropriately to a risk register that was regularly reviewed

In addition, there had been investment in regular Board and Council development; examples included Haelo, ‘Making Safety Visible’ programme and IOSH training.

The trust was one of the first trusts to achieve ISO 22301(Business Continuity Management).

Key Question - Safe

Nurse Staffing

The trust used a nationally recognised acuity tool to determine the number and skill staff required in wards, departments and services. Staffing establishments were reviewed twice yearly.

In adult inpatient services across the trust monthly safe staffing figures showed an overall fill rate of over 90% against funded establishments.

However, in Stepping Hill Hospital we found staffing shortfalls in Maternity, Paediatric and Urgent Care services. In medical services there was also a heavy reliance on staff moving across wards, coupled with the use of agency and bank staff to maintain adequate staffing levels. The use of staff in this way was not sustainable in the longer term and addressing staff vacancies was a priority for the trust.

Nurse staffing levels on the Treetops (children’s) ward did not reflect Royal College of Nursing (RCN) standards and staffing on the neonatal unit did not always meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM).

In the Urgent and Emergency care department the staffing levels also required improvement. The expected day time shift for the department were 12 registered nurses and three health care assistants. There were occasions when the required staffing levels were not met. This resulted in additional pressures on an already very busy department.

Midwifery staffing was described as a day to day “challenge” by the managers. 96 incidents had been reported between November 2014 and October 2015 about low staffing numbers that had affected patient care. The ratio of midwives to births was 1 to 30 which was worse than the England average of 1 to 27.

Actions to improve the midwifery staffing included an additional five full time midwives on 12 month contracts to cover maternity leave and long term sickness vacancies.

There was an escalation policy which included moving staff between areas, using non-clinical staff to provide cover in a clinical area or asking staff to come in from home. In order to support the staff on the maternity units the band 7 midwives had an on call rota and there was always a supervisor of midwives on call. There was a supernumerary co-ordinator on the delivery suite every day.

The trust was aware of its staffing challenges and had an ongoing programme of staff recruitment both locally and overseas. As a result the numbers of trained nurses and midwives was increasing and reliance on agency staffing was reducing.

Nevertheless the trust still faced a number of staffing challenges both in the hospital and community settings that meant there were times when services did not have appropriate numbers of staff to meet patient needs.

Community Nurse Staffing

Reviews of District Nursing services carried out by NHS England and by the trust indicated that the services were operating with reduced staffing levels that had not been planned to meet the needs of the local population. Nurses’ working beyond their contracted hours was not an exception but an almost daily occurrence. This was a matter that required focused action.

Medical Staffing

There were sufficient numbers of suitably skilled medical staff to care for patients. Where vacancies were present the trust employed locum doctors to support and maintain suitable medical cover to meet patient’s needs. Nevertheless we were concerned that there was a 50% vacancy rate for consultant posts within the emergency department. Managers were using locum consultants to maintain the consultant rotas; however, again this was not a sustainable long term position. Senior managers recognised this and were working to recruit additional consultants as a priority.

Mortality Rates

There was good oversight of mortality rates and there were robust systems and processes in place to review mortality and share learning as appropriate.

Mortality reports were regularly submitted to Business Group Quality Board.

In Surgical and Critical Care there were processes in place to review all deaths and in Medicine, review process were based on ‘red flag’ triggers that were condition or disease related.

The trust’s mortality rates compared well with the England average. (SHMI, RAMI, HSMR comparative data)

Safeguarding

Staff were able to identify and escalate appropriately issues of abuse and neglect. Practice was supported by ongoing staff training. The trust safeguarding team provided support and guidance for staff so that safeguarding issues were escalated and managed appropriately.

Trust data confirmed that 87% of all staff had completed their adult safeguarding training. (The trust target was 85%).

In services for children and young people 91% of staff in the children and families division were up to date with level 2 safeguarding adults training and 94% with safeguarding children.

In the last year staff were required to complete safeguarding in children training to level 3. In September 2015 80% of relevant staff had completed this training.

Staff had also received training in the recognition and reporting procedures for female genital mutilation (FGM). Midwives were aware of the trusts’ policy and changes to reporting requirements which had come into force in October 2015. However, not all junior doctors were conversant with FGM legislation.

Current procedures for reporting a safeguarding concern were readily available to staff in written format and on the intranet.

There were also procedures in place to safeguard patients who did not attend for antenatal or postnatal appointments. This included prompts to identify patients in vulnerable circumstances and steps to ensure their safety status was followed up.

Cleanliness and Hygiene

There was a good standard of cleanliness throughout the trust. Staff were aware of current infection prevention and control guidelines and were supported by staff training and the adequate provision of facilities and equipment to manage infection risks.

