Stockport NHS Foundation Trust

St
Stepping
epping Hill Hospit
Hospital
al
Quality Report

Stepping Hill Hospital

Poplar Grove
Hazel Grove
Stockport
SK2 7JE
Tel:0161 483 1010 Date of inspection visit: 21, 22 and 28 March 2017
Website: [Link] Date of publication: 03/10/2017

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found
when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the
public and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Urgent and emergency services Inadequate –––

Medical care (including older people’s care) Requires improvement –––

1 Stepping Hill Hospital Quality Report 03/10/2017

 Summary of findings
Letter from the 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.

2 Stepping Hill Hospital Quality Report 03/10/2017

 Summary of findings
• 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 ([Link]) 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.

3 Stepping Hill Hospital Quality Report 03/10/2017

 Summary of findings
• 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.

4 Stepping Hill Hospital Quality Report 03/10/2017

 Summary of findings
• 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.
5 Stepping Hill Hospital Quality Report 03/10/2017
 Summary of findings
• 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

6 Stepping Hill Hospital Quality Report 03/10/2017

 Summaryoffindings
Summary of findings
Our judgements about each of the main services

Service Rating Why have we given this rating?

Urgent and Inadequate ––– We rated urgent care services as inadequate
emergency because:
services • Although we noted an improvement in the senior
nurse leadership in the service and found a more
open and positive culture there were still
significant issues which persisted from the last
inspection.
• There was poor infection control compliance
including patients not being isolated
appropriately, visibly soiled equipment and less
that 60% compliance with key audits.
• Duty of candour was delayed in some cases.
• There were low nurse staffing levels and low shift
fill rates of less than 50% at times. This also
included very high use of agency staff.
• There was a low compliance with the early
warning score system and poor management and
recognition of sepsis.
• Medicine management issues persisted which
included lack of security and delayed
administration.
• We found poor compliance with risk assessment
processes and patients were being held in
corridors on routine basis. There had been no
improvement to the arrangements to manage the
patients held in the corridor area. We found that
very unwell patients were being held there with
very little or no supervision this included patients
with cardiac issues and sepsis.
• The performance in relation to the 15 minute face
to face assessment, four hour standard and
ambulance handovers remained very poor and
had deteriorated since the last inspection. Black
breaches had increased fivefold from 199 in 12
months in the last inspection to 218 in one month
during this inspection.
• Clinical guidelines were not always followed and
we found occasions when this had negatively
impacted on patient outcomes.

7 Stepping Hill Hospital Quality Report 03/10/2017

 Summaryoffindings
Summary of findings
• The department had undertaken one national
audit since the last inspection and this showed
that they were not complaint with all four
standards looked at.
• Audit findings were not always actioned and
action plans were not always monitored.
• Patients were left in an undignified manner in the
corridor areas including having physical
examination in the corridor areas. Some patients
told us that they were humiliated by their
treatment.
• Medical staff did not always feel supported and
felt that their education and development
program was not sufficient.
• The viewing room for deceased patients had not
improved since the last inspection and remained
visibly soiled and clinical.
• We found that deceased patient’s property was
not treated in a sensitive manner and we found
bags of unlabelled property stacked up on the
floor in the viewing room.
• We observed very poor record keeping which we
saw negatively impact on patient care and safety,
including staff being unaware that a patient had
left the department until three hours later when
inspection team noted this.
• There was routine overcrowding and the
department consistently failed to meet the
department of health standard of seeing, treating
and discharging or transferring patients within
four hours.
• Some risks were not identified or mitigated
appropriately.
• Medical staff told us that concerns they raised
were not listened to or acted on.
However:
• Staff were knowledgeable about how to manage
safeguarding issues and we observed them acting
on safeguarding concerns appropriately.
• Equipment was checked regularly and appeared
to be in good working order.
• The paediatric department had improved their
safety since the last inspection.

8 Stepping Hill Hospital Quality Report 03/10/2017

 Summaryoffindings
Summary of findings
• Staff told us that since the new matron and nurse
consultant had been appointed, safety was more
of a priority and focus.
• Staff spoke positively about the newly appointed
matron and the changes she had implemented.
• Staff sought appropriate consent from patients
before delivering treatment and care.
• The department had a team of highly skilled and
competent nurse and medical staff.
• Appraisal rates were much improved from the last
inspection.
• Staff were observed to be treating patients with
compassion and dignity in their one to one
interactions with patients.
• Some patients spoke positively about the way
staff treated them.
• Staff were caring and compassionate in their
approach to patient care.

Medical Requires improvement ––– We rated this service as requires improvement

care because:
(including • The trust had not responded appropriately to the
older risk expressed to them at our last inspection
people’s regarding the security of patients’ records.
care) • The trust regularly moved their own staff and had
a heavy reliance on agency and bank staff,
resulting in inappropriate skills mix and staff
feeling they were nursing in wards where they did
not have the required competence to care for
patients.
• Decisions to move nursing staff were made on
clinical judgment without a clear guidance
document or minimum set standards.
• Records completion was not in accordance with
best practice guidance.
• Incident reports did not have consistent
categorisation for the same type of incident.
• Infection protection audits showed low levels of
compliance with the trust’s policy. At the time of
reporting action plans to address this were not
provided.
• Safeguarding training levels for staff were not in
accordance with the trust’s own policy or best
practice guidance.
• There was a lack of consistency in how people’s
mental capacity was assessed and not all

9 Stepping Hill Hospital Quality Report 03/10/2017

 Summaryoffindings
Summary of findings
decision-making was informed or in line with
guidance and legislation. Decision-makers did
not always make decisions in the best interests of
people who lack the mental capacity to make
decisions for themselves, in accordance with
legislation. Restraint and deprivation of liberty
were not always recognised or less restrictive
options used where possible. Applications to
authorise a deprivation of liberty were not always
made appropriately or in a timely manner to the
Court of Protection or by using the Deprivation of
Liberty Safeguards.
• Due to staffing pressures, patients’ dignity was
not consistently maintained.
• The arrangements for governance and
performance management did not always
operate effectively.
• Risks, issues and poor performance were not
always dealt with appropriately or in a timely way.
The risks and issues described by staff do not
consistently correspond to those reported to and
understood by leaders.
• In view of the expenditure for agency staffing, the
sustainable delivery of quality care was put at risk
by the financial challenge.
However:
• Staff understood their responsibility to report
incidents.
• Staff were aware of the duty of candour and their
obligations regarding this.
• All areas we inspected were visibly clean and tidy.
• Throughout our inspection, in most wards we
visited, we did not identify any major
environmental risks or hazards.
• Safeguarding policies and procedures were in
place and staff knew how to refer a safeguarding
issue to protect adults and children from abuse.
• Medicine storage was secure and accurate logs
and records maintained.
• Since the last inspection, the service had
achieved JAG Accreditation for their endoscopy
services.
• Patients’ nutritional status and dietary needs
were assessed using a recognised assessment
tool.

10 Stepping Hill Hospital Quality Report 03/10/2017

 Summaryoffindings
Summary of findings
• Multidisciplinary team (MDT) working was
established on the medical wards. We saw good
examples of MDT working on all of the wards and
units we visited.
• Staff offered kind and considerate care to patients
and those close to them. We saw that for most
patients, privacy and dignity was maintained and
that most patients’ needs were appropriately
met. 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 all staff disciplines,
and staff were sensitive and compassionate in
supporting patients and those close to them
during difficult and stressful periods.
• .In geriatric medicine, the service was above the
England average for admitted RTT (percentage
within 18 weeks).
• There was a clear statement of vision and values,
driven by quality and safety. It had been
translated into a credible strategy with
well-defined objectives that were regularly
reviewed to ensure that they remain achievable
and relevant.
• The vision, values and strategy had been
developed through a structured planning process
with regular engagement from internal and
external stakeholders, including people who use
the service, staff, commissioners and others
• The trust’s staff in all areas knew and understood
the vision, values and strategic goals.

11 Stepping Hill Hospital Quality Report 03/10/2017

 St
Stepping
epping Hill Hospit
Hospital
al
Detailed findings

Services we looked at
Urgent and emergency services; Medical care (including older people’s care)

12 Stepping Hill Hospital Quality Report 03/10/2017

 Detailed findings
Contents

Detailed findings from this inspection Page

Background to Stepping Hill Hospital 13
Our inspection team 13
How we carried out this inspection 13
Facts and data about Stepping Hill Hospital 14
Our ratings for this hospital 14
Findings by main service 15
Action we have told the provider to take 58

Background to Stepping Hill Hospital

Stepping Hill Hospital is the main location providing During this inspection we inspected the accident and
inpatient care as part of Stockport NHS Foundation Trust. emergency department and medical care services at the
It provides a full range of hospital services including hospital that provide care and treatment for a wide range
emergency care, critical care, a comprehensive range of of medical conditions, including general medicine,
elective and non-elective general medicine (including cardiology ,respiratory and gastroenterology and a
elderly care) and surgery, a neonatal unit, children and specialist stroke centre serving the south of Greater
young people’s services, maternity services and a range Manchester. The hospital also provides surgical services,
of outpatient and diagnostic imaging services. critical care services, maternity and gynaecology services,
paediatric services, end of life care (EOLC) and a range of
Stockport Foundation Trust provides services for around
outpatient and diagnostic services which were not
350,000 people in and around the Stockport area with
inspected as part of this inspection.
approximately 912 inpatient beds. In total, Stepping Hill
Hospital has 833 inpatient beds.

Our inspection team

Our inspection team was led by: Inspection The team consisted of an inspection manager three CQC
manager Wendy Dixon, Care Quality Commission inspectors and a variety of specialists, including a
Consultant Physician, Clinical Nurse Specialist,
Emergency Department nurse specialist and a senior
Emergency Department doctor

How we carried out this inspection

To get to the heart of patients’ experiences of care, we • Is it effective?
always ask the following five questions of every service
• Is it caring?
and provider:
• Is it responsive to people’s needs?
• Is it safe?

13 Stepping Hill Hospital Quality Report 03/10/2017

 Detailed findings
• Is it well-led? patients and interviewed staff from the ward areas and
the accident and emergency department we visited. We
The inspection team inspected the following core
observed how people were being cared for, talked with
services at Stepping Hill Hospital:
carers and/or family members, and reviewed patients’
• Urgent and Emergency Department records of personal care and treatment. We would like to
• Medical care (including care older people's care) thank all staff, patients, carers and other stakeholders for
sharing their views and experiences of the quality of care
Following the unannounced inspection, we reviewed a
and treatment at Stepping Hill Hospital
range of information we held about the hospital and
requested further data from the Trust. We talked with

Facts and data about Stepping Hill Hospital

Urgent and emergency services at Stepping Hill Hospital From March 2016 – February 2017 the trust had 89,659
saw approximately 96,217 patients between January medical admissions including day case admissions.
2016 and January 2017. Approximately 32% of these 28,390 of these admissions were from the emergency
patients were admitted to hospital, this was above the department. This averaged 7,472 admissions per month
England average of 22.2%. The department is open 24 and with the exception on November 2016, remained
hours a day, seven days a week and provided treatment around that average figure month on month.
and care for children and adults. The department saw
There are a total of 833 beds at the hospital and serves a
21,147 children during this time period. There was a
population of 350,000 people.
resuscitation area, examination rooms and a waiting
area. There is also a self-contained children’s area.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergency Requires Requires Requires

Inadequate Inadequate Inadequate
services improvement improvement improvement
Requires Requires Requires Requires
Medical care Inadequate Good
improvement improvement improvement improvement
Requires
Overall Inadequate N/A N/A N/A N/A
improvement

14 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
Safe Inadequate –––

Effective Requires improvement –––

Caring Requires improvement –––

Responsive Requires improvement –––

Well-led Inadequate –––

Overall Inadequate –––

Information about the service Summary of findings

Urgent and emergency services are provided at Stepping
We rated urgent care services as inadequate because:
Hill Hospital. The Emergency Department (ED) at
Stepping Hospital is open 24 hours a day, seven days a • Although we noted an improvement in the matron
week, providing emergency and urgent care and level of leadership in the service and found a more
treatment for children and adults, across Stockport and open and positive culture there were still significant
wider Manchester area. issues which persisted from the last inspection and
safety remained not a sufficient priority.
The department saw approximately 21,147 patients
• There was poor infection control compliance
between January 2016 and January 2017. Approximately
including patients not being isolated appropriately,
32% of these patients were admitted to hospital, this was
visibly soiled equipment and less that 60%
above the England average of 22.2%.
compliance with key audits.
The Emergency Department consists of a four trolley • Duty of candour was delayed in some cases.
resuscitation area, 19 major’s trolleys, a three cubicle • There were low nurse staffing levels and low shift fill
hyper acute stroke area, one sub-wait area and four rates of less than 50% at times. This also included
examination rooms. very high use of agency staff.
• There was a low compliance with the early warning
There is a self-contained children’s ED (consisting of 3
score system and very poor management and
cubicles) and a minor’s stream which is run by enhanced
recognition of sepsis.
nurse practitioners seven days a week between 07:30am -
• Medicine management issues persisted which
00:00am.
included lack of security and delayed administration.
As part of our inspection we visited the emergency • We found poor compliance with risk assessment
department for an unannounced inspection on 21, 22 processes and patients were being held in corridors
and 28 March 2017. We spoke with patients and relatives, on routine basis. There had been no improvement to
observed care and treatment and reviewed 18 records, the arrangements to manage the patients held in the
including observation charts, medication charts and full corridor area. We found that very unwell patients
care records. We spoke with a range of staff at different were being held there with very little or no
grades including nurses, doctors, health care assistants, supervision this included patients with cardiac issues
reception staff, ambulance staff, senior managers and and sepsis.
matrons. • The performance in relation to the 15 minute face to
face assessment, four hour standard and ambulance

15 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
handovers remained very poor and had deteriorated • Equipment was checked regularly and appeared to
since the last inspection. Black breaches had be in good working order.
increased fivefold from 199 in 12 months in the last • The paediatric department had improved their safety
inspection to 218 in one month during this since the last inspection.
inspection. • Staff told us that since the new matron and nurse
• Clinical guidelines were not always followed and we consultant had been appointed, safety was more of a
found occasions when this had negatively impacted priority and focus.
on patient outcomes. • Staff spoke positively about the newly appointed
• The department had undertaken one national audit matron and the changes she had implemented.
since the last inspection and this showed that they • Staff sought appropriate consent from patients
were not complaint with all four standards looked at. before delivering treatment and care.
• Audit findings were not always actioned and action • The department had a team of highly skilled and
plans were not always monitored. competent nurse and medical staff.
• Patients were left in an undignified manner in the • Appraisal rates were much improved from the last
corridor areas including having physical examination inspection.
in the corridor areas. Some patients told us that they • Staff were observed to be treating patients with
were humiliated by their treatment. compassion and dignity in their one to one
• Medical staff did not always feel supported and felt interactions with patients.
that their education and development program was • Some patients spoke positively about the way staff
not sufficient. treated them.
• The viewing room for deceased patients had not • Staff were caring and compassionate in their
improved since the last inspection and remained approach to patient care.
visibly soiled and clinical.
• We found that deceased patient’s property was not
treated in a sensitive manner and we found bags of
unlabelled property stacked up on the floor in the
viewing room.
• We observed very poor record keeping which we saw
negatively impact on patient care and safety,
including staff being unaware that a patient had left
the department until three hours later when
inspection team noted this.
• There was routine overcrowding and the department
consistently failed to meet the department of health
standard of seeing, treating and discharging or
transferring patients within four hours.
• Some risks were not identified or mitigated
appropriately.
• Medical staff told us that concerns they raised were
not listened to or acted on.
However:
• Staff were knowledgeable about how to manage
safeguarding issues and we observed them acting on
safeguarding concerns appropriately.

