Archived: Stafford Hospital

Updated 9 October 2014

Much has been written about this trust in recent years. This is a different organisation to that from 2009 and the challenges it is facing are exceptional.

Mid Staffordshire Hospital NHS Foundation Trust (MSFT) serves the population of South Staffordshire. It is based on two sites, Stafford Hospital and Cannock Chase Hospital. There are approximately 350 beds, last year the trust had approximately 28,000 inpatients, there were 1800 births and over 45,000 people came to Accident and Emergency.

In 2013 the trust was declared clinically and financially unviable and the Trust Special Administrators (TSA) were appointed by Parliament in April 2013. In addition to taking on accountability for the day to day running of the Trust, the administrators were required to develop a plan for ensuring that clinically and financially sustainable services can be delivered for the local population currently served by the trust. The plan recommended that the trust be dissolved and responsibility for Cannock Chase hospital should be given to Royal Wolverhampton Hospital NHS Trust (RWT) and Stafford Hospital to University Hospitals of North Staffordshire NHS Trust (UHNS).

In January 2014, Monitor confirmed approval of the proposed dissolution of the Trust and passed the report to the Secretary of State for consideration, who approved the principal recommendation that the trust should be dissolved. The date for dissolution of the trust is currently set for 1 November 2014 and services will transfer to the new providers from that date.

This inspection has been requested by Monitor, the Trust Development Agency (TDA) (as both UHNS and RWT are not foundation trusts) and the TSA. All of these agencies have expressed serious concerns about the sustainability of safe staffing levels at MSFT and they have jointly asked for an independent review by CQC. We have carried out this focused inspection in response to this request.

Updated 9 October 2014

The key question we were asked to consider whether Mid Staffordshire Hospital NHS Foundation Trust (MSFT) is currently providing safe care and whether safety was likely to be sustainable in the future. We were aware that the planned date for the dissolution of MSFT and transfer of responsibility for services to University Hospital of North Staffordshire NHS Trust (UHNS) and Royal Wolverhampton NHS Trust (RWT) is 1 November 2014. We therefore considered whether safe provision of services was likely to be sustainable over the next four months and beyond that over winter 2014/15.

Our approach

To undertake this task within a very short timescale we modified our new approach to inspection of acute hospitals. We concentrated particularly on the first of CQC's five key questions i.e. Safety. Within this we looked very closely at staffing levels for nurses, doctors and allied health professionals in key clinical services and the approaches that Trust Special Administrators and Mid Staffordshire Hospital NHS Foundation Trust has made to recruit and retain staff. We also looked at the impact of any deficiencies in staffing levels on the quality of care being delivered by staff at MSFT. Finally we considered the leadership of services at MSFT.

During the pre-inspection phase we looked at the report from the Trust Special Administrators (TSAs) regarding future configuration of services currently provided at MSFT. These recommendations have been accepted by the Secretary of State for Health and we were not asked to reopen the debate on these recommendations. Rather, the report provided us with the agreed direction of travel for different clinical services. We are also aware that a further review into the configuration of maternity services is being commissioned. We reviewed the safety and sustainability of services at this trust in this context.

We were given access to the minutes of the Sustaining Services Board, chaired by the TSA representative, which brings together leaders of the local health economy around MSFT and to a copy of the due diligence report commissioned by the Board of UHNS. The Chief Executive of MSFT and her staff were extremely helpful in providing detailed information on current and projected staffing levels and other recent performance management information for the trust.

In this process, we are not providing ratings on the trust as we normally would do. This is deliberate and reflects both the bespoke nature of the remit and the planned disaggregation of the trust in November.

An overview of our findings

The commitment of staff at all levels to the delivery of high quality care at MSFT was evident throughout the hospital. However, it is important also to recognise the degree of fatigue reported by staff. This relates both to the relentless external scrutiny focused on MSFT and from uncertainty about the future.

The trust is facing major difficulties in recruiting and retaining medical and nursing staff both because of the continuing uncertainties about the future and because of the previous poor reputation of the trust outside the local area. These factors are creating a large destabilising influence across the organisation.

The senior managers at MSFT, including the Chief Executive, are spending inordinate amounts of time ensuring that individual nursing shifts are adequately filled and that sufficient numbers of medical staff will be available for different services. To date they have just been able to do this, but the emphasis here is on the word just. This has resulted in a significant reliance on temporary medical and nursing staff, which has a resultant impact on permanent staff working in the relevant clinical areas. In addition, there is an almost complete dearth of formal medical service level clinical leadership at MSFT. While additional staff have been supplied by UHNS in some clinical areas, in other areas the movement of staff has been from MSFT to UHNS.

Our inspection team members judged that safe care is currently being delivered in each of the clinical areas except for medical care which required some improvement. Staffing levels are only just adequate in some areas, particularly on the medical wards and of these, the winter escalation ward, (ward 11) was still open and gave the most cause for concern. Medical and nursing staffing pressures make this ward unsustainable.

The inspection team members were, however, much less assured about the sustainability of some services, even over the next four months. Should staffing levels fall by even one or two people in some key posts, services would become unsafe. The only option for handling such an eventuality identified to us either by the TSA or the trust management would be to reduce the bed base and almost certainly to restrict admissions to the hospital (unless flow through the hospital can be substantially improved). Indeed there have already been occasions when the West Midlands Ambulance Service has been asked to divert emergencies to UHNS or RWT. Undesirable as this is, this does indeed appear to be the only option available. The fragility of the provision of acute services cannot be overemphasised

The TSA and the trust management have proposed a reduction in the opening hours of A&E as a means of reducing the burden on acute services and thus maintaining safety. My inspection team had concerns about this approach. In particular they were concerned that it might not achieve the desired reduction in emergency admissions to the hospital and that it might render the junior doctor rotas unviable. This would at the very least need to be discussed with colleagues at Health Education England.

