All inspections: Stepping Hill Hospital

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

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Stepping Hill Hospital.

We inspected the maternity service at Stepping Hill Hospital, which delivers maternity services for Stockport NHS Foundation Trust, as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Stepping Hill Hospital provides maternity services to the population of Stockport and High Peak.

Maternity services include a maternity triage unit, a maternity ward including antenatal and postnatal care, co-located Stockport Birth Centre (midwifery led birth-unit (MLU)) consultant led delivery suite and enhanced care room, and transitional care area. The MLU has 4 individual birthing rooms, 3 of which have birthing pools and a 4 bedded bay for postnatal use when required. The MLU is located on the same floor as the maternity triage and antenatal day unit (ADU).

Between April 2021 to March 2022, there were 3250 babies born at Stepping Hill Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital stayed the same. We rated it as Required Improvement because:

Our rating of Requires Improvement for maternity services did not change ratings for the hospital overall. We rated safe as Requires Improvement and well-led as Requires Improvement.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited maternity triage, the delivery suite, 1 maternity ward which provided antenatal and postnatal care (which included 2 private rooms and a bay), the midwifery led unit (MLU), the antenatal day unit (ADU), delivery suite theatres and relevant recovery area, elective caesarean section theatres waiting area, the bereavement suite and the transitional care area provided within the neonatal unit. There was no transitional care area designated on the ward although staff told us they aimed to keep baby with mother, birthing person where possible.

We spoke with 25 midwives and 8 doctors, 3 maternity support workers and 6 women and birthing people. We received two positive feedback to our ‘give feedback on care’ posters which were in place during the inspection.

We reviewed 10 patient care records, 10 observation and escalation charts and 10 medicines records. We attended handover meetings and safety huddles.

Following our onsite inspection, we spoke with senior leaders within the service. We also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

We only inspected urgent and emergency care during this inspection and we re-rated this core service.

As a result of re-rating this core service, the ratings for the hospital location changed slightly with the effective domain changing from requires improvement to good. The overall ratings for the hospital location and the trust overall remained the same at requires improvement.

We inspected the urgent and emergency care service on site at Stepping Hill Hospital on 1 and 2 November 2021 and we interviewed departmental leads on 4 November 2021.

This was an unannounced inspection (the trust did not know that we were coming) in order to re-rate the service following all action plans from a previous inspection being completed.

During the inspection we spoke to 33 staff members, three people who worked for other organisations, three patients, attended two meetings and checked 14 sets of patient records.

We inspected the urgent and emergency services at this trust on 24 and 25 August 2020 because we had issued a Warning Notice in March 2020. The warning notice followed an inspection in January and February 2020 where we had identified areas of significant improvement that the trust needed to make. This was a short-announced inspection focused inspection, so the trust was aware of our visit three days before the inspection. This was because of COVID-19 restrictions in the emergency department.

We did not rate services at this inspection. The ratings from the previous inspection remain.

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

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

However,

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

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 22 and 23 June 2017.

We carried out this inspection to particularly look at the care and treatment received by patients in the medical care service at the hospital. We focussed our inspection on the safe domain, however, where we have found evidence in relation to other domains we have included this in the report. During the inspection we visited ward C2, A11 and the Coronary Care Unit.

We inspected these areas because of concerns identified through our ongoing monitoring and intelligence of the trust. We found that staff treated patients with dignity and respect, however, this was at times compromised due to a shortage of nursing staff and, as a result, patient safety was compromised.

We requested immediate assurance from the trust to address the areas identified during the inspection and following the inspection to assure patients safety. The trust responded to this and put a number of measures in place to address these concerns. Improvements were needed to ensure that all services were safe, effective, caring, well-led and responsive to people’s needs. We are monitoring this service to make sure that the necessary improvements are secured.

Incidents

We found that incidents were not consistently graded.
Staff did not always report incidents in line with the trusts policy and procedure.
There was insufficient oversight of incident data from the management team within the trust.
Incident forms lacked meaningful data.

Nurse Staffing.