16 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
It remained that the corridor was not equipped with the
Are urgent and emergency services safe? same equipment you would find in a designated
emergency department space including a lack of piped
Inadequate ––– oxygen and suction and monitoring equipment, which
may have been required in an emergency situation. We
We rated the Emergency and urgent services at Stepping raised this during the last inspection in January 2016
Hill as inadequate in relation to safe because: and found that this had not been improved or
progressed since the last inspection.
• There had not been sufficient progress to address safety • We identified five patients who were acutely unwell and
concerns from our last inspection. Safety was still not a were accommodated in the corridor.
sufficient priority • Training levels provided by the trust showed that 20.5%
• Early warning scores (EWS) designed to identify patient of clinical staff working in the emergency department
who were deteriorating, were not completed in line with had undertaken level 3 safeguarding children training.
the trusts protocol in all cases we reviewed. • We found that the documentation of nursing care
• The recognition and management of sepsis remained remained an issue from the last inspection. We found
unsatisfactory for the service following the findings of that some patients did not have any nursing records
the last inspection. We reviewed two patients with completed apart from their triage section. One of these
suspected sepsis and found that neither patient had patients was being treated for a serious infection and
received care in line the trusts own policy. was awaiting an inpatient bed. The patient approached
• The trust sepsis audit for the last twelve months showed us and asked what their plan of care was. When we
that less than 60% of patients with a diagnosis of sepsis approached staff and asked them; they were unaware of
received antibiotics within one hour of presentation. where the patient was located and could not tell us
• We found that infection control and prevention what the patient’s plan of care or progress was.
remained an issue within the adult department. We • In another case we found an empty cubicle space with
observed that trolleys and cubicles were not always an intravenous line still on the trolley stand with a
cleaned between patients use and the sluice room was cannula attached. Staff were unable to locate the
found in visibly soiled state. patient and there was confusion over where the patient
• Infection control audit results were below expected had gone. We were informed the next day that the
levels and significantly so in some areas including the patient had in fact been discharged but this was not
management of intravenous cannulas which scored an documented in their records.
average of 50% compliance against a target of 90%. • The department used an electronic board which was
• We found that patients were not always isolated when not always updated with the correct patient locations.
they had a suspected communicable infection. We found three patients in the corridor areas of the
• We found that medications security still remained an department who had been moved location. The
issue although this had improved significantly since the patient’s location had not been changed on the board
last inspection. We found some tablets and fluids left and therefore staff were unaware of where patients were
out on side in resuscitation room and drawer system to located.
secure medications was found to open and accessible • Nurse staff remained an issue from the last inspection;
on two occasions. shift fill rates for nursing staff were consistently below
• Patients were not always seen quickly by a nurse or 80%.
doctor when they initially presented to the department • There was a reliance on agency and bank staff which
for triage. For the period January 2016 to March 2017, was unsustainable in the longer term.
the department’s median performance against this
standard was longer than 15 minutes for all months in However:
relation to both ambulance handovers and walk in • Staff were knowledgeable about how to manage
patients. safeguarding issues and we observed them acting on
• We observed patients were still being accommodated in safeguarding concerns appropriately.
the main corridor of the department on a regular basis.

17 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• Equipment was checked regularly and appeared to be in • Staff were aware of duty of candour which is a legal duty
good working order. for hospital, community and mental health trusts to
• The paediatric department had improved their safety inform and apologise to patients if there have been
since the last inspection. mistakes in their care that have led to significant harm.
• There were appropriate major incident plans in place We found that duty of candour was considered and
and staff were knowledgeable about these. exercised as part of incident investigations. However in
• Staff told us that since the new matron and nurse one serious incident we found that duty of candour had
consultant had been appointed, safety was more of a not been exercised for over twelve months after the
focus. However they had been in post a short time and incident.
significant safety issues persisted.
Safety thermometer – need more data around
Incidents avoidable harm
• All staff had access to the trust wide electronic incident • The NHS safety thermometer is a national improvement
reporting system. Staff were aware of what type of tool for measuring, monitoring and analysing avoidable
incidents they should report and were able to show us harm to patients and ‘harm free’ care. Performance
how they would report an incident. Staff told us that against the four possible harms; falls, pressure ulcers,
they did receive feedback from the Matron or nurse catheter acquired urinary tract infections (CAUTI) and
consultants on all incidents they raised. Staff told us blood clots (venous thromboembolism or VTE), was
that they felt more involved in incident investigations monitored on a monthly basis.
since this last inspection in January 2016. • The Emergency Department were not recording and
• Serious incidents were reported through the Strategic monitoring data in line with this initiative.
Executive Information System (STEIS). Seventeen
Mandatory training
serious incidents were reported to STEIS between
February 2016 and February 2017. We reviewed three • Staff told us that they were encouraged to attend
root cause analysis investigation reports pertaining to mandatory training and that the Matron prompted them
incidents during this period. We found that two of these when their training was due to expire.
were comprehensive and identified learning points • The uptake levels for mandatory training varied across
where appropriate. In one case we found that the levels with most subjects having a lower level of uptake
investigation was not comprehensive and did not than the trusts target.
identify learning points. In all three cases we found that • Only 81% if staff had undertaken the safe use of insulin
some actions lacked due dates, were past their due date mandatory training which was below the trusts target of
and had not been updated. 90%. As was medicines management training levels
• Learning from incidents was shared with staff on a one which were 84%.
to one basis by the medical and nursing management • Staff were required to undertake basic life support once
team. Key issues arising from incidents were also yearly which equipped them with the skills to undertake
discussed within the monthly governance meeting. resuscitation procedures if required. The training level
• Strategic data from the service showed that staff for basic life support was well below the 90% target at
reported 728 incidents for the service between February 74%. This meant that 26% of staff working in the
2016 and February 2017. Of these 34 incidents were emergency department did not have the up to date
reported as occurring in the paediatric area and 18 skills to undertake basic life support and resuscitation
incidents occurred in the clinical decision unit. The procedures. However this was an improvement on the
highest category of incidents was the identification of compliance levels during the last inspection.
pressure ulcers which had been acquired prior to • The training rate for venous thromboembolism
patient’s attendances. The second highest reporting recognition and management was also below the target
category was medication incidents, which accounted for of 90% at 67%. However this was an improvement on
52 incident reports. the compliance levels during the last inspection.

18 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• However training rates for fire safety, health and safety parents should undertake training at level 3. Therefore
and manual handling were all above the trusts target of the service was not meeting this national guidance as
90%. they were providing care and treatment for children on a
• We requested information relating to how many staff daily basis.
had up to date advanced life support, advanced trauma • Staff were able to explain the application of the law and
life support and advanced paediatric life support. The their responsibilities in relation to female genital
trust did not provide this information. mutilation. There was also clear guidance available in
the emergency department in relation to this subject.
Safeguarding
Staff gave us examples of when they had suspected
• The emergency department records contained a female genital mutilation and told us how they had
safeguarding trigger area to prompt staff to consider acted on this.
safeguarding issues. We reviewed eight children’s • Staff were knowledgeable about child exploitation and
records specifically in relation to the safeguarding trafficking and considered this as part of their patient
trigger part of record and found that all eight records assessments.
had the safeguarding trigger section correctly • Staff considered domestic violence in their patient
completed. In one of these cases a safeguarding issue assessments and were aware of signs and indicators of
was identified by staff and we observed that they acted domestic violence.
on this appropriately and took all relevant steps to • Staff told us they received feedback from all
safeguard the young person in question. We reviewed 11 safeguarding concerns and referrals they raised. This
adults specifically in relation to the safeguarding trigger was cascaded from the trust safeguarding team to
part of record and found that all 11 records did not have frontline staff and their managers
this section completed. • The trust had safeguarding policies and procedures in
• Safeguarding training formed part of the trust’s place. Staff were aware of how to refer a safeguarding
mandatory training programme. Data provided by the issue to protect adults and children from suspected
trust showed that there was compliance with abuse. Staff showed us how they would access the trust
safeguarding training for nursing staff in urgent and intranet page relating to safeguarding and the trust had
emergency care services. Compliance with training for an internal safeguarding lead and team who could
safeguarding adult’s level 1 was 91% which was higher provide guidance and support to staff in all areas. Staff
than the trust’s target of 90%. However safeguarding were able to name this lead and told us that they were a
adult’s level 2 training was lower than the trusts target at visible presence and a good source of support.
83%. In addition, the compliance level for safeguarding
Cleanliness, infection control and hygiene
children level 1 was 95% which was above the trusts
target however the compliance level for level 2 • The training uptake levels for both levels of mandatory
safeguarding children was below the trusts target at training in infection control and prevention for staff
88%. working in the department were above the trusts target
• Data provided by the trust showed that 20.5% of staff of 90%.
working in the emergency department had undertaken • We observed that cubicles and trolley spaces were not
level 3 safeguarding children training. The percentage of always cleaned between uses during busy periods.
paediatric nurses working in the department who had However during less busy times we did observe staff
undertaken this training was higher at 86%. The cleaning trolleys and cubicle spaces.
intercollegiate document ‘Safeguarding children and • We found that the decontamination room which was
young people: roles and competencies’ (2014) sets out also used a deceased viewing room was still visibly
the levels of competencies and training required for staff soiled. This was despite highlighting this to the trust
working with children and young people. This during our last inspection in January 2016.
document states that all staff that assess, plan, • Staff were observed using personal protective
intervene and evaluate care with children and their equipment, such as gloves and aprons and changing

19 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
this equipment between patient contacts and we saw • We also noted during this inspection of the sluice room
staff washing their hands using the appropriate that commodes were visibly soiled with yellow and
techniques. We saw that staff followed the 'bare below brown stains. They also did not have ‘I am clean’ stickers
the elbow' guidance. attached which the trust uses to ensure staff knew when
• There was adequate access to hand washing sinks and an item is clean and ready for use. We also found a bed
hand gels. pan underneath a sink in the room with yellow fluid
• We reviewed hand hygiene audit results for a six month present. We highlighted this to the management team
period. These showed an average compliance over this and when we returned the next day and on our
period which was lower than expected by the trusts at unannounced visit we found that the commodes were
68.8% against a standard of 90%. We also reviewed the visibly clean and labelled with ‘I am clean’ stickers.
environmental and clinical practice infection control
Environment and equipment
audits for the same period and these showed that the
department performed well below the expected • Equipment in all areas of the department appeared well
standard with an average score of 52% against the 90% maintained with up to date portable appliance testing
standard. stickers where appropriate.
• The service also undertook audits which looked at how • There was a maintenance schedule which was
well the infection control and prevention measures in facilitated by the trust wide maintenance team.
relation to indwelling devices were managed. For both • Staff told us they had easy access to the equipment they
the urinary catheter and cannula care audits the service needed to care for patients. However when we reviewed
scored significantly below the expected standard for the incident report records we found that here were
same six month period with a compliance rate of 50% numerous occasions when patients encountered delays
against the 90% standard. in receiving important medications due to lack of
• The department undertook early screening for availability of infusion pumps.
infections including MRSA and CPE during patient • Records indicated that staff carried out regular checks
admissions. This meant that staff could identify and on key pieces of equipment. Emergency resuscitation
isolate patients early to help prevent the spread of equipment was in place and records indicated it had
infections. We observed that this was routinely been checked daily, with a more detailed check carried
undertaken even during busy periods. out weekly as per the hospital policy.
• There were appropriate facilities including three • There were arrangements in place for the handling,
individual rooms to isolate patients with a suspected storage and disposal of clinical waste, including sharps.
infection. However we found that one patient who had On two days of the inspection we observed that there
presented with vomiting and diarrhoea was not isolated were sharps disposed of in a bin which was not
appropriately. This patient had been in the department designed for their disposal and did not have a lid. This
for over eight hours and staff had not noted that they posed a risk of injury and communicable disease
required isolation. The patient was allocated a bed on transmission to staff working in the department. We
an inpatient ward which was not isolated and the highlighted this to the management team immediately.
receiving ward had not been informed by the • There was an x-ray department situated next to the unit
department that the patient had vomiting and for easy access which also provided portable x-rays.
diarrhoea. • Security staff were available on site 24 hours a day and
• We observed on one day of the inspection during a very were able to be contacted by telephone, if required.
busy period that the sluice room did not have a lock on Staff also had an emergency alarm which they could
the door. When we entered we found a bottle of half full activate in the event of an emergency which alerted
whiskey and numerous cleaning fluids in unlocked security wherever they were in the hospital.
cupboards and on shelves in this room. Some of these • In the paediatric area the facilities were very well
fluids were toxic and could be very harmful if ingested. maintained and segregated securely from the adult
We highlighted this to the management team who acted department.
immediately and ensured the room was fitted with a • Appropriate equipment was available in all clinical areas
lock within two hours. in the paediatric area including all equipment which
20 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
could be required specifically for children. Equipment area in a locked room and three were situated in a
was checked regularly and we reviewed the records for locked medication preparation room. We found that the
these checklists for a four week period and all checks fridges in the paediatric area and the medication
were fully completed for the period. preparation area were locked securely when checked on
• The admission route for patients was set up so patients all days of the inspection. We found the fridge in the
arriving by ambulance were seen and triaged in a resuscitation area unlocked on the first day of
designated cubicle area by a designated ambulance inspection. We highlighted this to senior staff in the
triage nurse. However this area was frequently full to department and found that on subsequent days this
capacity and patients were therefore triaged in the fridge was locked. All other fridges were found to be
corridor area. securely locked.
• We found that the daily checks required for the fridges in
Medicines
the emergency department were undertaken for all days
• An electronic storage system was used to store and in a one month period.
dispense medicines in the major’s area of the • Patient Group Directives (PGDs) were in use and there
department. Access to this system was secure and was a procedure in place to review them. PGDs are
required fingerprint and swipe access. We observed two written instructions which allow specified healthcare
occasions when the drawer system was left slightly open professionals to supply or administer a particular
and therefore left open access to medication stored in medicine in the absence of a written prescription. PGDs
this system. were being used by the triage nurses and emergency
• There had been 52 incidents relating to the nurse practitioners in the minor’s area to support
management of medicines reported for the department patient access to medicines in a timely way.
in the 12 months prior to the inspection. This was the • Controlled drugs were stored appropriately in locked
second highest category of incidents within the service. cupboards in line with legislation on the management
• Staff told us that the system for administering and of controlled drugs. Records showed that these
prescribing medications for patients allocated inpatient medications were checked on a daily basis. Controlled
beds was unsafe. The department operated an drugs require additional checks and special storage
electronic system of prescribing which did not transfer arrangements because of their potential for abuse or
to the main hospital electronic prescribing system. addiction and also require clear and precise
Therefore the inpatient teams reviewing patients in the documentation of any wastage. We found that staff
department would complete a paper based prescription undertook appropriate checks when administering
chart. This meant that there was the potential for errors controlled drugs and documented the administration
and double dosing of medications. It also meant that and checking appropriately.
staff working on inpatient wards could not access • An audit undertaken in 2016 which looked at the
records to inform them as to what medications patients management of controlled drugs found that in the
had received in the emergency department. We resuscitation area of the department there were three
highlighted this as a risk to the trust during our last areas for improvement in relation to the reconciliation
inspection and we were assured that this would be of controlled drugs. These were relating to
addressed. We found that there had been modest documentation which was required when stock was
progress to improve this risk. A corporate risk received and the area was found not to have a stock list
assessment had been undertaken in relation to these of controlled drugs. We requested the action plan in
issues which recognised the risks and put in place some response to this audit and it was not provided.
actions to mitigate against those risks. There were also • We also found oral medication left out on the side in the
plans to introduce the electronic patient which will align resuscitation area on one occasion. The medications on
the department with ward based prescribing. the side included medication for cardiac problems and
• There were five fridges which were used to keep epilepsy which could; if taken inadvertently or by the
medications in the department. One was situated in the wrong patient cause they harm. We highlighted this to
resuscitation area which was locked using a padlock in staff who rectified the issue immediately.
an openly accessible area, one was in the paediatric
21 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
• In the adult department we found that all oral liquid for the documentation of a discharge plan with 100% of
medications were correctly labelled with an opened records reviewed meeting these criteria for the six
date. In the paediatric department we found that four month period. The documentation of pain scores was
bottles of liquid medication did not have apart from one also above the expected target for 11 out of 12 months
bottle of morphine sulphate which did not have an audited. However there were areas which scored lower
opened date documented. than the expected range including the documentation
• Medications brought into the hospital by patients and of a nursing assessment which scored below the 90%
their relatives were stored securely. We had raised an standard on seven out of 12 months audited. For two of
issue relating to this with the trust during the last these months the score was below 50% and for the last
inspection in January 2016. We found that the five months prior to the inspection the service had
department had improved in this area and we found scored 80% on each month consecutively.
that patient’s medications were stored in the designated • Some paper records were left unsecured in pigeon holes
green bag system at all times. in front of the nursing station and were mixed together.
• We found that medications which required a double These records were accessible to staff, patients and
check and signature by two nurses were not always members of the public. We raised this with the
completed correctly. We reviewed four records which department management team and they arranged for
showed that medications including controlled drugs records to be separated in these pigeon holes but they
and intravenous antibiotics had been signed to state were still left unsecured and accessible to members of
that a staff member had administered them but the the public attending the department.
second check signature was completed sometime • The nursing records section of the electronic notes
afterwards in some cases hours later. system contained important prompts for staff to
• There were appropriate processes in place for ordering document that patients had been assessed and
medications and stock reconciliation. received care. We found that some patients did not have
• Discharge medications and prescriptions were managed any nursing records completed apart from their triage
well. Prescriptions for these medications were section. One of these patients was being treated for a
completed legibly and records for take home serious infection and was awaiting an inpatient bed. The
medications were amended accordingly. Discharge patient approached us and asked what their plan of
notifications were provided to patients and to their GPs care was. When we approached staff and asked them;
where appropriate. they were unaware of where the patient was located
• Guidelines on the use and preparation of medication and could not tell us what the patient’s plan of care or
were readily available including specific guidelines for progress was.
children in the paediatric area of the department. • In another case we found an empty cubicle space with
an intravenous line still on the trolley stand with a
Records
cannula attached. We asked staff where the patient was
• The department used electronic, computer based and they were initially unable to tell us as the records
patient records and very few paper records. Electronic were not up to date. After 30 minutes of attempts by
records were secure, restricted to authorised access and staff to locate the patient we were informed that they
easily accessible to authorised staff via the ED computer had been admitted to an admissions ward. Two hours
system. later we found that the patient had not arrived at the
• The matron for the department undertook weekly and admissions ward and was unable to be located. We
monthly record reviews in the form of nursing care raised this with the management team immediately
indicators. These indicators showed a mixed rate of who began investigations to locate the patient. We were
compliance across the six month period prior to our informed the next day that the patient had in fact been
inspection. These indicators covered a range of discharged but this was not documented in their
documentation areas within the emergency care record, records.
these included pain score documentation, nursing • The department used an electronic board which was
documentation, risk assessment completion and not always updated with the correct patient locations.
documented discharge plan. The service performed well We found three patients in the corridor areas of the
22 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
department who had been moved location. The previous year’s total number. Black breaches occur
patient’s location had not been changed on the board when the time from an ambulance’s arrival to the
and therefore staff were unaware of where patients were patient being handed over to the department staff is
located. greater than 60 minutes.
• An early warning score (EWS) system was in use in the
Assessing and responding to patient risk
department. The EWS system was used to monitor a
• Patients who self-presented to the department were patient’s vital signs and identify patients at risk of
seen by one of two receptionists and were booked in deterioration and prompt staff to take appropriate
and directed to the waiting room where they were action in response to any deterioration. Staff carried out
triaged by a nurse. monitoring in response to patients’ individual needs to
• Patients arriving by ambulance were alerted to the identify any changes in their condition quickly. Patient’s
ambulance triage paramedics working for the trust and observations and EWS were monitored using an
triaged in a designated ambulance triage cubicle. electronic system which alerted staff when observations
• The trust used a recognised triage system for the initial were outside of accepted parameters and were due to
assessment of all patients. Triage ensures that patients be repeated.
are directed to the appropriate part of the department • In all cases we reviewed we found that observations
and seen in a specified time frame decided by their were not completed in line with the trusts EWS
clinical condition. Serious life-threatening conditions guidance. In some of these cases there were significant
are also identified or ruled out so that the appropriate delays of up to two hours in taking observations.
care pathway can be commenced without delay. • In one case a patient had presented with sepsis. This
• The Royal College of Emergency Medicine (CEM) patient had an early warning score of 7 which should
recommends that a face to face assessment of patients have prompted continuous monitoring and
should be carried out by a clinician within 15 minutes of observations repeated within 15 minutes. The
arrival or registration. This is to ensure that any potential observations were not repeated for one hour and 20
life threatening conditions are identified and acted on minutes. The trusts sepsis action tool stipulates that
as quickly as possible. For the period January 2016 to observations should be undertaken at one hour
March 2017, the department’s median performance intervals at a minimum if sepsis is suspected. This was
against this standard was longer than 15 minutes for all not met for the patient on three occasions and when the
months in relation to both ambulance handovers and patients observations were repeated after one hour 30
walk in patients. minutes on one occasion the patients’ blood pressure
• The data relating to walk in patients showed that in this had significantly dropped and they required fluid
twelve months period the average time from arriving to resuscitation.
initial assessment was over 35 minutes for all months. • During the last inspection in January 2016 we found
For seven out of 12 months the average time exceeded that the department was not managing sepsis
45 minutes and for two months this time exceeded one adequately. We instructed the trust to improve on this
hour. area.
• The data relating to ambulance arrivals showed that for • During this inspection we found that the department
11 out of 12 months in this same period the time from had a sepsis pathway in place and based on best
arriving to initial assessment was over 20 minutes and in practice and national guidelines. The electronic system
two of these months the time exceeded 30 minutes. prompted staff to consider sepsis and contained
• During the last inspection we reported that there had guidance on actions required in response to this
been 199 black breaches between October 2014 and condition. We reviewed two patients with signs of
November 2015. We found that data showed that the sepsis.
number of black breaches had increased significantly. • One patient displayed signs of sepsis at triage and
This data showed that for eight out of 12 months the displayed two red flags. Despite this the sepsis
number of black breaches exceeded 50 per month. For
one of these months (January 2017) the number of
black breaches was 218 which were higher than the
23 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
screening tool and pathway was not completed for the we reviewed for patients being held in the corridor,
patient. They later received the diagnosis of sepsis. This there was no documented intentional rounding
patient did not receive care in line with the trusts sepsis undertaken. One of these patients had been in the
action tool. department for over two hours.
• The second patient had displayed two signs of sepsis • We identified five patients who were acutely unwell and
and according to the trigger form used by the were accommodated in the corridor. Two of these
department should have met ‘sepsis present’ criteria. patients had a suspected diagnosis of sepsis and
This meant that the patient should have received hourly another patient was suffering from acute new confusion.
observations, reassessment of sepsis and monitoring of We also found a patient in the corridor who was
urine output on an hourly basis. None of these accompanied by paramedics but had not been seen by
interventions were undertaken for the patient and they department staff despite arriving 30 minutes earlier. The
were placed on a chair in the corridor without review for patient was not haemodynamically stable and had a
over three hours. A sepsis screen and pathway was not suspected serious abdominal condition which had the
completed for this patient. potential to cause a life threatening haemorrhage.
• The trust had undertaken a monthly audit of Another patient was suffering from chest pain and had a
compliance with key aspects of the management of history of cardiac problems.
sepsis. This audit showed that between February 2016 • Some patients were observed to be in pain and in a
and March 2017 less than 60% patients who required visibly distressed state in this corridor area. One patient
antibiotics for sepsis were administered these within was calling out for pain relief and staff could not tell us
one hour in line with the trusts requirements for treating who had overall responsibility for this patient or others
sepsis. We also found examples of patient who had not in the corridor.
been placed on the sepsis pathway in incident report • The corridor area was not equipped with call bells and
records. the patients had no way to summon help apart from
• We observed patients being accommodated in the main calling out. We observed that the majority of patients
corridor of the department for two out of three days of held in this corridor required a call bell to call for help
the inspection. The time these patients were resident in due to the nature of their conditions.
the corridor ranged from a few minutes to just four • We found that patients were also being accommodated
hours. The corridor was not equipped with the same in the treatment room areas which lacked oxygen and
equipment you would find in a designated emergency suction equipment for use if patients became unwell.
department space including a lack of piped oxygen and Staff could not tell us how they decided which patients
suction and monitoring equipment, which may have were placed in these rooms and there was no document
been required in an emergency situation. We raised this or guidance to assist them. We found two examples in
during the last inspection in January 2016 and found incident reporting records which showed that patients
that this had not been improved or progressed since the placed in these areas had suffered collapses and
last inspection. required resuscitation.
• There was no standard operating procedure in place • On admission staff were required to carry out risk
which covered the use of the corridor. There was a risk assessments to identify patients at risk of specific harm
assessment in place which did not stipulate or guide such as pressure ulcers, self-harm and risk of falls. If staff
staff as to any criteria to follow to determine whether identified patients susceptible to these risks, they would
patients were clinically stable enough to be placed in place patients on the relevant care pathway and
the corridor. Staff told us that only stable patients, who treatment plans.
were not at risk of deterioration, should be • We identified two patients who had presented with a
accommodated on the corridor area. The risk history of self-harm and intentional overdose and staff
assessment also stated a control measure of ‘intentional had completed a self-harm risk assessment for both
rounding’. We found that in five out five patient records these patients.