The trust had introduced PCR testing for clostridium-difficile that ensured rapid results were available to medical teams to reduce the potential spread of infection within inpatient areas. We considered this to be an example of good practice.

There were regular audits of cleanliness and infection control standards with good levels of compliance. Where audits identified shortfalls in practice action plans were developed and implemented to secure improvement.

Infection rates were within the England average.

Key Question - Effective

Hydration and nutrition

Across all in - patient and community services patient records included assessments of patient’s nutritional requirements; fluid and food charts were reviewed and updated regularly.

Specialist dieticians were involved with patients who were identified as needing a special diet or support.

Patient records included appropriate assessment of nutritional requirements and were regularly reviewed.

Patients who required support and assistance with eating and drinking were supported in a sensitive and discreet way.

Patients were generally positive about the range and quality of food available.

Children and young people were offered a choice of meals that were age appropriate and met their individual needs. A review of meals available to children was being undertaken at the time of our inspection.

There were two paediatric dieticians available who supported children with specialist dietary needs.

However in the adult A&E department Patients’ nutritional and hydration needs were not always identified and addressed appropriately.

Key Question - Caring

Care and treatment was delivered by caring, committed, and compassionate staff.

Staff at all grades and in all disciplines treated people with dignity and respect. Patients were positive about their interactions with the staff team. Staff were open, friendly and helpful, many went out of their way to help and support patients.

Staff actively involved patients and those close to them in all aspects of their care and treatment. Patients felt included and valued by the staff and felt encouraged to be partners in care.

Patients and those close to them understood their treatment and the choices available to them.

Meeting people’s emotional needs was recognised as important by staff and they were sensitive and compassionate in supporting patients and those close to them during difficult and stressful periods.

Key Question - Responsive

Access and Flow

The trust continued to experience significant difficulties in the Accident and Emergency department. The trust had consistently failed to meet The Department of Health target for emergency departments to admit, transfer or discharge 95% of patients within four hours of arrival. This meant that large numbers of patients frequently and consistently experienced unacceptable waits and were not able to access emergency care in a timely way.

We also found that there was routine overcrowding in the adult A&E department. Ambulance crews frequently queued in the department corridors with patients waiting to be admitted and there were considerable delays in patient handovers.

The trust was aware of this long term problem and had invested in a number of improvement programmes as well as investment in extra medical and nursing staff. Initiatives included: the introduction of an Ambulatory Care Unit, a new Medical Assessment Unit, a Surgical Assessment Unit, a Short Stay Older People’s Unit, an electronic ED system, coupled with additional consultant investment in Cardiology, Gastroenterology, Acute Medicine and Older People’s Medicine.

However, many of these initiatives had been hampered by the designated service areas being used to place patients who were waiting to be moved to an inpatient area or to be discharged, consequently staff were not able to maximise the potential for impact on improving patient access and flow throughout the hospital.

The trust was working closely with the Local System Resilience Group on this important issue and the trust had met with local commissioning board’s to discuss performance and monitor the implementation and monitoring of improvement. Nevertheless performance remained poor and was in need of significant improvement.

More positively, the trust was meeting referral to treatment targets in many other areas. All cancer targets had been achieved, the national 6 week diagnostic target was achieved and pressures in Outpatient delays in Medicine were resolving and performance was improving. The rescheduling of cancelled operations had been of concern; however, performance had improved considerably over the last six months.

We saw several areas of outstanding practice including:

  • The introduction of PCR testing for clostridium-difficile ensured rapid results were available to medical teams to reduce the potential spread of infection within inpatient areas.

  • The paediatric unit had created specific packs to support parents whose children were having specific procedures for example a DVD and self-help pack had been created for children having spica surgery. This included contact details for parents who had had a similar experience.

  • The neonatal unit had a range of leaflets that complemented their ‘baby passport’. The leaflets were staged depending on the baby’s development. Parents were prompted via the ‘baby passport’ and nursing staff to know which information leaflets were relevant to them at a particular point in time.

  • Care on the Laurel suite and on the Bobby Moore Unit was outstanding. Staff were strongly person centred and understood and respected the totality of patient’s needs. They involved patients as partners in their care and provided high levels of emotional support.

However, there were also areas where the trust needs to make improvements.

Importantly, the trust must:

Stepping Hill Hospital

Urgent and Emergency Services

  • The trust must ensure that all medications in the emergency department are securely stored at all times.

  • The trust must ensure that patients received their medications in timely manner and ensure that any necessary checks are completed in line with local and national guidance and policy in the emergency department.

  • The trust must ensure that patient records are accurate, up to date and reflect the care the patient received in the emergency department.

