What our icons mean
|Outstanding – the service is performing exceptionally well.|
|Good – the service is performing well and meeting our expectations.|
Ticks and crosses
|The service must make improvements.|
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.
Mental capacity and deprivation of liberty safeguards (DoLS)
Cleanliness, infection control and hygiene
Access and Flow
There were areas of poor practice where the trust needs to make improvements.
Importantly, the trust must:
In addition the trust should:
Professor Ted Baker
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;
Safe, high quality and compassionate care.
Clean and safe environment for better care.
To treat patients, their families and our staff with dignity and respect.
To communicate with everyone in a clear and open way.
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.
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
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.
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.
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)
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.
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
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.
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.
Chief Inspector of Hospitals
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.
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.
We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.
What our icons mean
|Outstanding – the service is performing exceptionally well.|
|Good – the service is performing well and meeting our expectations.|
|The service must make improvements.|
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