24 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• We saw evidence that comfort round took place to equated to half or more of the total number of staff
check if a patient needed water, access to the toilet, working on a shift. The trust spent £8,700,829 on the
pain level or repositioning. However this was infrequent employment of agency staff in the 2016/17 financial
and in some cases completely absent. year. This was above their ceiling target of £6,998,844.
Nursing staffing Medical staffing
• The staffing levels expected which were set by the trust • We requested the vacancy rate medical staff within the
on a day time shift for the department were 14 emergency department but this was not provided. We
registered nurses and four health care assistants. These were provided with an overall rate for the medical
levels of staffing were frequently not met. In March 2017 division which showed that 17.3% of posts across the
prior to the inspection we found that on 28 out of 28 medical division were vacant.
days reviewed the department was at least one • We requested the medical staffing skill mix for the
qualified member of staff short. In some cases this figure emergency department however this was not provided.
rose to ten. In the same period we found that 15 of 28 • Consultants worked on a rota basis to provide cover on
days were short staffed by at least one health care weekdays between 9am and 10pm. From 10pm until
assistant. 9am the most senior doctor on duty would be a registrar
• The vacancy rates across the medical division were high grade doctor (very experienced senior doctor).
at 17.3%. However the overall vacancy rate for the Consultant cover after 10pm was available on an on call
department was lower at 3.15%. basis. During weekend periods consultant cover was
• Shift fill rates varied across the months but were provided in the department between 9am and 9pm.
consistently below 80%. In some cases the numbers of Outside these hours consultant cover was provided on
shifts unfilled by bank or agency staff exceeded 50%. an on call basis.
• Staff told us that they felt that staffing had improved • There was a consultant with a responsibility and lead for
since the last inspection and although they were still paediatrics and they had additional qualifications to
very busy they did feel more able to deliver the care they undertake this role.
needed to. • Some junior and registrar grade doctors told us that
• Only 20% of respondents to the 2016 staff survey agreed they were did not always feel supported by their seniors
that there were enough staff in their area (emergency and they felt morale was low.
department) to do their job properly. • Medical staff told us that the rotas for duty were
• We observed occasions where patient care was delayed frequently completed last minute and were only ever
during busy periods including moving patients to completed one month in advance which did not allow
inpatient beds, providing food and drinks, undertaking them to plan their lives around work.
clinical observations and medication administration. • The general medical council had implemented
• The department did not complete nurse staffing audits enhanced monitoring of the trust medical staffing due
and did not use a workforce planning tool. to safety concerns raised by junior doctors in the
• The paediatric area was well staffed with competent emergency department.
staff. The department aimed to staff this area with • Nursing staff told us that they were able to access
registered paediatric nurses. If this was not possible medical assistance and advice easily.
then the area would be staffed by experienced nursing • We saw evidence that patients were seen promptly by
staff who had undertaken higher level safeguarding medical staff if flagged up by the nurse following triage.
children training and more advanced paediatric life
Major incident awareness and training
support.
• Staffing levels within the department were displayed on • The trust had a major incident policy in place which was
a board. The number of staff on duty was reflective of available on the trust intranet site. Staff were able to tell
the duty rota. us how they would access this policy and showed a
• There was a reliance on agency and bank nursing staff. good understanding of the policy.
The number of agency and bank shifts frequently • There were designated store rooms for major incident
equipment.
25 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
• Staff received major incident training including • Staff sought appropriate consent from patients before
participation in simulated training exercises. delivering treatment and care.
• Staff could describe processes and triggers for • The department had a team of highly skilled and
escalation. They described to us the arrangements to competent nurse and medical staff and appraisal rates
deal with casualties contaminated with hazardous were much improved from the last inspection.
materials (HAZMAT) such as chemical, biological or
Evidence based care and treatment
radiological materials.
• Action cards to guide staff on what to do during a major • The emergency department used both National
incident were easy to follow and fit for purpose detailing Institute for Health and Care Excellence (NICE) and Royal
roles and responsibilities. College of Emergency Medicine (RCEM) guidelines to
guide the care and treatment they provided to patients.
Are urgent and emergency services However these guidelines were not always followed. An
example of this was the management of sepsis. We
effective?
found that the trusts guidelines which were based on
(for example, treatment is effective) national guidelines and papers were not followed in two
cases we reviewed.
Requires improvement ––– • A range of evidence based clinical care pathways were
available electronically and put in place for patients
We rated urgent care services as requires improvement with relevant conditions. These included sepsis, stroke
because: and certain fractures. These pathways included prompts
and treatment steps for staff to follow. Patients were
• The department’s pathways and treatment plans required to be placed on appropriate pathways as soon
followed national clinical guidelines including those as their condition was diagnosed which ensured that
from the National Institute for Health and Care they received timely and appropriate interventions. The
Excellence (NICE) and Royal College of Emergency pathways were regularly reviewed on a trust wide basis
Medicine (RCEM) but staff did not always follow these. and reflected current guidance from NICE and RCEM.
• The service participated in local and national clinical • We found that these pathways were not always put in
audits, however the results of these audits were below place or followed. An example of this was a patient who
the expected standards and action plans had not presented with chest pain and was later diagnosed with
fostered meaningful improvements. a myocardial infarction. The chest pain guidelines and
• Pain relief was managed effectively and audited on a pathway recommended an immediate
monthly and weekly basis. However we did observe that electrocardiogram (ECG) and administration of aspirin if
it was delayed during busy periods and we observed not contraindicated. This patient did not undergo an
one patient in distress. ECG until two and half hours after their presentation.
• Data from national surveys showed that patients treated They did not receive aspirin until eight hours after their
within the hospital had outcomes which were worse presentation.
than expected in some cases. • Another example was a patient who was receiving
• Medical staff told us that they felt they didn’t have chemotherapy and presented with a low temperature.
sufficient opportunity for development and that they felt The trusts pathway for this presentation stipulated that
that the medical education program was poor. if a patient was receiving chemotherapy and presented
• Staff did not have a good understanding of the Mental with a low temperature they should receive antibiotics
Capacity Act (2005) and did not undertake assessments within one hour of presentation. This pathway was in
in line with this. place as patients receiving chemotherapy are at a
However: higher risk of developing life threatening sepsis. This did
not occur in this patient’s case and the patient was not
• There was access to food and drink but the provision of seen within one hour. They subsequently left the
this to patients was variable. department to seek treatment elsewhere as they were
concerned about the delays.
26 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
• We also found that in the case of two serious incidents most months over a twelve month period. The areas
clinical guidelines in place were not followed and this covered in these audits were relating to pain score
was listed as a main contributory factor of the incidents. documentation and provision of pain relief in a timely
In one case the patient involved unfortunately died as a manner.
result of the incident. • The department undertook monthly care indicators
• Policies and procedures reflected current national which looked at how pain relief was managed for adults
guidelines and were easily accessible via the trust’s and children. These indicators showed that for ten
intranet site. months out of 12 (February 2016 to March 2017) the
department had scored above 90% in relation to the
Nutrition and hydration
management of pain relief.
• Staff had access to facilities for making drinks and food • We reviewed one patient record relating to a patient
such as sandwiches was available if needed. suffering from dementia who had suffered a displaced
• We observed that some patients were offered food and fracture. The patient pain score was documented as
drinks by staff members. However three patients told us zero, however the patient was in clear distress and was
that they had not been offered any food or drink despite crying out in pain.
being in the department for a number of hours. One • The trust scored about the same as other trusts of a
patient told us that they had asked for a drink and a staff similar size in England for both questions related to pain
member told them that they could not have one as they relief in the A&E survey 2014.
would have to make everyone a drink if they gave this
Patient outcomes
patient a drink.
• Staff identified patients who were not able to eat and • The department participated in the national Royal
drink and their records reflected their needs clearly. College of Emergency Medicine (RCEM) audits. RCEM
Staff provided assistance to patients who required it. audits allow trusts to bench mark their practice against
• We identified three patients who required their fluid national best practice and encourage improvements.
balance recording and in all cases the fluid balance was The department had participated in one such audit
either absent or incomplete. Two of these patients had a since the last inspection. This audit was the recording
suspected sepsis diagnosis and one required and management of vital signs in children. The results of
monitoring for their renal function. The trusts sepsis this audit showed that the department was not
action tool states that close fluid balance monitoring compliant with four out of four standards looked at. The
including hourly urine monitoring should take place in associated action plan had a target due date of March
any diagnosis of suspected sepsis. 2017. We found that this had not been updated to
• The trust scored about the same as other trusts of a reflect any changes to practice or improvements.
similar size in England for the one question related to • The department participated in the national Royal
nutrition and hydration in the A&E survey 2014. College of Emergency Medicine (RCEM) initial
management of the fitting child audit 2014/15 audit.
Pain relief
They scored 100% compliance with three of the
• In the A&E survey 2014 the department scored about the standards in this audit. In one the standards which
same as other trusts in England for all indicators relating related to documenting an eye witness history the
to timely access to pain relief. department scored 94% which was lower than the 100%
• We observed that pain relief was routinely offered on target. They also scored lower than the 100% standard
triage to walk in patients experiencing pain. This pain in the measure relating to provision of discharge
relief was commensurate with the patient’s level of pain. information to parents with 24% compliance against the
• Audits of pain relief provision were undertaken locally 100% standard. An action plan in response to the areas
on a monthly and weekly basis. These showed that the which did not meet the standards was in place. These
service performed above the expected 90% standard for actions were all due to be completed by December
2015, but had not been completed by the time of our
visit in January 2016 and there was no update recorded
against these actions during this inspection either.
27 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
• The unplanned re-attendance rate for urgent care • There was effective communication and collaboration
service within seven days was between 6% and 7% between multidisciplinary team members within the
between January 2016 and January 2017. This meant emergency department and other specialities. Staff told
that less patients re attended A&E in this trust than us that medical and surgical doctors routinely attended
others in England. the department to review patients and provide support.
• Multidisciplinary staff handover meetings took place
Competent staff
during shift changes to ensure all staff had up-to-date
• We found that 91.5% of nursing staff within the information about risks.
department had received their annual appraisal. This
• Nursing staff told us they had good relationships with
was slightly below the trusts target of 95% but had
consultants and doctors of different disciplines. We
improved significantly since the last inspection. An
observed the senior consultants leading the department
appraisal gives staff an opportunity to discuss their
working closely with the shift coordinator to facilitate
progress and any concerns or issues with their manager.
patient care and flow.
The rates of appraisal for medical staff was significantly
• Medical staff told us they were not always informed of
lower at 50%.
developments in the department. An example of this
• The nursing and medical staff were positive about
was that they were unaware that paramedics had been
learning relevant to their role and development
employed to triage patients arriving by ambulance.
opportunities. Staff told us that they felt able to seek
• Staff told us they received support from pharmacists,
further development opportunities and that this was
physiotherapists, occupational therapists, social
actively encouraged by the new matron and nurse
workers and diagnostic support.
consultant.
• The RAID team who were employed by a neighbouring
• The newly appointed matron and nurse consultant had
trust; provided mental health services and worked
plans in place to improve development for staff working
closely with staff to ensure patients were supported on
in the department and had discussed these in staff
discharge.
meetings.
• Staff working for two ambulance services told us that
• The nurse consultant would work alongside staff and
they felt the staff in the department communicated
provide real time supervision and training as needed.
effectively and they told us that they felt the
• A number of newly appointed advanced nurse
communication had significantly improved since the
practitioners had taken up post and this provided
appointment of the new matron.
development opportunities and pathways for staff
working in the department while also improving the Seven day services
provision of services to patients.
• Access to radiology services was available 24 hours a
• Medical staff told us clinical supervision was available
day, seven days a week.
and they felt adequately supported.
• Consultants provided on call cover for 24 hours, seven
• New nursing staff received emergency department
days a week. A middle grade or registrar doctor was also
specific competency based training. They were
present in the department 24 hours each day, seven
supported by a mentor and were supernumerary for a
days per week.
period of time which varied depending on their previous
experience and learning needs. Access to information
• Medical staff told us that they did not feel they had
• The information needed for staff to deliver effective care
sufficient developmental pathways and support. They
and treatment was readily available in a timely and
also told us that they felt the education program for
accessible way.
doctors was very poor and did not make them want to
• Staff in the department used electronic, computer
stay employed in the trust.
based system for recording all care. All staff could access
Multidisciplinary working these records from tablet and computer devices.