Across the Medical services division there remained significant shortfalls in nursing staff.
During the inspection we saw examples where this had impacted on the safety and quality of care patients received; for example patients waiting longer than expected to receive basic nursing care and medications.

Mental capacity and deprivation of liberty safeguards (DoLS)

Across the medical services departments, staff still 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 with staff, there was a limited understanding of the trust’s own policy regarding MCA and DoLS.
The application of both the MCA and DoLs at ward and department level remained inconsistent and in the majority of cases we inspected records that were unclear and incomplete.

Records

Records were not completed fully and were not secure

Assessing and responding to risk

The early warning scoring system in use at the trust was not always followed and observations were frequently delayed.
Risk assessments were incomplete and in some cases not completed.

In medical services:

The trust must ensure that records are securely stored, legible and completed fully.
The trust must ensure that patients with diabetes receive safe and effective care.
The trust must ensure that incidents are managed and reported in line with their own policy.
The trust must ensure that medications are managed appropriately and secured safely.
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 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 there is consistent categorisation of the same type of incident in the trust’s incident reporting system.

Professor Ted Baker

Chief Inspector of Hospitals

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

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

Stepping Hill Hospital is the main location providing inpatient care as part of Stockport NHS Foundation Trust. It provides a full range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, a neonatal unit, children and young people’s services, maternity services and a range of outpatient and diagnostic imaging services.

Stockport Foundation Trust provides services for around 350,000 people in and around the Stockport area with approximately 912 inpatient beds. In total, Stepping Hill Hospital has 833 inpatient beds.

We carried out an announced inspection of Stepping Hill Hospital on 19–22 January 2016 as part of our comprehensive inspection of Stockport NHS Foundation Trust.

Overall, we rated Stepping Hill Hospital as ‘Requires Improvement’. 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.

Our key findings were as follows:

Cleanliness and infection control

The hospital had infection prevention and control policies in place which were accessible to staff.
We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
‘I am clean’ stickers were used to inform staff at a glance that equipment or furniture had been cleaned and was ready for use.
Overall, patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines however some areas in the maternity suite were dusty such as emergency equipment, feet of chairs and some work surfaces. Monthly audits took place and those for September and October showed areas had been identified where furniture and fittings were marked and dust had accumulated. Actions taken included requests for new furniture, changes to cleaning regimes and additional cleaning records. Some of these measures had been put into place.

In the medical division hand hygiene audits were completed monthly and results showed varying compliance with an average compliance of 92.3% in July to 71.8% in October.2015 showing inconsistency and an overall downward trend

Also in the accident and emergency department we reviewed hand hygiene audit results for an eleven month period. This showed that for seven out of eleven months the department scored less than 90% in these audits that was less the Trust target.

Medicines management

In the Urgent and Emergency care department medications were not always securely stored and some patients experienced delays in receiving pain relief.
In the Critical Care unit there was a practice of pre-filling syringes with intravenous medicines and then storing them in the fridge which was left unlocked. This was not safe practice. We raised this with the trust at the time of our inspection and the practice was immediatley ceased.
In the paediatric unit during our unannounced inspection, staff medications were found to be stored within a cupboard with patient medication. On examination of the cupboard, codeine phosphate belonging to the trust was found in with staff’s own medications. This gave cause for concern that trust medications may be being taken for staff members’ personal use. Additionally this medication should have been securely stored.
The high-dependency unit fridge was running with a high temperature (15 degrees C) and had not been checked that day. This meant medications may not have been stored appropriately and as a result efficacy could be affected.