  • The trust must ensure that all staff are up to date with their mandatory training in the emergency department. Specifically in relation to life support and patient manual handling.

  • The trust must ensure that patients are protected from infections by isolating patients with suspected infections and cleaning areas where patients receive care in line with their infection control policies and procedures in the Emergency Department.

  • The trust must ensure that patients risk is appropriately identified and all possible measures are taken to minimise risks to patients safety are in place. Specifically in relation to patients being accommodated in areas not designed for clinical care such as corridor areas.

  • The trust must ensure that patients are treated with dignity and compassion and that their dignity and privacy is maintained at all times while they are in the emergency department.

  • The trust must ensure that patients can access emergency care and treatment in a timely way.

  • In times of pressure the trust must ensure that the trusts internal escalation policies are followed appropriately.

  • The trust must ensure that there is an adequate policy or procedure to guide the practice of 'boarding' to ensure patient safety.

  • The trust must ensure that all risks identified in relation to the emergency department are appropriately risk assessed and appropriate control measures are in place.

Critical Care

  • The trust must ensure that the practice of pre-filling syringes with intravenous medicines and then storing them in the fridge is not continued. For any scenario where a clinical decision results in this practice being reconsidered, then a detailed risk assessment should be undertaken, which should include the involvement of the critical care pharmacist.

Maternity and Gynaecology

  • The trust must ensure all staff are up to date with adult basic life support training
  • The trust must ensure there is a system in place to learn and share learning from incidents.
  • The trust must ensure all steps of the safer surgery checklist are completed for all surgical procedures in the obstetric theatre.
  • The trust must ensure a system is in place to monitor patient outcomes against set local or national targets.
  • The trust must ensure midwives are up to date with skills and drills training
  • The trust must ensure midwives assisting the anaesthetist in the obstetric theatre are trained in line with national guidance.
  • The trust must ensure there is a system for continuous monitoring of the quality of the service provided and make necessary improvements.

Children and Young People

  • The trust must ensure there is a senior staff member on each shift on the paediatric unit.

  • The trust must ensure there is a staff member that is HDU trained on each shift on the paediatric unit.

  • The trust must ensure the door exit systems on the paediatric and neonatal unit are secure.

  • The trust must ensure staff members’ medications are securely stored and do not include the trust’s generic medications.

  • The trust must ensure that fridge temperatures are regularly checked, documented and acted upon in accordance with the trust’s policy and procedures.

  • The trust must ensure all staff working with children and young people have level three safeguarding training.

Community services

Action the provider MUST take to improve

  • The trust must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff in District Nursing services to make sure that they can meet people’s care and treatment needs in a timely and appropriate way. Staffing levels and skill mix must be reviewed continuously and adapted to respond to the changing needs and circumstances of people using the service.

  • The trust must desist from the sharing of treatment rooms for patients at Hazel Grove Health Centre to ensure the privacy and dignity of service users.

  • The trust must screen off or move the area in reception used for a Mother and Baby Clinic at Hazel Grove Health Centre to ensure the privacy and dignity of service users.

  • The trust must ensure that patient consent to treatment is indicated on Diabetic Clinic notes, even if this is just implied consent.

Professor Sir Mike Richards

Chief Inspector of Hospitals

19-22 January 16

During an inspection of Community health services for adults

Overall, we have rated community adult health services as Requires Improvement.

Stockport NHS Foundation Trust provided a wide range of community-based health services for adults, supporting health and wellbeing promotion, minor ailments, serious or long-term conditions and facilitates discharge from hospital and aim to prevent admissions to hospitals.

Services were provided across Stockport, Tameside, and Glossop in people’s homes, residential and nursing homes, clinics and health centres.

The services provided included district nursing; podiatry; dietetics; optometry; continence; integrated diabetes and high risk foot teams; learning disability; adult speech and language therapy; MSK physiotherapy and orthotics.

We carried out an announced inspection on 19-22 January 2016 and an unannounced inspection on 1 February 2016.

As part of the inspection we held focus groups with a range of staff who worked within the service, such as nurses, doctors, therapists. We spoke directly with 80 members of staff, including 35 staff who attended focus groups. We talked with people who used services. We observed how people were being cared for in their own homes and in clinics. We talked with carers and/or family members and reviewed 16 care or treatment records for people who use services.

As part of our inspection, we observed patient survey results and spoke to six patients.

We left comment boxes for patient feedback in a number of clinics. We received 223 responses.

87% of the responses were positive feedback about the service received; 2% was negative feedback and 11% was neither positive or negative.

Negative comments were mainly in relation to long waits for appointments or results; poor communications; poor information and estates.