28 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• The records we looked at were easy to locate on the
system and easy to follow. This meant staff could access
Requires improvement –––
all the information needed about the patient at any
time.
• Medical staff produced discharge summaries and sent We rated caring as requires improvement because:
them to the patient’s general practitioner (GP) in a
• Although staff tried their best to ensure that patients
timely way. This meant that the patient’s GP would be
received compassionate and dignified care, due to
aware of their treatment in hospital and could arrange
pressures within the department, patient’s privacy and
any follow up appointments they might
dignity was not always maintained.
• We saw patients being transferred from the department
• We observed occasions where patients were treated in
to medical and surgical wards. The information
the corridor in a state of undress.
provided in these handovers was accurate and detailed,
• Some patients told us that they felt their care was
which ensured that the receiving staff had all the
undignified and one patient told us they felt humiliated.
relevant information they needed.
• Staff did not always have time to support patients and
Consent, Mental Capacity Act and DOL’s ensure that they knew what was happening to them.
• We also observed that patient’s personal property was
• Staff sought consent from patients prior to undertaking
piled up in the deceased viewing room with no
any treatment or procedures and documented this
identifying tags on it. We asked staff if they knew who it
clearly in patient records where appropriate.
belonged to and they told us that they did not know but
• Staff had the appropriate skills and knowledge to seek
believed it belonged to deceased patients.
consent from patients. Staff were able to clearly
• Audit results from the department showed that they
articulate how they sought informed verbal and written
scored below the 90% standard for six out of twelve
consent before providing care or treatment.
months the privacy and dignity indicator audit
• 84% of staff had undertaken he mandatory training
undertaken on a monthly basis.
provided by the trust on the mental capacity act (2005).
• Patient’s confidentiality was not always maintained as
• Staff did not have a good understanding of the legal
there was a visible screen in the department with
requirements of the Mental Capacity Act 2005 and
patient’s details visible and conversations held in the
assessments of mental capacity were not undertaken
triage area could be overheard in the waiting area.
when indicated. An example of this was a patient who
had confusion and a history of dementia. The decision However:
was made to administer treatment to this patient and
• Staff were observed to be treating patients with
they were resisting this treatment. There was no
compassion and dignity in their one to one interactions
assessment of the patients mental capacity or evidence
with patients.
of discussion of a best interests decision
• Some patients spoke positively about the way staff
• Staff had awareness of what practices could be deemed
treated them.
as restraint and displayed an understanding of the
• Staff were caring and compassionate in their approach
deprivation of liberty safeguards and their application.
to patient care.
• A trust-wide safeguarding team provided support and
guidance for staff in relation to any issues regarding Compassionate care
mental capacity assessments and deprivation of • Data provided by the NHS friends and family test (FFT)
liberties safeguards during working hours. During out of showed an average of 20% of patients responded to this
hours period’s staff were able to seek advice and test which was a higher percentage of respondents
support from the senior nurse on site. when compared to the England average of 13%. This
showed that for five out of 12 months at least 90% of
Are urgent and emergency services patients, who completed the survey between March
caring? 20015 and March 2016 would recommend the
emergency department at Stepping Hill hospital to their

29 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
friends and family. However the department narrowly • The main electronic tracking screen for the department
missed the 90% benchmark for seven out of 12 months which displayed patient’s full names and clinical status
with between 80% and 90% of patients saying that they was still situated in the middle of the department and
would recommend the emergency department at was visible to members of the public attending the
Stepping Hill hospital. department.
• The emergency department scored the about the same • The triage area situated in the main reception area was
as other trusts for 23 out of 24 standards related to still separated by a curtain. We observed that patients
compassionate care in the 2014 A&E survey and better triage could still be heard clearly from the waiting room
than other trusts in one out of the 24 standards. including sensitive clinical details.
• The department undertook weekly and monthly audits • Six patients told us they felt that they had received
for a nursing care indicators program. The results of this compassionate care from staff in the department. We
audit showed that for six out of 12 months the service also observed staff treating patients in a compassionate
performed worse that the 90% expected standard for manner when the department was not overcrowded.
privacy and dignity. For four of these months the service • Staff told us that they sometimes felt unable to provide
performed significantly worse than expected with rates care and undertake tasks to improve patient experience
below 80%. when the department was very busy. They also told us
• Some patients and their relatives told us that they did that they felt that this had improved with additional staff
not feel supported and that they did not receive and the new matron who was in post at the time of the
compassionate care. On patients relative told us they inspection.
felt that staff had ignored them since they had arrived. • There were private rooms available where staff could
• Following the last inspection we told the trust that they speak to patients privately if required, in order to
must improve the service to ensure patients received maintain confidentiality.
care which maintained their dignity and privacy. During • In the deceased viewing room which was also used as a
this inspection observed occasions where patients decontamination room, we found bags of patient’s
dignity and privacy was not maintained. property stacked up and when we asked staff what
• During busy periods the holding areas which were these items were they told us that they belonged to
present during the last inspection were still in use and patients who had died in the department. These
were situated on the main through corridor of the belongings had no identifying features such as address
department and paper curtains had been installed labels and they contained personal belongings and
around them. Patients were also held in areas where items which may have been of sentimental value to
there were no curtains. patients relatives. We raised this with staff and they
• The curtains in these holding areas did not fully enclose assured us that they would try and identify whose
the patient’s trolley and when closed the curtains were belongings they were and return them to their rightful
approximately 10cm from the patient’s trolley. owners. We found further corroborating evidence in
• We observed five patients receiving clinical care in this incident reports which outlined incidents where
corridor area with either the curtains open or on the deceased patient’s property could not be located for
corridor. This included patients and the procedure fully family members.
visible to members of the public and staff passing by.
Understanding and involvement of patients and
The patients were receiving various interventions
those close to them
including blood tests, intravenous cannula siting and
physical examinations. In one of these case the patients • Staff communicated with patients in a way they could
was undressed in the corridor and was left with a bare understand.
chest. • Most patients told us that staff kept them informed
• Two patients told us they felt undignified being about their treatment and care. They spoke positively
examined in the corridor. One patient told us they felt about the information staff gave to them verbally and in
humiliated as they were in the corridor in thin night
clothes with staff and members of the public passing by.

30 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
the form of written materials, such as discharge • Patients frequently and consistently experienced
information leaflets specific to their condition. Two unacceptable waits and were not able to access
patients told us that they had not received any emergency care in a timely way. There was routine
information about their care and treatment plan. overcrowding in the adult department and this
• The department scored about the same as other trusts impacted negatively on patients care and treatment.
in England in relation to questions about the amount of However the trust had taken actions to try and improve
information patients received and how involved they these waits for patients.
were with their care in the 2014 A&E survey • Ambulances crews were sometimes queued in the
• Staff were able to tell us how they would identify when department corridors and handovers were often
patients required additional support such as advocacy delayed, in some cases for over, on occasions these
and told us that they knew how to access these services handovers were delayed over 60 minutes.
if they identified this need. • Patients in the adult department often experienced
excessive and unacceptable waits to see a clinician and
Emotional support
be allocated an inpatient bed.
• Patients and relatives told us that staff supported them • The Department of Health standard for emergency
with their emotional needs. departments is to admit, transfer or discharge 95% of
• There was a viewing room available for deceased patients within four hours of arrival. The trust
patients so that their relatives could be with them and consistently failed to meet this standard and was one of
grieve privately. This room was also used as a the worst performing in relation to this standard in the
decontamination room during major incidents. greater Manchester area. This was despite extensive
• We observed the room and it was very cold and visibly support from external agencies including NHS
soiled. The room was clinical without any comforting improvement.
features that may help relatives when experiencing such • Patients were frequently accommodated in the main
a difficult time. There was also patient property piled up through corridor of the department. This corridor was
in this room with no identifying information. Staff told us not equipped to accommodate patients for any length
that this was likely to belong to deceased patients but of time. It lacked adequate privacy measures and there
they could not identify who these patients were. were limited means for patients to call for help and
assistance. The service had undertaken some actions to
• Chaplaincy services were available on site and staff were
address this issue but this remained a concern at the
able to tell us how they would access these for patients.
time of the inspection.
• There were private rooms available for patient’s relatives
• The deceased viewing room was not fit for purpose and
to wait when patients were very unwell or deceased.
did not meet the needs of deceased patients and their
These rooms were equipped with comfortable seating
families.
and drink making facilities.
• Staff confirmed they could access management support However:
or counselling services after they had been involved
• The department did have a dementia Trolley which
with a distressing event.
consisted of a variety of items to reduce distress
behaviours and anxiety. The items consisted of music,
Are urgent and emergency services activity mitts, and doll therapy. There was also a
responsive to people’s needs? dementia champion who led on dementia training for
(for example, to feedback?) all staff in the department.
• There was a separate paediatric department which was
Requires improvement ––– well equipped to deal with paediatric patients and
patients in this area experienced minimal waits to be
seen and referred to appropriate specialities.
We rated responsive as inadequate because:

31 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• The trust had an escalation plan in place for the trust as • Staff told us that they could access a language
a whole and also an internal escalation process. We interpreter if needed and were able to show us how they
found that staff did follow this most of the time and would do this.
there was an improvement in staff compliance with this • Access to psychiatric support was readily available from
policy. the RAID team which was provided by a neighbouring
• The trust was trying to improve access and flow and had trust.
trialled a number of initiatives.
• The department did not use a pathway when caring for
Service planning and delivery to meet the needs of patients living with dementia. However the department
local people did have a dementia Trolley which consisted of a variety
of items to reduce distress behaviours and anxiety. The
• The department was overcrowded and there were
items consisted of music, activity mitts, and doll
insufficient cubicle spaces. The trust had opened an
therapy.
area with six extra cubicle spaces however this had not
• The department also had a dementia champion who
provided the expected improvement in capacity.
led on dementia training for all staff in the department.
• At times of peak demand patients conveyed by
• Families were also given This is me booklets to
ambulances queued in the department’s corridors and
complete whilst in the department as this provided
outside. The waiting room was also frequently crowded
information on how to support the patient whilst they
and on one day of the inspection there were large
were in the department and also gave staff an
numbers of patients sitting on the floor.
awareness of likely triggers for anxiety and distress
• The trust had a designated paediatric area which was behaviours such as noise.
separated from the main department. This area • Staff could also contact the Matron for Dementia Care
contained all relevant equipment required for treating within working hours if required to offer support to
children and was securely segregated from the main families, patients, and staff.
department. • We saw staff making adjustments to best care for a
• There was a large local population of elderly patients in patient with dementia. Staff obtained a radio and
the Stockport area. In response to this the trust were placed this by the patient as her admission details
working with a national charity to and avoid admissions stated music helped calm her in new environments.
from patients in this group. The department had also • Staff could access appropriate equipment such as
implemented a dementia screening prompt on all specialist commodes, beds or chairs to support the
records and frailty screening on all records. We found moving and handling of bariatric patients (patients with
these were not always completed and were not obesity).
completed for two out of two patients we reviewed with • There was a viewing room available for deceased
a diagnosis of dementia. patients so that their relatives could be with them and
grieve privately. This room was also used as a
Meeting people’s individual needs
decontamination room during major incidents and had
• The waiting area in the paediatric area was well no comforting features which may have helped relatives
equipped with toys and children’s height furniture. experiencing such a difficult time. We highlighted this to
• There were adequate facilities to allow access and use the trust on our last inspection and found that it had not
by disabled patients. Including wide corridors and rails improved on this inspection.
in disabled bathrooms. A patient who used a wheelchair • We found that the room remained cold and visibly
for mobilising told us that they felt the department was soiled with brown stains to the floor and walls. The
very accessible and that their needs had been met. room was clinical without any comforting features that
• Information leaflets about services available and may help relatives when experiencing such a difficult
discharge advice were readily available in the time.
department. Leaflets could also be provided in different
Access and flow
languages or other formats, such as braille, if requested.