Nurse staffing

The hospital used a nationally recognised acuity tool to determine the number and skill staff required this was reviewed twice yearly.
Care and treatment were delivered by committed and caring staff who worked well together to provide patients with good services.
In the Urgent and Emergency care department the staffing levels required improvement. The expected day time shift for the department were 12 registered nurses and three health care assistants. These levels of staffing were not always met. In a four month period we found that 54 out of 121 shifts were short staffed by at least one registered nurse. In the same period we found that 42 of 121 shifts were short staffed by at least one health care assistant.
On two of the five days we visited the department the staffing establishment was lower than planned. On one day there was one less nurse and one less health care support worker than planned and on another day there was one less nurse.
Registered nurses were moved to other clinical areas on occasion, leaving the department short staffed. An incident reported by the department in October 2015 outlined that staff had been moved from the emergency department on three dates. This incident outlined that patients experienced delays in receiving treatment on one of these days due to staffing levels in the emergency department.
The matron told us that the expected ratio for staff to patients was one nurse to four patients in the major’s area and one nurse to two patients in the resuscitation area. We observed times when these ratios were not met. The nurse who was responsible for the patients placed in the corridor was observed caring for between eight and ten patients in the corridor. These patients were all awaiting trolley spaces in the majors or resuscitation area. This meant that there was double the number of patients to one nurse than expected at times.
There were a number of trained nurse vacancies across the medical service , these varied across wards with some wards being fully staffed , however some areas had significant vacancies, for example vacancy rates were 64% on the frail elderly unit.
Shortfalls were covered by bank and agency staff, however, this is not a sustainable position and nurse vacancy rates within the service were of concern.
Similarly staff turnover rates varied with the highest being 67% on the escalation ward.
Nurse staffing numbers within the paediatric services required improvement. Nurse staffing levels on the Treetops ward did not reflect Royal College of Nursing (RCN) standards and on the neonatal unit did not always meet standards of staffing recommended by the British Association of Perinatal Medicine (BAPM). The trust did not have a senior nurse, above band five, on 37 of 93 shifts from 14 December 2015 to 13 January 2016. Over the same timeframe the trust did not ensure there was a nursing staff member who was Advanced Paediatric Life Skills (APLS) trained on 12 of 93 shifts. From 14 December 2015 to 13 January 2016 the trust did not ensure there was a nursing staff member with HDU training on 14 of 93 shifts. On three of the shifts there was no staff member that was APLS or HDU trained.
For each shift on the paediatric ward one nurse was identified to go into the HDU should patients’ needs require HDU care. This member of staff was not always HDU trained.
BAPM guidance recommends there is a supernumerary co-ordinator on each shift in the neonatal unit. There was no supernumerary shift co-ordintaor on any shifts.
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 which had affected patient care.
In October 2015 19 midwifery day shifts and 12 night shifts were not filled with bank or agency staff. These shifts were then working with below the identified number of staff needed.
Birth rate plus acuity tool was used to assess the necessary staffing numbers for the maternity service. To assess the acuity on an ongoing basis the clinical lead midwife or the bleep holder for the service checked the roster for the service at 8am including any sickness then did a walk around the unit including the gynaecology ward, to ensure there were sufficient staff with the necessary skills and experience to meet the needs of the patients.
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 fill the 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 midwives 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. This met with safe staffing guidance.

Access and Flow

In December and January 2015 the hospital performed worse that the England average with 20% and 30% of patients respectively waiting between four and twelve hours to be admitted.
Data showed that the percentage of patients leaving Emergency and urgent care before being seen was consistently worse than the England average, apart from September 2014 where the hospital performed about the same as the England average and May 2015 where they performed better than the England average.
From July 2013 to July 2015, the total time patients spent in the emergency department (average per patient) was consistently higher than the England average. This means that on average patients spent more time in the emergency department at Stepping Hill Hospital that at other hospitals of a similar size across England.
There were 199 black breaches from November 2014 to October 2015. 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.
We observed the department lacked capacity to accommodate patients on all five days of our visit.
We observed patients being accommodated in the main corridor of the department during all five days of our visit. The time these patients were resident in the corridor ranged from ten minutes to just over two hours.

As a result of bed pressures medical patients were often placed on surgical wards In August 2015 there were 193 medical patients placed on surgical wards and 142 in September 2015.This meant that this group of patients were not always placed in areas best suited to their needs.
In addition patients experienced a number of moves during their stay. There were also examples of patients being moved across wards out of hours and some patients experienced one or more moves during their stay in hospital. Between October 14 to September 15 257 patients moved more than 4 times and 632 moved more than 3 times

This is not considered a positive experience for patients.