We rated the community adult health services as Requires Improvement because:

  • Reviews of District Nursing services carried out by NHS England and by the trust indicated that the services were operating with reduced staffing levels that had not been planned to meet the needs of the local population.Nurses’ working beyond their contracted hours was not an exception but an almost daily occurrence.

  • Staff reported incidents in a timely way though feedback and learning from incidents was ad hoc and did not follow any set processes.

  • A number of incorrect insulin doses had been administered because of paperwork being misread and we were not provided with evidence of remedial actions taken to prevent this from happening again despite an incident being logged.

  • Consent was not always recorded in patient notes.

  • Clinical competencies were not being shared between services and organisations, leading to clinicians being unable to carry out their full range of duties and putting additional pressures on colleagues[FA1]. Competencies gained elsewhere were not added to “Clinical Competency Passports” and had to be regained when staff moved into Community Healthcare. This did not meet patient needs and put added pressure on colleagues who had to cover additional tasks for those staff who had not yet been re-assessed as being clinically competent in them.

  • There were delays in staff receiving appropriate training and the receiving of formal supervision.

  • The trust had not met their target on the numbers of staff who had received an appraisal.

  • There was a lack of access to information leaflets in different languages or in braille or large print.

  • Some clinic facilities and buildings were generally not fit for purpose, requiring maintenance and having floors that were inaccessible to service users.We saw that some of the doors in the more modern clinics made mobility through the building difficult for wheelchair users.

  • Staff did not always receive feedback and learning from complaints.

  • Staff told us that members of the trust and Community Business Group senior management team were not visible in community bases.

  • There was no staff retention or recruitment plan in place despite a service review identifying a shortage of District Nursing staff and a number of District Nurses (especially at Band 6 level) leaving the service.

  • There were communication issues between staff above Band 7 level and those below.Staff in Tameside and Glossop Community Adults Team did not feel that they had been fully informed about their transition to Tameside Hospital NHS Foundation Trust and their concerns about working in an integrated team had not been addressed.The management board was unaware that the introduction of a clinical competencies passport was not working as intended.

  • There were high staff turnover and sickness absence rates in the Community Business Group with high levels of stress-related absences, especially in Band 5 Nurses.

However:

  • The Community Business Group was above the trust target for mandatory training completion.

  • There was an excellent winter planning policy and staff were aware of their roles and responsibilities in the event of adverse weather to maintain services, especially for more vulnerable patients.

  • There was comprehensive care planning in which NICE guidelines and local CQuIN quality innovation was used.

  • There was good evidence of multidisciplinary team working that facilitated patient access and flow, appropriate discharges and helped to prevent hospital admissions or readmissions.Appropriate guidance was given to stakeholders such as care homes and carers to enable co-ordinated care pathways for patients.

  • Staff were kind, caring and compassionate and made efforts to alleviate patient fears.

  • Patients were treated with dignity and respect and encouraged to agree treatment aims.

  • There were 'Dignity Champions' in clinics and many staff and stakeholder organisations were accredited with the Daisy quality marker (a quality standard awarded for organisations to demonstrate that they deliver a service which has dignity and respect embedded in it.).

  • There was timely access to appointments and treatment.

Band 6 and 7 staff were very supportive of their teams and led by example.  Team members were supportive of each other, covered the work of absentees and worked extra hours to get the job done.

19 to 22 January

During an inspection of Community health services for children, young people and families

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.

19 - 22 January 2016

During an inspection of Community health inpatient services

Overall rating for this core service GOOD

We rated community inpatient services as good in the safe, effective, responsive, caring and well led domain because:

  • The ward areas were fit for purpose, clean and spacious.

  • Staff followed good hygiene practices and there were good systems for handling and disposing of medicines.

  • There was good evidence of multidisciplinary team working with regular meetings held to review patient’s ongoing development and needs.

  • Staffing levels were adequate although agency staff and staff from the ward would work extra shifts to fill some shifts. Recruitment was ongoing to fill current vacancies

  • Compliance with mandatory training was mainly above target for most staff.

  • Incidents were reported through effective systems and lessons learnt or improvements made following investigations were shared.

  • Staff were aware of their role and responsibilities around the Mental Capacity Act (2005) and Depravation of Liberty Safeguards.

  • Staff had access to information they required, for example diagnostic tests and risk assessments.

  • Best practice guidance in relation to care and treatment was followed across the service.

  • The service participated in national and local audits and action plans were formulated following the results of audits.

  • The care provided by the service was patient centred and patients were involved in their care and planning individual goals.

  • Patients were observed receiving compassionate care and their privacy and dignity were maintained.

  • There was strong local and service level leadership across the service.

  • Staff said they felt supported, that morale was good and they felt part of the team.

19-22 January 2016

During an inspection of Community end of life care

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.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.