32 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• There is a Department of Health target for emergency when no cubicle spaces were available we saw that four
departments to admit, transfer or discharge 95% of patients had been allocated beds and had not been
patients within four hours of arrival. From January 2016 moved. We found no clinical reason to stop the moves
to January 2017, the hospital did not meet this standard and the time elapsed from the bed being available
for the twelve months. Their performance was ranged from 30 minutes to an hour.
consistently below 85% with an overall annual • We found that the emergency department live tracking
performance of 77.4%. The trust was the second worst screen was still not always updated with current patient
performing trust in the Greater Manchester area in locations. We observed delays of up to in entering
relation to this standard. We observed the department patient’s correct location of up to four hours. This meant
lacked capacity to accommodate patients. Nursing and staff were unaware of which patients were in their area
medical staff told us that they felt unable to care for and lent to an environment which was sometimes noted
patients safely and effectively because of the lack of by staff and patients to be chaotic. We identified two
capacity in the department. patients who department staff were completely
• On this last inspection senior staff told us that the main unaware of and were not on the electronic board. We
corridor of the department had been made into identified a further four patient in incorrect locations
makeshift waiting areas. We were advised that these and one patient who had left the department and this
areas were only used as a last resort and it was not had not been noticed by staff.
routine to accommodate patients in these areas for • All staff we spoke with told us that they remained
lengthy periods of time. However we found that this concerned about the capacity of the department and
area was still being used to routinely hold patients and patient flow.
staff told us this was a daily occurrence and had • The department had a clinical decision unit (CDU) which
become ‘the norm’. was used to accommodate emergency department
• We observed patients being accommodated in the main patients who were awaiting clinical decisions and
corridor of the department on two out of three days of required an additional period of observation. We found
our visit. The time these patients were resident in the that although some medical patients were
corridor ranged from 20 minutes to just five hours. accommodated on his unit the number had significantly
• The trust had two escalation processes in place for reduced since the last inspection. Staff told us that this
periods when excessive demand was placed on the had improved their ability to stream patient through the
urgent care services. One of these processes was a department.
hospital wide policy and process and one was • Emergency nurse practitioners worked within the
specifically for the emergency department. The purpose department and facilitated a minor injuries streaming
of these policies and processes was to ensure the system to treat patients with minor injuries. This helped
effective management of the trusts bed capacity and to improve the flow of patients through the department
give staff clear processes and triggers to follow in times and reduced waiting times for patients with minor
of increased demand. injuries.
• The emergency department internal escalation policy • The department provided an Emergency Nurse
gave four levels of escalation green, amber, red and Practitioner Service (ENP) which provided nurse-led
black. Green meaning that the department was not over care for all the adults and children who presented to the
capacity and was able to cope with the demands placed department and were streamed into the “minors’
on it through to black when the department was unable stream”. The ENPs worked independently which helped
to cope with demand and the flow of patients was free up medical staff to see patients with more complex
severely impeded. We found that the staff in the problems and therefore contributed to improving
department were knowledgeable about these processes overall performance in the ED.
and followed them most of the time. • The department also had a team of Advanced Nurse
• During the last inspection we found that patients were Practitioners (ANPs) who assessed, examined,
not always moved to inpatient beds as they became diagnosed and treated the whole range of patient
available. We found that this was still the case although presentations in department. This service was
the number had reduced. At a time of peak demand
33 Stepping Hill Hospital Quality Report 03/10/2017
 Urgentandemergencyservices
Urgent and emergency services
developed as part of the workforce plan in light of local • Staff were frustrated by the executive and divisional
and national recruitment challenges. The ANPs are leadership and told us that they had continually raised
involved in departmental teaching, clinical audit and concerns and felt they were not listened to. We saw
lead various clinical projects within ED. evidence of this in incident reports where repeated
issues around staff capacity to deliver care was impeded
Learning from complaints and concerns
due to pressures in the department.
• Information on how to raise a complaint was • In particular medical staff felt they were not listened to
prominently displayed around the department. and their concerns were not actioned.
• Staff understood the process for receiving and handling
However:
complaints and were able to give examples of how they
would deal with a complaint from a patient effectively. • Nursing staff spoke positively about the matron and
• The service had received 110 complaints between nurse consultant.
January 2016 and January 2017, 69 of these complaints
• Staff told us that the culture in the department had
were upheld. Throughout these 13 months there were
improved since the last inspection.
103409 attendances therefore this equates to 0.07% of
• Managers made efforts to engage the public and staff
patients’ complaints being upheld.”
when planning services.
• The trust recorded complaints on the trust-wide system.
• The department had a business plan in place and there
were areas of innovation.
Are urgent and emergency services
Leadership of the service
well-led?
• The local leadership in the department reflected the
Inadequate ––– vision and values set out by the trust. Staff spoke
positively about their local managers and leaders.
Leaders were visible, respected and competent in their
We rated well led as inadequate because:
roles.
• Risks were not always appropriately identified, • Some staff told us that that they did not feel that their
monitored and there was not always evidence of action concerns were listened to by managers above matron
taken where appropriate. One example of this was the level and that they were frustrated by this. An example a
poor performance in a number of care indicators. staff member gave to us was that they had repeatedly
• Significant areas of concern persisted across all completed incident forms stating that they were unable
domains from the last inspection. These had not been to deliver aspects of care due to the business and
actioned at the pace expected. pressures in the department. They advised that the
• Audits and their results were not always acted on and matron had fed back to them about his and had offered
identified as areas of concern by the senior leadership support and had escalated their concerns but no
team. meaningful change had taken place.
• The senior management team working outside the • There were clearly defined and visible local leadership
service did not have a full understanding of the roles in the department.
significant challenges that remained across the service. • Both the matron and nurse consultant were visible
• Areas for improvement were not always identified and during our visit. Staff spoke positively about the changes
appropriate actions plans were in some cases not in implemented since the matron and nurse consultant
place and not updated. had been appointed.
• Medical staff did not always feel supported by managers • Medical staff told us their senior clinicians in the
and felt their concerns were not listened to. department supported them well and they had access
• The new local matron level leadership had started to to senior clinicians when they required.
make some changes to improve safety however this was
not moving at a sufficient pace to ensure safe care and
treatment for patients.

34 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• However some medical staff told us that they felt months for this indicator and compliance figures varied
unsupported by the executive level management team between 30% and 90%. Another example was the
and told us that they felt the executives did not listen to indicator for privacy and dignity where the data
their concerns about safety or take them seriously. provided showed that for six out of twelve months this
indicator scored below 90%. Neither of these issues
Vision and strategy for this service
were entered on the emergency department risk
• The trusts vision was to be nationally recognised for our register. The trust provided an action plan during the
specialism in the care of older people and as an factual accuracy process; which showed that the matron
organisation that provides excellent cancer care. The for the department had taken some actions to address
trust had a five year strategy which ran from 2015 to these areas for improvement.
2020 which set out key priorities for the five year period. • The emergency department had a risk register which fed
Progress against this plan was measured at board level into the divisional risk register. The register identified
on a monthly basis. risks and contained associated risk assessments with
• The trust said that they had a set of values which were clear actions set out and timeframes.
based on three key themes Quality & Safety, • The register reflected some of the current risks the
Communication and Service. Underneath these themes department had identified, for example registered nurse
were sets of expected behaviours set out. staffing. However some risks identified within the
department were not present on this register. One
• Staff we spoke with were aware of the trust vision and
example of this was the poor performance in a number
values and told us that they could locate these on the
of care indicators.
trust website.
• The matron and nurse consultant were clear on their
Governance, risk management and quality roles in relation to governance but acknowledged that
measurement there were areas which still needed addressing.
• The department was part of the medicine business • There were regular monthly clinical governance
group. This business group is led by a triumvirate – the meetings and we saw minutes from this meeting. The
director, the head of nursing and the associate medical subjects discussed included current risks, themes and
director. A governance lead was also identified in the trends of incidents and recent incidents.
business group. Locally the responsibility for
Culture within the service
governance was with the matron, nurse consultant,
clinical director and clinical governance lead. • There was an open culture within the department where
• The governance framework within the emergency nursing staff told us that they were encouraged to raise
department had improved since the last inspection. The any concerns about safety. Nursing staff told us that
matron and nurse consultant were aware of some of the they had confidence that local leaders would act on any
issues identified and were reviewing incidents to concerns they raised.
identify themes. However there were still issues relating • However some medical staff told us that they would
to the governance arrangements. raise concerns but had little confidence that they would
• A monthly nursing care indicators dashboard was be listened to or actioned.
completed by the department and fed into monthly • Staff told us that they felt that the culture had improved
governance meetings and up to board level. We found since the appointment of the new matron and nurse
that there were a number of areas within this dashboard consultant and that they had an open door policy.
which had scored poorly consistently over a twelve However staff told us that they had not seen any
month period. The matron was trying to address the improvement in the pressures they faced from a lack of
issues identified but due to the breadth of the issues capacity in the department and long waits for inpatient
performance improvements in these indicators were not beds.
sustained and inconsistent. An example of this was the
indicator for infection control and prevention. This
indicator did not score above 90% for any of the 12

35 Stepping Hill Hospital Quality Report 03/10/2017

 Urgentandemergencyservices
Urgent and emergency services
• Medical staff told us that their morale was low and they • The department participated in the NHS Friends and
felt unable to undertake their roles to their full Family test, which gives people the opportunity to
capabilities due to the ongoing pressures in the provide feedback about the care and treatment they
department including lack of capacity and reduced received.
staffing.
Staff engagement
• Staff described the pressure in the department as
relentless and some staff told us that they felt ‘burnt • Staff participated in regular team meetings led by the
out’. department’s managers. Staff told us that they felt these
• Three areas of the department had a sickness level of meetings were informative and helpful.
over 3.5% in January 2017 this had improved from 6.5% • Staff told us they received support and regular
in January 2016. The top three reasons for sickness communication from their managers in the form of
within the Medicine Business Group (including ED) were emails, newsletters and individual interactions.
cold or flu, gastrointestinal illness and anxiety, stress • All staff we spoke with told us they felt they had
and depression. opportunity to discuss any developments or changes
• The trusts had undertaken a staff survey in 2016. This within the hospital.
survey showed that 80% of staff who responded felt • The trust also engaged with staff via newsletters and
enthusiastic about their job and going to work. In through correspondence displayed on notice boards in
addition 66% of staff responded by saying they would staff areas.
recommend the department to their friends and family. Innovation, improvement and sustainability
• All nursing staff we spoke with told us they felt respected
and valued. • We saw evidence in business plans and strategic
objectives that leaders had assessed the sustainability
Public engagement
of these plans and improvements. There was evidence
• Staff told us they routinely engaged with patients and that these were monitored and actioned where
their relatives to gain feedback from them. Information appropriate.
on number of incidents, complaints and the results of • The department had implemented innovative initiatives
the NHS Friends and Family test was available in the in their efforts to improve access and flow through the
department. department. An example of this was the introduction of
• The trust website provided information on how patients primary care streaming. This initiative meant that a
and their relatives could provide feedback to the trust practitioner would ‘pull’ patients from the triage stream
and offered a number of ways to do so. The department if their presenting condition could be best seen by a
also had an active service user group who were able to primary care practitioner.
feed back any changes or improvements and were also • The department had a full team of advanced and
consulted on any changes planned to the department. emergency nurse practitioners led by a nurse
consultant. This highly skilled team of practitioners
supported the medical staffing establishment to ensure
patients were seen in timely way.

36 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
Safe Inadequate –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the service Summary of findings

Stockport NHS Foundation Trust became one of the first
We rated this service as requires improvement because:
Foundation Trusts in the country in 2004. They provide
hospital services for children and adults across Stockport • The trust had not responded appropriately to the risk
and the High Peak area, as well as community health expressed to them at our last inspection regarding
services for Stockport, Tameside and Glossop. The trust the security of patients’ records. Across the medical
work as part of the ‘Stockport Together’ partnership to division in all areas we visited, except A11, records
integrate local health and social care more closely to trolleys were unlocked. We were advised by the Trust
people’s homes. that a decision had been made to keep records
unlocked to ensure easy access to the records. Whilst
Stepping Hill Hospital is the Trust’s main acute site, which
the records trolleys were located at the front of
provides emergency, surgical and medical services. The
nursing stations, we observed that these areas were
trust serves a population of approximately 350,000
not always manned therefore representing the same
people. The medical services provided at the hospital
risk.
included general medicine, endoscopy, cardiology,
• The trust regularly moved their own staff and had a
geriatric medicine, endocrinology, gastroenterology,
heavy reliance on agency and bank staff, resulting in
rehabilitation, respiratory and stroke medicine. We
inappropriate skills mix and staff feeling they were
inspected Stepping Hill hospital between 21 March 2017
nursing in wards where they did not have the
and 22 March 2017.
required competence to care for patients.
From March 2016 – February 2017 the trust had 89,659 • Decisions to move nursing staff were made on
medical admissions including day case admissions. clinical judgment without a clear guidance
28,390 of these admissions were from the emergency document or minimum set standards.
department. This averaged 7,472 admissions per month • Records completion was not in accordance with best
and with the exception on November 2016, remained practice guidance.
around that average figure month on month. • Incident reports did not have consistent
categorisation for the same type of incident.
During our inspection we visited the Acute Medical Unit
• Infection protection audits showed low levels of
(AMU), A1, A3, A11, A12, E1, E2, C2, C3, B2, B3 and the
compliance with the trust’s policy. At the time of
coronary care unit. We reviewed 24 complete (paper and
reporting action plans to address this were not
electronic) patient records, 12 paper based patient
provided.
records and a further 32 sets of electronic records, talked
to 18 patients and 39 members of staff.

37 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• Safeguarding training levels for staff were not in • Staff understood their responsibility to report
accordance with the trust’s own policy or best incidents.
practice guidance. • Staff were aware of the duty of candour and their
• There was a lack of consistency in how people’s obligations regarding this.
mental capacity was assessed and not all • All areas we inspected were visibly clean and tidy.
decision-making was informed or in line with • Throughout our inspection, in most wards we visited,
guidance and legislation. Decision-makers did not we did not identify any major environmental risks or
always make decisions in the best interests of people hazards.
who lack the mental capacity to make decisions for • Safeguarding policies and procedures were in place
themselves, in accordance with legislation. Restraint and staff knew how to refer a safeguarding issue to
and deprivation of liberty were not always protect adults and children from abuse.
recognised, or less restrictive options used where • Medicine storage was secure and accurate logs and
possible. Applications to authorise a deprivation of records maintained.
liberty were not always made appropriately or in a • Since the last inspection, the service had achieved
timely manner to the Court of Protection or by using JAG Accreditation for their endoscopy services.
the Deprivation of Liberty Safeguards. • Patients’ nutritional status and dietary needs were
• The appraisal rate for the medicine division was assessed using a recognised assessment tool.
91.3% (88.1% in nursing care indicators), which was • Between September 2015 and August 2016, patients
below the trust’s target of 95%. at the trust had a lower than expected risk of
• The trust participated in the 2015 Lung Cancer Audit readmission for non-elective admissions and a lower
and the proportion of patients seen by a Cancer than expected risk for elective admissions.
Nurse Specialist was 78.9%, which was worse than • Multidisciplinary team (MDT) working was
the audit minimum standard of 80%. The 2014 figure established on the medical wards. We saw good
was 86.4%. examples of MDT working on all of the wards and
• Due to staffing pressures, patients’ dignity was not units we visited.
consistently maintained. • Staff offered kind and considerate care to patients
• The arrangements for governance and performance and those close to them. We saw that for most
management did not always operate effectively. patients, privacy and dignity was maintained and
• Risks, issues and poor performance were not always that most patients’ needs were appropriately met.
dealt with appropriately or in a timely way. The risks Staff actively involved patients and those close to
and issues described by staff do not consistently them in all aspects of their care and treatment.
correspond to those reported to and understood by Patients felt included and valued by the staff team.
leaders. • Patients and those close to them understood their
• The approach to service delivery and improvement treatment and the choices available to them.
was reactive and focused on short-term issues, for • Meeting people’s emotional needs was recognised as
example nurse staffing. important by all staff disciplines, and staff were
• In view of the expenditure for agency staffing (£1, sensitive and compassionate in supporting patients
138,444 for February 2017), the sustainable delivery and those close to them during difficult and stressful
of quality care was put at risk by the financial periods.
challenge. • Between October 2015 and September 2016 the
• Some of the information that was used to monitor average length of stay for medical elective patients at
performance or to make decisions is inaccurate, trust was 4 days, which is similar to England average
invalid, unreliable, out of date or not relevant. of 4.1 days.
However:

38 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• Between December 2015 and November 2016 the Are medical care services safe?
trust’s referral to treatment time (RTT) for admitted
pathways for Medical services has been about the Inadequate –––
same as the England overall performance.
• In geriatric medicine, the service was above the We rated safe as inadequate because:
England average for admitted RTT (percentage within
18 weeks). • The trust had not responded appropriately to the risk
• The vision, values and strategy had been developed expressed to them at our last inspection regarding the
through a structured planning process with regular security of patients’ records. Across the medical division
engagement from internal and external stakeholders, in all areas we visited, except A11, records trolleys were
including people who use the service, staff, unlocked. We were advised by the Trust that a decision
commissioners and others had been made to keep records unlocked to ensure
• The trust’s staff in all areas knew and understood the easy access to the records. Whilst the records trolleys
vision, values and strategic goals. were located at the front of nursing stations, we
observed that these areas were not always manned
therefore representing the same risk.
• In 32 records we reviewed we found gaps in the
frequency of bed rails assessments, falls risk
assessments and in three instances bed rails were in
place but no risk assessment had been undertaken.
• During our inspection, we identified an issue with the
trust’s mandatory training recording and reporting
system. This meant that some nurses did not have
assigned to them, so they had not been provided with
the relevant training they should have had.
• There were significant gaps between the trust’s target
and current levels of staff members’ mandatory training
completion in some subjects including adult life
support and resuscitation.
• Incident reporting categorisation was not the same for
similar incidents resulting in incidents not receiving the
same level of scrutiny.
• The approach to assessing and managing day-to-day
risks to people who use services was sometimes
focused on clinical risks and did not consistently take a
holistic view of people’s needs.
• Safeguarding training levels for staff were not in
accordance with the trust’s own policy or best practice
guidance.
• Services were not consistently delivered in a way that
focused on a person’s holistic needs.
• There were high vacancy rates (17.4%) for nursing and
medical staff within the service. Agency and bank nurses
and locum doctors routinely filled gaps in shifts and
rotas. This led to an insufficient skill mix of staff in most
areas.