Leadership and Management

The senior team in the majority of core services were visible and accessible and well known to the staff.
However not all staff in the Urgent and Emergency care department could articulate the current strategy and vision for the service, however staff told us that they felt supported by their senior leaders.
Governance systems in the Maternity and Gynaecology had not identified several clinical issues we found. There was a lack of monitoring of performance against trust or national targets and therefore a lack of understanding of where improvements were necessary. Also there was no date of entry or review for risks on the divisional risk register for Maternity and Gynaecology services. Not all risks that had been identified were recorded.
Risks in the Urgent and Emergency care department were not always appropriately identified and monitored. Risks on the risk register were past their date for review and actions taken in response to these risks were not always evident.

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 spiker 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 of poor practice where the trust needs to make improvements.

Importantly, the Hospital must:

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 patient manual handling.

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 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 the trusts internal escalation policies are followed appropriately.

Ensure that there is an adequate policy or procedure to guide the practice of 'boarding' to ensure patient safety.
Ensure that all risks identified in relation to the emergency department are appropriately risk assessed and appropriate control measures are in place.

Medical Services

Ensure the agreed establishment of qualified nurses are employed an deployed in the medical division
Ensure patients are not transferred from ward to ward for none clinical reasons and out of hours

Critical Care

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

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

Children and Young People

Ensure there is a senior staff member on each shift on the paediatric unit.
Ensure there is a staff member that is HDU trained on each shift on the paediatric unit.
Ensure the door exit systems on the paediatric and neonatal unit are secure.
Ensure staff members’ medications are securely stored and do not include the trust’s generic medications.
Ensure that fridge temperatures are regularly checked, documented and acted upon in accordance with the trust’s policy and procedures.
Ensure all staff working with children and young people have level three safeguarding training.

In addition the hospital should:

Urgent and emergency care

Ensure that there is an adequate provision of equipment used for resuscitation in all areas of the emergency department.
Ensure patients are offered food and drinks where clinically advised by staff members
Ensure that staff within the emergency department receive their annual appraisals
Ensure that the care provided to patients presenting with sepsis is evidence based and in line with national and local guidance and ensure that this is reviewed and audited regularly.

Medical Services (Including Older People services)

Ensure that records trollies are kept locked when unattended to ensure they are not accessible to the general public.
Ensure hand hygiene rules are met by staff
Ensure patients receive care on a designated medical ward wherever possible

Surgery

Ensure the standardisation of defibrillators across the trust to comply with Resuscitation UK guidelines.
Enusre the procedures for checking of resuscitation equipment and whether this is now a daily or monthly check to ensure consistency between wards.
Ensure that all resuscitation trolleys are sealed at all times when not in use. They should also ensure that when they are checked and re-sealed the relevant unique reference number recorded for safety and audit purposes.
Ensure that there is compliance in with the medicines administration policy concerning the recording of wastage of controlled drugs that have not been used.
Ensure the policy regarding storage of IV medicines which are not in a recognised medicines cabinet, to ensure this complies with RPSGB guidance.
Ensure their policy and procedures concerning PGD and ensure staff awareness in light of new electronic prescribing practice.
Ensure that patient records are stored securely and cannot be accesses by non-designated persons.
Ensure steps to improve compliance with mandatory training and improve recording and accuracy of compliance are taken.
Ensure compliance with staff annual appraisal targets are achieved .

Critical Care

ensure that all staff receive training on the principles of Duty of Candour.
ensure that work continues to improve the access and flow in the department and improvements are made to the issue of delayed discharges.
ensure that nutritional supplements are not stored in the visitors kitchen
consider how it is going to meet the requirements of the latest health building notes guidance in any future expansion of the critical care service.