Looking beyond the planned date of transition in November 2014, inspection team members were unanimous in their view that services would be unsustainable should any degree of winter pressures arise. It is therefore imperative on safety grounds that the transition should not be delayed.

Transition

We were both surprised and very concerned that a clear transition plan has yet to be developed to ensure the safe transition of responsibility for clinical services to the agreed model of care over the next four months. This clearly requires full involvement of MSFT and other organisations in the wider health economy. Although the Sustaining Services Board has provided a useful forum for bringing together the relevant stakeholders it is not a decision making group and has no authority to take action. In addition the workforce at MSFT needs clarity as soon as possible about what is going to happen and when. The current uncertainty is contributing to the fatigue and fragility amongst staff. The transition plan should therefore include a commitment by the acquiring organisations to actively support medical and nursing staffing levels at Mid Staffs over the next four months so that services remain safe.

It is now imperative that a clear and timetabled transition plan should be developed and implemented without delay. This should set out the steps that will be taken to ensure services remain safe, effective, caring and responsive to patients’ needs. Leadership responsibilities and accountabilities need to be clearly defined. This will require high level input and commitment from TSA/MSFT, UHNS and RWT and from CCGs and WMAS. No single organisation can achieve this on its own. High level oversight from Monitor and TDA, as the organisations which oversee the various providers will be essential.

Yours sincerely

Professor Sir Mike Richards

Chief Inspector of Hospitals

Updated 9 October 2014

There were enough staff to care for patients. There was a high use of agency and locum staff and this did increase pressure on permanent staff at times. There were systems to manage the risks of staff who did not work regularly at the department.

The department was well led at a local level. Staff were working cohesively to provide care and to improve services. There were systems in place to monitor the quality of care.

The pressures to manage patient flow through the hospital were impacting on the A&E’s ability to move patients through the hospital. The lack of detailed communication about the transfer of services was causing pressure for staff and contributing to problems in recruiting and retaining staff.

Updated 9 October 2014

We considered that medical care services required some improvement for safety and was very fragile. There were vacancies in all areas we visited for both nursing and medical staff, with additional long term staff sickness and maternity leave evident. The use of locum, bank and agency staff had an impact on the continuity of care for patients. It was positive to see that identified care pathways with proformas for locum doctors to follow were available to provide guidance on best practice. However vacancies for senior doctors and nurses and their replacement by temporary staff provided concern for the supervision and support of junior doctors and nurses.

There was regular monitoring of key safety measures however the high use of temporary staff did not give assurance that all incidents were appropriately reported. We were not assured that the high staff turnover on some wards meant that appropriate lessons were learnt from complaints. Some medicines were not stored appropriately which may affect their effectiveness.

Patients received compassionate care and we saw that patients were treated with respect. There was regular monitoring of key safety measures, and ward areas were clean.

Updated 9 October 2014

Patients and relatives we spoke with gave us examples of the outstanding care they had received in the unit. Staff worked as a team and built up trusting and consistent relationships with patients and their relatives by working in an open, honest and supportive way. They worked hard at good communication by providing clear information and listening to people.

There was strong local leadership of the units. Openness and honesty was encouraged at all levels. The units were well covered by consultants and registrars and had good, flexible nursing, including senior nurses and stable bank cover.

Quality outcomes were measured, staff were encouraged and supported to report incidents and learning from incidents was passed on through regular staff meetings.

Updated 9 October 2014

Good care is provided for women and babies. We were told that women were satisfied with the care they had received and this was supported by evidence in local and national surveys.The staff reported that the department was a friendly and supportive environment to work in but that it could become busy at times.

There were processes in place for reporting, responding to and learning from incidents although more could be done to encourage staff to take part in generalised learning opportunities.

Staff reported uncertainties about the future which impacted on morale but that they were following a business as usual model.

Updated 9 October 2014

The radiology service of Mid Staffordshire hospital was providing a safe service at the time of our inspection. Radiologist staffing levels have reduced significantly during the past few months and are set to reduce further during August and September 2014. However, the service has put in place a strategy to address current and future radiology staffing levels making the service sustainable until November 2014.

Updated 9 October 2014

Currently patients received safe, compassionate care. The ward managers ensured to the best of their ability, that the staff on duty were suitably skilled and competent. Staffing shortages had impacted on the day to day running of the wards and the ward managers were tasked with covering the 31% staff vacancies in surgery. The patients that we spoke with told us they had been shown respect, treated with dignity and had been well cared for. However, due to the increased use of agency staff and the increasing numbers of medical outliers within surgical beds, the challenge of meeting demand was increasing.

Monitoring systems were in place to promote patient safety and incident reporting was promoted although we were told that learning from incidents had not been widely cascaded. Adherence to the WHO checklist was embedded by staff carrying out surgery or interventional procedures. Safety checks of equipment were carried out in wards and theatre theatres and records were available. Elective patients were pre-assessed before admission and were admitted to the wards or the day unit. Discharge planning began reasonably early in the patient’s pathway of care and there was a multidisciplinary approach.