39 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• Wards were not adequately staffed at the time of our England between February 2016 and February 2017. The
inspection. Shift fill rates showed that over one quarter trust undertook trend analysis approximately six
of shifts were not filled by either trust or agency staff. months after serious incidents were reported, for
The reliance on bank and agency staff on some wards example their December 2016 report covered trends
and departments meant that this was not a sustainable from incidents in October 2015 – March 2016. This
position. meant there was no real-time overview of trends as the
• Staff were frequently moved from their usual area of review was delayed.
practice to fill gaps in rotas. This resulted in staff being • From February 2016-February 2017 there were 4916
placed in areas where they felt they did not have the incidents reported across the medicine division. 54.9%
necessary skills and competence to meet the needs of of these were low or no harm incidents, which is below
patients in these areas. the average of this type of incident across similar
organisations.
However:
• We reviewed all the summaries of incidents for the 4916
• Staff understood their responsibility to report incidents. incidents reported in the medical division. We noted
• Staff were aware of the duty of candour and their inconsistency in the grading of incidents, for example a
obligations regarding this. clostridium difficile ([Link]) infection was categorised as
• All areas we inspected were visibly clean and tidy. minor, moderate and major. We requested the incident
• Throughout our inspection, in most wards we visited, grading criteria and this confirmed that the
we did not identify any major environmental risks or categorisation should have been major. The data had
hazards. not been amended by the senior staff reviewing the
• Safeguarding policies and procedures were in place and incidents or the governance team. This also meant the
staff knew how to refer a safeguarding issue to protect data for the number of serious incidents was inaccurate,
adults and children from abuse. as the error in the reporting had not been identified.
• Medicine storage was secure and accurate logs and • The trust’s incident grading criteria did not mirror across
records maintained. to general incident grading criteria used in other NHS
Incidents organisations, for example the trust did not use no or
low harm categorisation instead using ‘moderate’ as a
• Staff understood their responsibility to report incidents, categorisation for minor incidents. This left the trust
provided us with examples of the type of incidents they open to mistakes in incident reporting categorisation
would report and explained that they were encouraged particularly by bank and agency staff which the trust
to do this. The hospital used an electronic incident heavily relied on.
reporting system that triggered an email to senior staff • Staff reported 431 incidents in relation to staffing
to alert them to an incident once a staff member had concerns within the medical division. At the time of our
reported it. Staff told us that learning from incidents was inspection the trust did not hold regular morbidity and
disseminated through emails, communication files, mortality meetings within the medical division. Senior
newsletters and at daily meetings. However, senior staff staff told us that there was no set criteria for mortality
told us that when they incident reported staffing reviews in the medical division and that approximately
concerns they did not get feedback and the situation did 5% of deaths were reviewed by individual groups. There
not change. was no process identifying who learning should be
• There were no never events. Never events are serious shared with or the frequency that meetings should be
incidents that are wholly preventable as guidance or held. We requested meeting minutes but were informed
safety recommendations that provide strong systemic these were not kept. This is not in accordance with best
protective barriers are available at a national level and practice and recommendations in national guidance.
should have been implemented by all health care However, in January 2017 the trust had arranged for
providers. independent consultants and the Medicine Business
• In accordance with the Serious Incident Framework
2015, the trust reported 53 serious incidents (SIs) in
medical care which met the reporting criteria set by NHS
40 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
Group Associate Medical Director to review deaths as a • The trust was working to achieve stretch targets for
one off that fit the National Confidential Enquiry into pressure ulcers. A stretch target is a target that pushes
Patient Outcome and Death grading criteria and health the limit beyond what was previously achieved. The
round table grading criteria. stretch target for Stockport Acute services is zero
• The trust told us they had recently reviewed the process tolerance of avoidable pressure ulcers grade 3 and 4 by
to make these improvements. We requested meeting the end of 2017. In February, there had been two
minutes, but received the report that was reviewed at category three and above pressure ulcers reported for
the meeting. Whilst this was comprehensive, we were acute services, both of which were deemed avoidable.
unclear who attended this meeting and how lessons The total avoidable pressure ulcers this financial year
learnt were shared with the wider medical team. was 21 at the time of our inspection. The number of new
• Staff we spoke with advised that they were encouraged pressure ulcer incidents and the severity being reported
to be open and honest with patients. within the acute trust had decreased significantly in
• Staff we spoke with understood the duty of candour. February by more than 50% (new pressure ulcer
Duty of candour is a requirement under The Health and incidents reduced from 30 to 14.
Social Care Act 2008 (Regulated Activities) Regulations • The safety cross was monitored via the nursing
2014 on a registered person who must act in an open dashboard with subsequent action plans developed.
and transparent way with relevant persons in relation to The action plans were monitored on a monthly basis by
care and treatment provided to service users in carrying the quality governance board.
on a regulated activity. • Safety thermometer results were displayed on the wall
at each ward entrance. This was to inform members of
Safety thermometer
the public and promote staff understanding.
• The NHS safety thermometer is a national improvement • Results and any relevant actions were discussed at ward
tool for measuring, monitoring and analysing avoidable meetings.
harm to patients and ‘harm free’ care. Performance
Cleanliness, infection control and hygiene
against the four possible harms; falls, pressure ulcers,
catheter acquired urinary tract infections (CAUTI) and • Monthly infection control audits were undertaken across
blood clots (venous thromboembolism or VTE), was all wards, which looked at standards such as the
monitored on a monthly basis through the nursing cleanliness of patient equipment. We reviewed the
dashboard. infection prevention audits. Overall, across all wards in
• Safety thermometer information for medical services the medicine division the audit findings were below the
showed that from April 2016 to February 2017 the trust trust’s target of 95% compliance. In the clinical practice
had reported 21 avoidable pressure ulcers, , 34 falls with audit, the medicine business group’s average was 67%.
harm and 17 catheter urinary tract infections between In the environment practice’s audit, the medicine
December 2015 and December 2016. We requested up business group’s average was 69%. The overall audit for
to date data at the time of our inspection but did not the medicine business group’s average was 68%. We
receive this at the time of reporting. requested an action plan, which outlined actions to be
• This year’s target for avoidable falls across the trust is 19 taken, how this was to be actioned and an estimated
or below. In February, there were two patients who had completion date.
a fall. One of these falls was still under investigation. • Monthly hand hygiene audits were undertaken by staff
Across the trust there have been 44 falls graded major being observed. Results for the hand hygiene audit from
and above between April 2016 to the end of February October 2016 to February 2017 across the medicine
2017. 37 falls have occurred in medicine. There had division averaged 79.4%, which was below the trust’s
been seven avoidable falls, which had occurred on B2, target of 90%. The trust had an action plan in place to
E2, C2, A11, AMU1, the transfer unit and A10. 31 falls out address these issues.
of the 44 were deemed unavoidable. Seven falls were • From October 2016 to February 2017, the cannula care
still under investigation. To date the trust is on target to audit averaged 80.4%, which was below the trust’s
meet its trajectory for 2016/17. target of 90%.

41 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• Infection prevention and control staff training figures • Patient led assessments of the environment (PLACE)
were 90% for level one training and 87% for level two between February and June 2016 showed a standard of
training, which were both below the trust’s target of 98.3% in the trust for cleanliness, which was in line with
95%. the England average.
• In our records review we found 11 sets of patients’ • Side rooms were used as isolation rooms for patients at
records where both MRSA and stools chart assessments increased risk of cross infection. There was clear signage
were between 13 hours and 4 days late. This outside the rooms so that staff were aware of the
represented a patient safety issue which was escalated increased precautions they must take when entering
to the trust at the time of our inspection. At the time of and leaving the room.
our inspection, most areas we inspected were visibly • Cleaning schedules were in place and had been
clean and tidy. However, during our inspection we found completed as required, therefore reducing the risk of
several commodes in clinical areas that were still in use. cross infection.
These commodes had large sections of cracked plastic
Environment and equipment
coating were patients’ hands would be positioned thus
representing an infection control risk. We escalated this • Throughout our inspection, in most wards we visited,
issue at the time of our inspection. we did not identify any major environmental risks or
• Between April 2015 and December 2015 medical hazards. However, in the acute medical unit (AMU) we
services reported no cases of clostridium difficult, found two tubs of fluid thickening agent that were in
methicillin-resistant staphylococcus aureus (MRSA) or close proximity to patients. All hospitals had received an
methicillin-susceptible staphylococcus aureus (MSSA). alert that fluid thickening agents should be kept in a
We requested an update in this information from the locked area away from patients. The presence of the
trust, but at the time of reporting had not received it. fluid thickening agent represented an immediate
However, the medicine business group meeting minutes patient safety risk, which we escalated at the time of our
stated there had been no cases of MRSA since April 2016 inspection.
and 5 cases of [Link] in February 2017. • On the AMU the sluice room was unlocked at the time of
• Wards used the ‘I am clean’ stickers to inform colleagues our inspection. We escalated this at the time of our
at a glance that equipment or furniture had been inspection because there were toxic substances in the
cleaned and was ready for use. Staff we spoke with room that were not stored within the trust’s lockable
understood this labelling system. However, the ‘I am cupboard.
clean’ stickers we observed were not dated or signed. • At the time of our inspection the resus trolley on the
• We observed that the disposal of sharps, such as needle Coronary Care Unit (CCU) and Short Stay Older People’s
sticks followed good practice guidance. Most sharps (SSOP) unit were not locked.
containers were dated and signed on assembly. • Each ward had designated toilets and showers for male
However, the temporary closure was not used in all and female patients. However, on one ward we visited
areas we visited when sharps containers were not in male patients had to walk through the female part of
use. the ward in order to access the bathroom. This was
• We saw evidence that staff followed good practice because the shower/toilet had been reported as faulty.
guidance in relation to the control and prevention of However, the shower facility being used was also used
infection in line with trust policies and procedures. to store wheelchairs.
There was a sufficient number of hand wash sinks and • Staff told us that nursing ward A11 could prove
hand gels. Hand towel and soap dispensers were challenging in view of the environment and ward layout.
adequately stocked. We observed staff following hand We observed that there were not clear lines of sight to
hygiene practice, bare below the elbow and using patients. During our inspection, we observed that two
personal protective equipment where appropriate. patients had absconded from the ward. Staff told us
• Hand gel and personal protective equipment was that due to staffing levels at that time and the ward
accessible on each ward and was utilised by staff and environment, it was felt the patients may have been
visitors.