Maternity and Gynaecology

Ensure that improvement in the assurance that all emergency equipment is in full working order at all times.
Ensure input from the pharmacy department for the management of medicines on the maternity services.
Ensure there is a system in place to monitor improvements identified during through audits.
Ensure sufficient specialist midwifery cover to support patients with additional mental and physical health needs is provided.
Ensure I times against the national 2 week cancer referral to treatment targets areimproved .

Children and Young People

Ensure there is supernumerary co-ordinator on the neonatal unit in accordance with BAPM guidance.
Ensure there is a staff member with APLS training on each shift on the paediatric unit.

End of life care

Ensure that when audit results are sent to the business groups for actions these are consistently followed up. Issues with the completion of DNACPR forms had been highlighted in audits yet the completion of these continued to be variable in in quality.
Ensure that the actions in the audit that identified a risk in terms of lapsed syringe driver training is followed up and ensure all syringe driver training is up to date.
Ensure all risks affecting the provision of EOLC are identified on one risk register. Some risks identified by the service, for example the level of EOLC consultant cover, were not included on the risk register. This meant that potential risks may not be managed as effectively as they would if they were regularly reviewed.

Outpatients and diagnostic Screening

Ensure that number of overdue outpatient follow-up appointments, particularly in gastroenterology, are reduced.
Ensure that floor areas in outpatients B can be cleaned in line with HBN00-09 guidance for Infection Control in the Built Environment.
Ensure the staff groups requiring level three children’s safeguarding training in the Safeguarding Children Training and Competency Strategy is reviewed.
Ensure theprovision of sufficient car parking for patients at the Stepping Hill site is considered.
Ensure patient feedback about changes made to outpatient services as a result of complaints is considered.
Ensure participation in the Imaging Services Accreditation Scheme (ISAS) and the Improving Quality in Physiological Services (IQIPS) accreditation scheme

Professor Sir Mike Richards

Chief Inspector of Hospitals

This unannounced inspection visit took place on the evening of 1 July and during the day of the 2 July 2013. The inspection focused on the accident and Emergency Department (ED) and wards A1 and A3 which are acute medical units in order to evaluate the emergency care pathway.

As part of this inspection we spoke with Healthwatch who told us they had not received any concerns from the people regarding the areas of the hospital this inspection visit focused on. The inspection team spoke with people using the service, their relatives/ or visitors, staff and ambulance personnel.

All the patients we spoke with told us that their privacy and dignity had been respected. Patients and relatives/visitors told us that they had experienced high standards of care. One visitor told us 'The staff have been absolutely amazing.' People were positive about the care they had received and we were told us that all care needs had been met and decisions were made quickly and efficiently.

We found that staff were trained and supported in order to treat and care for patients. There were enough qualified, skilled and experienced staff to meet people's needs in the departments inspected.

There was an effective complaints system available. However it was not widely displayed.

Over the course of this inspection visit we saw that the ED experienced a higher than expected rate of patients seen in the department. The situation was managed to a high standard and patients experienced safe, appropriate and effective care.

During our inspection of Stepping Hill Hospital on 17 and 19 September 2012 we visited four wards: the MAU (Medical Assessment Unit), ward D2 (elective orthopaedics), ward E2 (medicine for older people ) and A11 (diabetes and endocrinology). During our visits we spoke with several patients on each of these wards and one visiting relative. As part of the inspection we also followed up action taken by the trust following our previous inspection in March 2012.

The patients we spoke with told us they were treated with dignity and respect. For example, one said; 'They close the curtain when they are talking to you in private or helping you. They don't patronise you or belittle you and they explain things well.' Another said; 'Everyone has acted properly and is respectful.' All said they were satisfied with the information they were given and that updates from nurses and doctors met their needs.

Patients we spoke with were also very positive about how their care and welfare needs were met. They told us that staff were kind and caring, looked after them well and helped them when they needed. None had any concerns about their care. For example one said; 'I am very satisfied and happy. I have all the help I need. I only have to ring and they come.' Another said; 'I am very happy with my care and can't speak highly enough of them all.' Another said; 'It's very good on this ward. I have no complaints whatsoever. Nothing is too much trouble for the staff.' And another; 'I have no issues with the staff at all. I want for nothing. They know what they are doing and they know the patients here.'