42 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
missing for longer than they suspected as they were not date, indicating there were stock management systems
seen leaving the unit. Senior staff told us that the acuity in place. However, on A1 there were medications in use
tool did not take into consideration the ward without opened dates and a limited supply that were
environment. out of date.
• The hospital has been higher than the England average • We looked at the prescription and medicine records for
for the Patient-Led Assessments (PLACE) from 15 patients. We saw arrangements were in place for
2013-2016. recording the administration of medicines. These
• Equipment was routinely maintained and serviced. Each records were clear and fully completed. Allergies were
clinical area had resuscitation equipment readily clearly documented. The trust’s audit also confirmed
available. There were systems in place to ensure it was these findings.
checked and ready for use on a daily basis. Records • Medicines requiring cool storage at temperatures below
indicated daily checks of the equipment took place on eight degrees centigrade were appropriately stored in
all of the wards and units we visited. This meant there fridges. Daily temperature checklists were completed on
was emergency equipment available and in date when the wards we visited. Staff were able to tell us the
required. system identified to follow up if there were gaps in these
• The hospital had a quality management system in place records.
that complied with ISO 9001:2008 in relation to asset • Controlled drugs (medicines which are required to be
management, maintenance and repair of medical stored and recorded separately) were stored and
equipment. The ISO 9000 standards are designed to recorded appropriately on the wards we visited. Access
help organisations meet statutory and regulatory was limited to qualified staff employed by the trust. Two
requirements related to equipment. nurses were observed following the correct procedures
• Records showed equipment was routinely maintained for the recording and administration of controlled drugs
in accordance with manufacturers’ guidance including for a patient.
portable appliance testing (electrical equipment). • Emergency medicines were available for use and
records indicated these were regularly checked.
Medicines
• Patients were provided with a lockable drawer or
• The trust undertook controlled drug (CD) spot check cupboard in which to store their medication.
audits. These audits reviewed two medicine wards and • A member of the trust’s pharmacy team visited medical
showed across both wards the record of receipt of CDs wards regularly. Pharmacy staff checked that the
were completed on 60% of occasions. The trust's target medicines patients were taking when they were
was 100% compliance. Across both wards the record of admitted to the wards were correct and that records
receipt of CDs in the CD record book were completed on were up to date.
70%-80% of occasions. This was below the trust’s target • Staff within the hospital had a clear guidance document
of 100%. We requested an action plan outlining how the in place that explained the procedure regarding
trust was addressing this issue. The trust told us they medication to them when they discharged patients to
had not created an action plan to address the audit’s the community unit.
findings, despite the latest audit being on 1 March 2017
Records
and our data request being made at the end of March
2017. • The hospital used electronic and paper based patient
• Nursing care indicators outlined that there were eight records across the medicine division.
medication incidents involving nursing staff in February • During our last inspection we identified that the records
2017, which was above the trust’s target. trolleys that were inspected were unlocked which
• Suitable cupboard and cabinets were in place to store meant they were potentially accessible by members of
medicines. This included a designated room on each the public. During this inspection in all areas, except
ward to store medicines. We sample checked medicines A11, records trolleys we visited were unlocked. Whilst
on the wards and in most instances found them to be in 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.
43 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
• Records showed that most patients had their needs capacity assessments had not been undertaken for
assessed on admission to hospital and care plans were patients that lacked capacity and the records generally
created with review dates. were not comprehensively completed. Notes lacked
• Records audits were undertaken to review compliance evidence of regular MDT involvement. We escalated our
with the trust’s record policy. We reviewed the trust’s concerns regarding this at the time of our inspection for
record keeping audits for the last two quarters. The immediate action.
October 2016 audit showed 40% compliance with the • Mental capacity assessments were not evidenced in 9/
trust’s record keeping policy. The key gaps were in the 10 patients’ records for patients who should have been
areas we identified during our inspection. The assessed for their care to be in line with the trust’s
November 2016 audit showed 73% compliance with the policy. In one case we observed nurses restricting a
trust’s record keeping policy. December’s audit showed patient from leaving the ward when there was no
75% compliance, which is defined as an acceptable capacity assessment or DoLs application in the patient’s
level by the trust. January’s audit showed 100% records.
compliance despite there being short falls identified • In three records we reviewed student nurses’ signatures
within the audit. However, February’s audit showed 33% were not countersigned, which is not in accordance with
compliance with the trust’s record keeping policy. The best practice. The trust had had a serious incident in
overall compliance rate for October-December 2016 was 2016 where countersigning student nurses’ notes had
55%, which was a significant decrease in compliance been identified as a concern, but at the time of our
from that at our last inspection and the previous inspection this had not been resolved.
quarter’s figures (91% compliance). We requested • In 32 out of 36 records we reviewed we found gaps in the
details how the trust were addressing these issues but frequency of bed rails assessments, falls risk
had not received this at the time of reporting. assessments and in three instances bed rails were in
• During our inspection we reviewed 24 complete (paper place but no risk assessment had been undertaken.
and electronic) patient records, 12 paper based patient Patient information boards provided, at a glance, an
records and a further 32 sets of electronic records. overview of patients and the public.
• We reviewed 56 sets of electronic records. In 17 sets of • Patient information boards did not respect patient
records the observations were recorded as between one confidentiality as they were visible by the key risks,
hour and seven days late. All 56 records showed that medication and discharge plans for each patient.
intentional rounding observations were between 54 • During our inspection we observed that four out of five
minutes and 12 days late. The average delay in do not attempt cardiopulmonary resuscitation
completion of these records was that they were 1.5 (DNACPR) forms were not comprehensively completed.
hours late. Intentional rounding is a structured process We escalated this to the provider at the time of our
where nurses on wards in acute and community inspection. At the time of our unannounced inspection
hospitals and care home staff carry out regular checks this issue had been addressed.
with individual patients at set intervals, typically hourly. • Records were legible, signed and dated. However, staff
During these checks, staff carried out scheduled or members’ names and designation was not always clear
required tasks. 10 sets of records showed MRSA and or printed, which is not in accordance with best practice
stools chart assessments were between 13 hours and 4 guidance on record keeping outlined by the GMC and
days late. When discussing this issue with staff they NMC. This was particularly important as nursing and
advised that due to the situation with nurse staffing, medical records were written on the same continuation
completion of paperwork was the first thing that was sheets.
impacted upon. We escalated these issues at the time of • The nursing records on the AMU had full assessments
our inspection. completed including MUST, waterlow, falls and pressure
• On one ward we reviewed all 12 patients’ paper based ulcer documentation.
records and they were particularly poor. There were two
Safeguarding
missing observation charts, three missing fluid balance
charts, one pressure ulcer risk assessment was out of • During our inspection we identified a concern with the
date, two DNACPR forms were not fully completed, trust’s mandatory training recording and reporting
44 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
system. This meant that some nurses did not have (50%), resuscitation (76.5%), adult basic life support
competency requirements assigned to them, so they (61%), blood transfusion (77.4%) and venous
had not been provided with the relevant training they thromboembolism (75.8%). We asked for amended data
should have had. It also meant that in terms of to reflect our findings on inspection, but did not receive
reporting, senior managers had no true oversight of the this.
mandatory training levels for nursing staff. For example • Staff confirmed they had a corporate induction on
on one ward 50% of the nursing staff had not been commencing work and this induction also included
allocated the competency for Mental Capacity Act and temporary staff.
DoLs training. These staff were not showing on the • Annual mandatory training included infection control,
trust’s database as requiring the training so the records fire safety, information governance and safeguarding.
did not show they had not completed it. We escalated • Staff told us they received electronic reminders to
this issue at the time of our inspection and were attend training and were given the time to attend.
informed the issue was not limited to one ward or • Staff we spoke with were aware of the trust’s sepsis
mandatory training subject and that it would be fully policy.
investigated. This meant that the trust’s safeguarding
Assessing and responding to patient risk
figures provided were the highest they could be, but
they may actually be lower than those reported below. • During our inspection, we saw evidence that upon
• The trust target for safeguarding compliance was 95%. admission to medical wards, staff carried out risk
At the time of our inspection across the medicine assessments to identify patients at risk of harm. Patients
division 79.8% of staff had completed their safeguarding at high risk were placed on care pathways, and care
vulnerable adult’s level one training and 82.5% of staff plans were put in place to ensure they received the right
had completed their level two safeguarding vulnerable level of care. The risk assessments included falls, use of
adults training. This was not in accordance with best bed rails, pressure ulcer and nutrition (malnutrition
practice outlined in the intercollegiate guidance. The universal screening tool or MUST). However, these
trust did not have an action plan to address thee assessments were not consistently reviewed and
shortfalls but did review training records at a monthly updated on the medical wards. In 32 records we
meeting. reviewed we found gaps in the frequency of bed rails
• Safeguarding policies and procedures were in place and assessments, falls risk assessments and in five instances
staff knew how to refer a safeguarding issue to protect bed rails were in place but no risk assessment had been
adults and children from abuse. The trust had a undertaken.
safeguarding team, which provided guidance during the • We saw evidence that electronic early warning scores
day in the week. Staff had access to advice out of hours (EWS) were completed to identify patients who were at
and at weekends from the hospital on-call manager. risk of deteriorating. The computer system would
automatically calculate the observation period required
Mandatory training
depending on a patient’s observations e.g. pulse,
• During our inspection we identified a concern (outlined temperature etc.
above under safeguarding) with the trust’s mandatory • We reviewed 56 sets of electronic records. In 17 sets of
training recording and reporting system, which was records the observations were recorded as between one
escalated to the trust at the time of our inspection. This hour and seven days late. Staff explained that this was
meant that the trust’s mandatory training figures because of the nurse staffing situation, which breached
provided were the highest they could be, but they may the trust’s guidance on staffing. For example, on one
actually be lower than those reported below. ward we visited there was one qualified nurse to 11.5
• The trust target for mandatory training compliance was patients. On another ward we visited there was one
95%. In January 2017 across the medicine division nurse to 13 patients.
training compliance was 85.1%, which was below the • On ward A12, where the computer indicated there were
trust’s target of 95%. Areas of concern included ‘safe use delays in observations between 3 and 7 days, staff
of insulin’ (80.5%), equality and diversity (82%), explained that the computer system did not work there
information governance (83.4%), conflict resolution so paper based records were used. These records did
45 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
not have the same trigger points as the electronic ward during our inspection there was one registered
system and no EWS chart for interpretation purposes nurse to 10.5 patients. On another ward, there was one
was readily available. A EWS chart sets out the registered nurse to 13 patients. Staff explained they
parameters when a patient’s observations indicate incident reported this situation every day and nothing
further action should be taken. This represented a was done about it. Staff told us the impact on patient
patient safety risk, which we escalated at the time of our care is that falls assessments and risk assessments are
inspection. not completed as priority has to be given to direct
• On ward A12 care was not delivered in a way that patient care and the provision of medication. We
focused on a person’s holistic needs. Call bells were out reviewed 426 incident reports and they confirm a direct
of reach, which represented a patient safety issue as impact on patient care as a result of the staffing
patients were unable to call for assistance.. An inspector situation.
had to intervene to stop one patient from falling. • Staff on the coronary care unit (CCU) looked after
• In the Coronary Care Unit (CCU) the telemetry monitors patients who needed level one and level two care. They
were not continuously observed. Staff explained that assessed the acuity of the patients on a regular basis to
patients also had alarms set to alert them if patients’ determine if they were level one or level two patients.
observations went outside the parameters they had set. This was done to ensure appropriate skill mix of staff.
We escalated our concerns regarding this patient safety Level two patients require higher levels of care and
issue at the time of our inspection. more detailed observation and intervention. However,
• Staff told us that 99% of patients were seen and staff told us that the unit was continually staffed by two
assessed by a consultant within 12 hours of admission nurses. This meant staff were unable to leave the unit
or within 14 hours of their time of arrival at hospital. The during their breaks.
trust told us that they do not record and audit this • We reviewed incident reports for the CCU and noted that
information, which is against best practice and the on 26 occasions between February 2016 and February
trust’s Commissioning for Quality and Innovation 2017 the unit was inappropriately staffed. The incident
(CQUIN) national goals. reports outline direct evidence of impact on patients
• Records we reviewed showed the escalation process and patient safety concerns.
had been follow appropriately when required. • On the SSOP unit, a ward we observed several staff
• Records we reviewed confirmed patients were regularly moves on during our inspection, 66 staffing incidents
reviewed. had been reported between February 2016 – February
2017
Nursing staffing
• Senior nurses who were supernumerary (in addition to
• The service used the Safer Nursing Care Tool to measure the planned number of nurses so they could oversee the
staffing levels. However, this tool did not take into running of the ward and assist where necessary) said
consideration the environment and layout of wards. On they often completed shifts due to shortage of staff due
ward A11, there were several areas where there was no to short notice sickness. This meant management tasks
line of sight from the nursing station or other bays. At were often left uncompleted.
the time of our inspection there were two nurses and • We noted that nursing staff were moved mid-shift and
three HCAs on duty, when there should have been three decisions were made to do this by different senior
nurses and four HCAs. Two patients had absconded nurses based on their clinical judgment. There was no
without being observed, one of which was on a DoLs. set criteria to benchmark this decision against.
Ward staff had taken appropriate action once they • During our inspection we noted that some nurses were
discovered the patients had absconded, but steps had moved multiple times in a shift. Whilst each ward had a
not been put in place to address the staffing issue until planned nurse staffing rota and reported on a daily
we escalated this to the trust. basis if shifts had not been covered, the off duty rotas
• During our inspection, on all the wards that we visited did not consistently reflect what staff were on a shift as
there was one to two nurses less per shift. Senior
nursing staff told us that patient care was compromised
when staff were taken away from the wards. On one
46 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
moves mid-shift were not always documented in the off • The sickness rate across the medicine business group in
duty rotas we reviewed. The trust could therefore not January 2017 was 3.7%, which was below the trust’s
tell us with any degree of accuracy how many nurses target of 4%. From January 2016 – January 2017 the
were on a ward at a specific point in time. sickness rate averaged 4%, which was in line with the
• Nursing staff told us that they had an induction and a trust’s target.
supernumerary period. However, they were not • Medical wards displayed nurse staffing information on a
consistently permitted to be supernumerary as staffing board at the ward entrance in line with guidance
levels did not always permit this. contained in the Department of Health document ‘Hard
• The trust told us that it could not tell provide us with the Choices’. This included the planned and actual staffing
number of patients that were on a ward at a point in levels. This meant that people who used the services
time. This meant there was no mechanism for ensuring were aware of the available staff and whether staffing
staffing numbers were safe. levels were in line with the planned requirement.
• For 2017 the percentage of shifts filled (by trust staff, • The service used the trust escalation procedures if there
temporary and agency staff) ranged between 26% and was a reduction in the number of nursing staff of duty.
82% (average 65%) in January 2017, 32.7% and 88.79% This included undertaking a risk assessment and
(average 74%) in February 2017 and 35% and 88.8% escalating the issues to the 1090 bleep holder.
(average 74%) in March 2017. Particular areas of concern • Nursing handovers were structured and information
included the coronary care unit (CCU). From October handed over to the incoming staff included allergies,
2016 to March 2017 the percentage of unfilled shifts mobility of patients, incidents and expected date of
ranged from 29.5% to 57.5% with an average of 47.6% discharge. Each member of staff on the ward had access
unfilled shifts. to a copy of the handover sheet at the beginning of each
• We reviewed staffing figures for March 2016 to February shift.
2017. Most medical wards were below the national
Medical staffing
benchmark of 80% during the day and night. In January
2017, one out of 19 medical wards was above the • Rotas were completed for all medical staff which
benchmark, in February 2017 three out of 19 medical included out of hours cover for all medical admissions
wards were above the benchmark and in March 2017 and all medical inpatients across all wards. All medical
two out of 19 medical wards were above the trainees contributed to this rota.
benchmark. • There was an on call rota which ensured there was a
• We reviewed the use of agency and bank nurses consultant available 24 hours a day seven days a week
between January 2017 and March 2017 and found that for advice. The trust told us that a medical consultant is
all medicine wards regularly used temporary staff. contactable during week days on a bleepfrom 09:00 to
Figures showed temporary staff usage consistently 19:00. Beyond thatan on call consultant is on site till
exceeded 29% across all wards. Particular areas of 10pm and available through switchboard. At weekends
concern were the acute medical unit, A11 (acute there is a constant consultant presence on the Acute
medical ward), B2 (medical ward) and A3 (cardiology Medical Unit (AMU) until 20:00. AMU is in close proximity
unit) were temporary staff usage consistently exceeded to the emergency department. After 20:00 at weekends
50%. and 22:00 on weekdays a consultant is available via
• In December 2016 there were 17.3% staff vacancies switchboard and if needed will be present within 30
across the medicine division. This meant there were minutes to one hour.
208.7 whole time equivalent (wte) staff vacancies. • Some wards had developed a consultant of the week
• The staff turnover rate was 17.6% from February 2016 – system, which staff felt was particularly beneficial for
January 2017. This was above the trust target of 4%. patients and patient flow. However, we observed that
• The appraisal rate for the medicine division was 89.7%, this system was not in place on the coronary care unit,
which was below the trust’s target of 95%. an issue the trust were addressing.

47 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• In September 2016, the proportion of consultant staff • Staff had access to the materials they needed to deliver
reported to be working at the trust were about the same effective care and treatment to patients in a timely
as the England average (32% vs 37%) and the manner including test results, risk assessments, and
proportion of junior (foundation year 1-2) staff was medical and nursing records. However, because nursing
lower (13% vs. 20%). intervention records were not consistently completed
• In December 2016 there were 17.4% staff vacancies and reviewed, the information available within records
across the medicine division. The staff turnover rate was was not comprehensive.
17%. This was above the trust target of 4%. • From January 2017 – March 2017 87.9% of patients’
• We observed two ward rounds which were attended by discharge summaries were published within 48 hours.
the consultant as well as junior doctors and nurses. This was below the trust’s key performance indicator of
There was effective verbal communication between 95%.
each other and the patients.
However:
Major incident awareness and training
• Since the last inspection the service had achieved JAG
• Senior staff told us there was a business continuity plan Accreditation for their endoscopy services.
and major incident plan. • Patients’ nutritional status and dietary needs were
• Staff were able could access the major incident policy assessed using a recognised assessment tool.
via the intranet. • Between September 2015 and August 2016, patients at
the trust had a lower than expected risk of readmission
Are medical care services effective? for non-elective admissions and a lower than expected
risk for elective admissions.
Requires improvement ––– • Multidisciplinary team (MDT) working was established
on the medical wards. We saw good examples of MDT
working on all of the wards and units we visited.
We rated effective as requires improvement because: • The trust had a process in place for assessing its
• Staff did not demonstrate a good understanding of the compliance with NICE guidance.
trust’s policy regarding the Mental Capacity Act and Evidence-based care and treatment
Deprivation of Liberty Safeguards (DoLs).
• There was a lack of consistency in how people’s mental • The trust told us that all National Institute for Health
capacity was assessed and not all decision-making was and Clinical Excellence (NICE) standards are monitored
informed or in line with guidance and legislation. through the trust’s software by business group leads. For
Decision-makers did not always make decisions in the the medicine business group the primary link is the
best interests of people who lack the mental capacity to governance and quality manager supported by the
make decisions for themselves, in accordance with governance administrator. As and when new NICE
legislation. Restraint and deprivation of liberty were not documents were shared these get added to the
always recognised, or less restrictive options used software. The documents were then reviewed and
where possible. Applications to authorise a deprivation shared with the relevant clinical director or clinical
of liberty were not always made appropriately or in a speciality lead for review and opinion regarding
timely manner to the Court of Protection or by using the compliance.
Deprivation of Liberty Safeguards. • NICE compliance is a regular agenda item within the
• Mental capacity assessments were not evidenced in 9/ monthly medicine business group quality governance
10 patients’ records for patients who should have been board. Reports are reviewed at monthly business group
assessed for their care to be in line with the trust’s executive performance review meetings. They are also
policy. In one case, we observed nurses restricting a reviewed on a monthly basis at the trust wide quality
patient from leaving the ward when there was no governance committee.
capacity assessment or DoLs application in the patient’s • We requested evidence of compliance with NICE
records. guidance. The trust’s records showed that they were
compliant with 45 relevant guidelines including CG181
48 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
(Updated Sep) Cardiovascular disease: risk assessment • Specialist dietary support was available to patients who
and reduction including lipid modification, CG126 required a particular or individualised diet.
(Updated Aug) Stable angina: management, NG049 • Specialist support was available from the speech and
Non-alcoholic fatty liver disease (NAFLD): assessment language team to support patients who experienced
and management, CG152 (Updated May) Crohn's difficulty with eating and drinking.
disease: management, NG039 Major Trauma: • Staff were sensitive in assisting patients to eat and drink
assessment and initial management and NG040 Major where required.
Trauma: service delivery. In a further 37 areas, the trust • Patients we spoke with said they were happy with the
were mostly compliant (9), partially compliant (5), had standard and choice of food available. If patients missed
an assessment in progress (14) or have not yet assessed a meal, as they were not on the ward at the time, staff
compliance (9). The areas were assessments had not yet were able to order a snack for them.
been made were all from 2017 and included QS086 • We saw drinks were available and in reach for most
(Updated Jan) Falls in older people, QS143 Menopause patients.
and QS144 Care of dying adults in the last days of life. • Fluid balance charts we inspected were not
• The Trust participates in both National and Local clinical comprehensively completed and appropriately
audit activity. The trust used their computer system to maintained.
capture the clinical audits. • Wards had protected meal times. However, staff told us
• The trust has registered for the National audit of that they could use discretion regarding this to allow
inpatient falls (NAIF) for 2017. Data will be inputted relatives to help with eating and drinking as per
between 15 January to 2 June 2017. individual need or request.
• The trust told us each business group held quarterly
Patient outcomes
clinical audit & quality forum meetings where the
findings from audits were shared and the • Between September 2015 and August 2016, patients at
recommendations were discussed. Following the the trust had a lower than expected risk of readmission
meeting the action plan was created, logged and then for non-elective admissions and a lower than expected
implemented. If there were issues with the timescales of risk for elective admissions. Of the top three specialties
actions being completed this was fed through the for elective admissions, only Geriatric Medicine had a
business group quality board. slightly higher relative risk of readmission. For the top
• Nursing care indicators were used across the medicine three specialties for non-elective admissions,
division. In September 2016 nursing care indicators were Cardiology was the only specialty with a higher than
at 97.7% overall for the medicine division, before a expected relative risk of readmission.
deterioration to 94.4% in November 2016. The figure • The trust takes part in the quarterly Sentinel Stroke
steadily improved to 95.6% in January 2017. In February National Audit programme. On a scale of A-E, where A is
2017 the division were achieving 95.3% overall. This was best, the trust achieved grade A in the latest audit,
above the trust’s overall target of 95%. March 2017. This is an improvement in rating from the
previous audit and is better than the England average of
Pain relief
a D rating.
• Pain relief was managed on an individual basis and was • The trust’s results in the 2015 Heart Failure Audit were
regularly monitored. Patients told us they were better than the England and Wales average for two of
consistently asked about their pain and supported to the four of the standards relating to in-hospital care –
manage it. received echo, and input from specialist. For the
• We saw that patient’s pain levels were recorded on early remaining two standards, cardiology inpatient and
warning scores records. input from consultant cardiologist, the trust scored
lower than the England average.
Nutrition and hydration
• Patients’ nutritional status and dietary needs were
assessed using a recognised assessment tool.