We spoke with patients on ward A11 and the MAU about their medicines. Overall patients we spoke with were very positive about how their medicines were handled. Comments they made included: 'kept well informed', 'they have explained everything to me', 'medicines all ok' and 'they have told me about my medicines.'

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We carried out this review because concerns had been raised with us by a number of people about the standard of care on the Medical Assessment Unit at the hospital. For this reason we focussed our inspection on this unit. We also visited two wards Medical short stay unit - male and Medical short stay unit- female.

We spoke to patients about their care when we visited Stepping Hill Hospital. Most people we spoke with were happy with their care. They told us they had not had to wait long to be seen by a doctor and they said they felt well cared for. Comments included: "It's been very good." " They've been great here. Everyone is very good."

We asked patients and their families how their medicines were managed at the hospital. Most of the people we spoke with said there had been no problems. They had got their medicines when they needed them.

Patients told us that staff were respectful and treated them with kindness and patience, maintaining their privacy and dignity.

Comments included 'Staff are brilliant, very kind and caring', 'they are very caring and tell you everything they are doing', 'if I need help I press the buzzer and they come as quickly as they can' and 'they always close the curtains when they use the hoist'.

Patients told us they enjoyed the food provided for them and staff helped people when needed.

Comments included 'The food is very good indeed for such a large hospital, always nice and hot. I get plenty of drinks between meals', 'They always tell you what is for lunch and they sit and help me cut up my food', 'the food is very tasty' and 'I have not felt like eating but they always try and tempt you with something'. One patient told us that although she did not need help herself she had noticed that staff helped others willingly and were very professional.

Overall throughout the inspection staff told us that following the original Dignity and Nutrition inspection, where shortfalls in practice were found, awareness of these essential standards had been raised across the trust. Staff told us they had reflected on practice and did feel that the increased focus had highlighted to them where improvements could be made. From our observations and from feedback from patients we were satisfied that the measures put in place for addressing the issues raised from our first inspection had resulted in improved outcomes for patients.

The majority of patients we spoke to felt they were treated with respect and dignity. Patients told us that for the most part staff explained any treatment and care they were receiving and made sure they understood what was happening. Patients said that staff put them at ease and comments included 'They (staff) are very caring' and 'Nothing is too much trouble for them'.

Prior to our visit we looked at information provided by patients on the NHS Choices website. There were six positive comments from NHS Choices relating to the respect and involvement experienced by patients between May and November 2010. These comments all praised the staff involved and the care received at the trust. One patient commented 'My dignity was respected at all times'.

The majority of patients that we spoke to were happy with the food provided at the hospital. We were told that a choice was always offered and that the food was presented well and served at the correct temperature. Most patients said that they never felt rushed and that staff offered the right level of support to ensure they enjoyed their meals. We asked patients what they thought of the meal they were eating on the day of our inspection and comments included 'good', 'tasty' and 'fine'. One patient who required a soft diet said they did not like their meal.

Stepping Hill Hospital

All Inspections

Other CQC inspections of services

28 September 2023

During an inspection looking at part of the service

1 to 2 November 2021

During an inspection looking at part of the service

24 Aug to 25 Aug 2020

During an inspection looking at part of the service

28 Jan to 27 Feb 2020

During a routine inspection

11 Sep to 4 Oct

During a routine inspection

22 – 23 June 2017

During an inspection looking at part of the service

Professor Ted Baker

21, 22 and 28 March 2017

During an inspection looking at part of the service

Professor Ted Baker

19-22 January 2016

During a routine inspection

Professor Sir Mike Richards

1, 2 July 2013

During a routine inspection

19 September 2012

During a routine inspection

22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

26 March 2012

During an inspection in response to concerns

16 November 2011

During an inspection looking at part of the service

4, 15 April 2011

During a themed inspection looking at Dignity and Nutrition