49 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• The trust’s results were better than the England and • Staff told us that they were given access to development
Wales average for five of the seven standards relating to within their roles and were given time to access courses.
discharge. The two standards they scored lower than • Link nurses attended relevant training and cascaded
the England average on were Referral to HF nurse for this at ward level. For example staff caring for patients
follow up and Referral to cardiology for follow up. suffering from diabetes had received training from Link
• The trust took part in the 2015 National Diabetes nurses to their wards that enabled them to manage
Inpatient Audit. They scored better than the England patient care more effectively. Staff also told us they
average in nine metrics and worse than the England could access link nurses for support with specific
average in eight metrics. The indicator regarding “foot patients when needed.
risk assessment during stay” had the largest difference • New guidelines from the Royal College of Physicians had
versus the England average with 26.1% more patients been circulated for taking lying and standing blood
receiving an assessment in Stockport. pressure. These will be incorporated into the revised
• The trust took part in the 2013/14 MINAP audit and training programme.
scored worse than the England average for all of the • The trust had introduced an improving wound care
three metrics. Performance had remained similar to the diploma devised and agreed by the newly formed
2012/13 audit. We requested updated information but Wound Care Steering Group, chaired by the district
at the time of reporting had not received it. nursing service.
• The trust participated in the 2015 Lung Cancer Audit and
Multidisciplinary working
the proportion of patients seen by a Cancer Nurse
Specialist was 78.9%, which was worse than the audit • Multidisciplinary team (MDT) working was established
minimum standard of 80%. The 2014 figure was 86.4%. on the medical wards. We saw good examples of MDT
• The proportion of patients with histologically confirmed working on all of the wards and units we visited. This
Non-Small Cell Lung Cancer (NSCLC) receiving surgery included nursing staff as well as therapy staff such as a
was 28.4%, this is not significantly different from the physiotherapists and specialist nurses.
national level. The 2014 figure was 25%. • All medical records we reviewed showed appropriate
• The proportion of fit patients with advanced (NSCLC) MDT involvement.
receiving chemotherapy was 61.3%, this is not • Ward teams had access to the full range of allied health
significantly different from the national level. The 2014 professionals and team members described good,
figure was 43.3%. collaborative working practices. There was a joined-up
• The proportion of patients with Small Cell Lung Cancer and thorough approach to assessing the range of
(SCLC) receiving chemotherapy was 82.6%, this is not people’s needs and a consistent approach to ensuring
significantly different from the national level. The 2014 assessments were regularly reviewed by all team
figure was 80%. members and kept up to date.
• The JAG Accreditation Scheme is a patient centred and • Daily ward meetings were held on most of the wards we
workforce focused scheme based on the principle of visited. These were called board rounds or safety
independent assessment against recognised standards. huddles and they reviewed discharge planning and
The endoscopy service at the trust was level one JAG confirmed actions for those people who had complex
accredited in March 2016. JAG Accreditation is the factors affecting their discharge.
formal recognition that an endoscopy service has • Patients were referred to community services if they
demonstrated that it has the competence to deliver required ongoing aftercare.
against the measures in the endoscopy GRS Standards. Seven-day services
Competent staff
• Staff and patients told us diagnostic services were
• Staff told us they received appraisals that supported available 24 hours a day, seven days a week.
them in their role and professional development. • Operating services for stroke patients were available 16
However, the appraisal rate for the medicine division hours per day seven days a week.
was for February 2017 was 89.7%, which was below the
trust’s target of 95%.
50 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
• Staff told us that services such as physiotherapy and • Mental capacity assessments were not evidenced in 9/
SALT were routinely available five days a week. At 10 patients’ records for patients who should have been
weekends physiotherapy and SALT access could be assessed for their care to be in line with the trust’s
obtained for urgent cases. policy. In one case we observed nurses restricting a
• Staff told us and we saw evidence that patients in high patient from leaving the ward when there was no
dependency areas were reviewed by a consultant twice capacity assessment or DoLs application in the patient’s
daily. The trust was rolling out a consultant of the week records. Of 10 records reviewed, one record showed that
model across the medicine works to promote continuity the policy had been correctly followed. We escalated
of care. However, the trust told us that on the coronary this issue to the trust at the time of our inspection.
care unit there were concerns with this system because • Not all staff we spoke to on the wards knew that the use
some consultants only saw their own patients. The trust of bed rails can be a form of restraint as outlined in the
was addressing this issue. Royal College of Nursing (RCN) rights, risk and
• Patients’ records evidenced daily medical ward rounds. responsibilities guidance.
• Most staff had the appropriate skills and knowledge to
Access to information
obtain consent from patients. Most staff we spoke with
• Staff had access to the materials they needed to deliver were clear on how they sought verbal informed consent
effective care and treatment to patients in a timely and written consent before providing care or treatment.
manner including test results, risk assessments, and We saw written records that indicated consent had been
medical and nursing records. However, because nursing obtained from patients prior to procedures or
intervention records were not consistently completed treatment. However, on one ward we saw evidence of
and reviewed, the information available within records four patients with confusion whose capacity was
was not comprehensive. questionable at the time the consent had been given.
• There were computers available on the wards we No capacity assessment had been undertaken.
visited, which staff accessed for patient and trust
information. Policies, protocols and procedures were Are medical care services caring?
kept on the trust’s intranet, which meant staff had
access to them when required. Good –––
• On the majority of wards there were files containing
minutes of meetings, ward protocols and audits, which
were available to staff. We rated caring as good because:
• Patients were discharged from hospital with a copy of • Staff offered kind and considerate care to patients and
their discharge summary. This was also forwarded to the those close to them. We saw that for most patients,
patient’s GP and contained a summary of care provided privacy and dignity was maintained and that most
along with medications patients were discharged with. patients’ needs were appropriately met. Staff actively
From January 2017 – March 2017 87.9% of patients’ involved patients and those close to them in all aspects
discharge summaries were published within 48 hours. of their care and treatment. Patients felt included and
This was below the trust’s key performance indicator of valued by the staff team.
95%. The trust told us that they had recruitment plans in • Patients and those close to them understood their
place to improve performance in this area. treatment and the choices available to them.
Consent, Mental Capacity Act and Deprivation of • Meeting people’s emotional needs was recognised as
Liberty Safeguards important by all staff disciplines, and staff were sensitive
and compassionate in supporting patients and those
• Staff did not demonstrate a good understanding of the close to them during difficult and stressful periods.
trust’s policy regarding the Mental Capacity Act and
Deprivation of Liberty Safeguards (DoLs). We spoke with However:
39 members of staff and none of them were able to • Due to staffing pressures patients’ dignity was not
describe the correct process, outlined in the trust’s consistently maintained.
policy, to undertake mental capacity assessments.
51 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
Compassionate care • We observed staff introducing themselves to patients
and their relatives.
• Medical services were delivered by caring and
• Relatives were encouraged to participate in the care of
compassionate staff. We observed numerous examples
patients when this was appropriate. For example, we
of compassionate care provided to patients. There was
observed relatives assisting with personal care and
a positive rapport between patients and staff.
supporting patients to eat at meal times.
• Staff treated patients with dignity and respect. However,
on one ward a female patient, who was nursed in close Emotional support
proximity to a male bay, was completely exposed at the
• Meeting people’s emotional needs was recognised as
time of our inspection. We escalated this to the trust. We
important by all staff disciplines, and staff were sensitive
revisited the ward and found that the patient was
and compassionate in supporting patients and those
partially exposed. We escalated this to the trust again.
close to them during difficult and stressful periods.
On our unannounced inspection this patient had been
• Patients had access to emotional and psychological
moved to a side room and was appropriately covered.
support from nurses specialising in cancer, heart failure,
• We spoke to 17 patients throughout our inspection.
diabetes, pain relief and safeguarding.
Most patients we spoke with were positive about their
• We observed staff offering emotional support and
care and treatment.
listening to patients’ and families concerns in a helpful
• On most wards people had access to call bells and staff and reassuring way.
responded promptly. However, on the AMU and A12 • The chaplaincy and spiritual service was also available
patients did not have their call bells within reach. We for spiritual, religious or pastoral support to those of all
escalated this at the time of our inspection. faiths and beliefs.
• Staff maintained patients’ confidentiality.
• The Friends and Family Test response rate for Medical
Are medical care services responsive?
care at trust from February 2016 to February 2017 was
45.3%, which was better than the England average of
Requires improvement –––
25% . However, in the nursing care indicators data
submitted the response rate for February 2017 was We rated responsive as requires improvement because:
30.8%.The trust told us this data would not match the
• Services were not consistently delivered in a way that
figures shown by the ward dashboard due to escalation
focused on a person’s holistic needs.
wards being included in the trusts total but not in the
• Delayed transfers of care had significantly increased
nursing dashboard. All wards had an average
from our last inspection. From January 2017 to February
recommendation rate of more than 90%.
2017 the trust had an average of 77 patients per day
Understanding and involvement of patients and with delayed transfers of care, which was above the
those close to them trust’s key performance indicator of 10 patients per day.
• We observed that leaflets in the hospital were all in
• Patients all had a named nurse and consultant. Patients
English. The trust is located within a Polish and
were aware of this, and on the wards we visited, the
Bangladeshi community. Staff advised us they could be
relevant names were displayed on a board above the
translated, but were not readily available in other
bed. Patients said they had been involved in their care
languages.
and were aware of the discharge plans in place. Most
patients could explain their care plan. However:
• The patients and most relatives we spoke with told us
• Between October 2015 and September 2016 the
staff were caring and professional. They felt involved in
England length of stay for Medical elective patients at
their care and were given adequate information about
trust was 4 days, which is similar to England average of
their diagnosis and treatment. Most relatives felt they
4.1 days.
had time to ask questions and that their questions were
answered in a way they could understand.

52 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• Between December 2015 and November 2016 the trust’s non-elective admissions was lower than the England
referral to treatment time (RTT) for admitted pathways average. Of the top three specialties, only Cardiology
for Medical services has been about the same as the had a higher length of stay than the England average
England overall performance. with 8.7 days compared to 5.3.
• In geriatric medicine the service was above the England • Between December 2015 and November 2016 the trust’s
average for admitted RTT (percentage within 18 weeks). referral to treatment time (RTT) for admitted pathways
for Medical services has been about the same as the
Service planning and delivery to meet the needs of
England overall performance. The latest figures for
local people
November 2016, showed 94.7% of this group of patients
• Services were planned to meet the needs of the local were treated within 18 weeks versus the England
population and included national initiatives and average of 88.9%. Over the last 12 months the trust has
priorities. Part of the trust’s overall strategy was to focus seen a mixed performance. From December 2015 to
on the care of older people to better meet the care April 2016 the trust was performing better than the
needs of the local population. England average before performing worse than the
• The facilities and premises in medical services were England average between May 2016 to October 2016
appropriate for the services that were planned and before seeing an improvement in November 2016.
delivered. • In geriatric medicine the service was above the England
• Engagement with other trusts in the area assisted with average for admitted RTT (percentage within 18 weeks).
planning services for the population and supporting However, two specialities (general medicine and
neighbouring trusts. This was the case in the provision rheumatology) were just below the England average at
of intermediate care for patients before returning to 95.7% and 95.6%.
their place of residence. • From January 2017 to February 2017 the trust had an
• At the time of our inspection two patients had average of 77 patients per day with delayed transfers of
absconded from a ward without being seen. One patient care. This had increased from an average of 41 patients
was on a DoLs. The patients had been able to abscond per day at the time of our last inspection (January 2016)
without being seen due to there being less staff on duty and was above the trust’s key performance indicator of
than the acuity tool required and due to the ward 10 patients per day.
environment. Staff told us the acuity tool did not take • From January 2017 to February 2017 19% of patients
into account the environment. The decision to move were discharged before 12:00.
nurses was made by senior staff using their clinical • We observed the wards we visited had daily ‘board
judgement without any guidance materials. rounds.’ In records we reviewed there was evidence that
• The trust had an ambulatory care unit. We requested discharge planning had been started on admission.
the standard operating procedure but at the time of • From 1 April 2016 – 28 Feb 2017 the trust had 5000
reporting had not received it. medical outliers. A medical outlier is a medical patient
that is not in a medical ward during their hospital stay.
Access and flow
The average was 15 medical outliers per day.
• From March 2016 – February 2017 the trust had 89,659 • We asked the trust to confirm to us the number of time a
medical admissions including day case admissions. patient moved during their stay. From March 2016 to
28,390 of these admissions were from the emergency February 2017, 20, 344 patients moved once (so were
department. This averaged 7,472 admissions per month admitted then moved to a different ward), 4872 were
and with the exception on November 2016, remained moved twice, 1077 were moved three times, 239 were
around that average figure month on month. moved four times, 67 were moved five times, 25 were
• Between October 2015 and September 2016 the average moved six times, 6 were moved seven times, 5 were
length of stay for Medical elective patients at trust was 4 moved eight times and 4 were moved nine times.
days, which is similar to England average of 4.1 days. For • The service have a transfer unit to facilitate discharges
Medical non-elective patients, the average length of stay from the hospital.
was 6.4 days, which is similar to England average of 6.7 • The trust had introduced a short stay older people’s unit
days. General medicine stays for both elective and aiming to discharge patients within 72 hours. Staff told
53 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
us this had been particularly effective when the service • We observed that leaflets in the hospital were all in
had had seven day access to MDT staff, but weekend English. The trust is located within a Polish and
discharges had reduced now the service had five-day Bangladeshi community. Staff advised us they could be
access to MDT services. translated, but were not readily available in other
• The endoscopy unit were open from 8am to 10pm languages.
Monday and Tuesday and 8am to 6pm on Wednesdays • All inpatient admissions that had a learning disability
to Saturdays. were flagged on the electronic record and staff then
planned and provided an individualised and
Meeting people’s individual needs
appropriate care plan in place.
• The trust had a lead nurse for dementia and a flag • The trust had a chaplaincy and spiritual care
system on the electronic record to alert staff so staff department. The services were available within working
could plan patients care accordingly. hours and also provided an on-call system seven days a
• On ward A12 staff told us that they struggled to access week.
MDT involvement on the ward.
Learning from complaints and concerns
• On ward A11 a long-term patient was exposed several
times during our inspection and was nursed in close • From March 2016 – February 2017 255 complaints were
proximity to a male nursing bay. This was escalated and received across the medical division. The trust
the following day the lady was exposed when we responded to the complainant in the agreed timescale
revisited the ward. This did not demonstrate 87.5% of the time. Over the same time period, 70.6% of
responsiveness or a holistic approach to the patient’s complaints were upheld.
care. • Monthly performance reports included the response
• Dementia Awareness training was offered to clinical staff and timeliness of responses and details of complaints
focusing on how dementia affects the brain and how partially upheld or upheld by the Parliamentary Health
staff can communicate effectively with people with Service Ombudsman (PHSO).
dementia and understanding the realities of the person • Staff aimed to resolve complaints locally. PALS
living with dementia and how best to support them is information was given to those wishing to forward a
delivered on a monthly basis. Non-clinical staff were complaint.
offered ‘dementia friends’ training which focuses on • Patient advisory and liaison service (PALS) details and
helping them understand how dementia affects people leaflets were available on wards and leaflets were
and provides knowledge on how best to communicate available.
with people with dementia. • There were examples of practice improving as a result of
• However, the trust averaged 61.2% in the 2016 PLACE learning from complaints.
assessments for dementia, which was below the
England average of 75.3%. Are medical care services well-led?
• Between January 2017 and March 2017 96.7% of
patients were asked dementia finding questions with 72 Requires improvement –––
hours of admission, which was above the trust’s key
performance indicator of 90%. Over the same period
92.3% of patients received a dementia assessment and We rated well-led as requires improvement because:
investigation, which was above the trust’s key • The arrangements for governance and performance
performance indicator of 90%. Over the same period management did not always operate effectively.
100% patients had received a dementia referral. • Risks, issues and poor performance were not always
• We observed that wards had appropriate equipment for dealt with appropriately or in a timely way. The risks and
bariatric patients. issues described by staff do not consistently correspond
• The trust utilised interpretation and translation services, to those reported to and understood by leaders.
for patients whose first language was not English. • The approach to service delivery and improvement was
reactive and focused on short term issues, for example
nurse staffing.
54 Stepping Hill Hospital Quality Report 03/10/2017
 Medicalcare
Medical care (including older people’s care)
• In view of the expenditure for agency staffing, the • There was a governance structure in place, which
sustainable delivery of quality care was put at risk by the ensured some risks to the service were captured and
financial challenge. discussed. However, during our inspection the trust’s
• Some of the information that was used to monitor governance processes had not identified some key risks
performance or to make decisions is inaccurate, invalid, including: mandatory training allocation of
unreliable, out of date or not relevant. competencies, completion of capacity assessments and
• We identified an issue with the trust’s mandatory the quality of DNACPR form completion.
training records system that the trust’s own governance • Incident reporting categorisation was not consistent
procedures had not highlighted. The issue meant that across the medicine division, as outlined above (see
figures senior managers used to evidence compliance safe). This meant that the board could not be assured
were inaccurate (too high) and that all staff did not that similar incidents were consistently reviewed or
receive the training the trust had decided staff of their reported externally.
level and grade required. • Senior nursing staff expressed concern that there was a
lack of understanding regarding the acuity and ward
However:
environments from nursing managers who made
• There was a clear statement of vision and values, driven decisions on staffing. We established that the decisions
by quality and safety. were made based on individual clinical judgement and
• The vision, values and strategy had been developed there was no guidance document or risk assessment
through a structured planning process with regular undertaken regarding the decisions. Nurses told us and
engagement from internal and external stakeholders, we saw evidence that they repeatedly reported their
including people who use the service, staff, concerns regarding staffing. Staff told us that despite
commissioners and others incident reporting concerned, nothing changed.
• The trust’s staff in all areas knew and understood the • The governance framework enabled the dissemination
vision, values and strategic goals. of shared learning and service improvements and a
Vision and strategy for this service pathway for reporting and escalation to the trust board.
• In terms of clinical audits, a quarterly report was
• The trust’s vision is to be nationally recognised for their submitted to each business group with detail of their
specialism in the care of older people and as an audits undertaken. A summary report was then
organisation that provides excellent cancer care. submitted to the quality governance committee as part
• Staff we spoke with were aware of the vision and of the governance framework. This report advised the
strategy. committee on the audits completed within a timeframe
• The trust’s values were based on the ‘Your Health. Our and whether assurance was given or not. If not what the
Priority’ promise. They were around the behaviours staff risk factor is. If there was a risk the business group
and patients felt helped deliver safe, effective and advised the committee of the risk or requested support/
compassionate care. action to be taken.
• These values were grouped into three subjects’ quality • Meeting minutes reviewed showed discussion of
and safety, communication and service. governance issues and shared action plans to secure
• The trust’s staff were aware of the trust values and these service improvement.
were displayed on notice boards. • There were regular team meetings and huddles to
Governance, risk management and quality discuss issues and management actions.
measurement • Across the medical division we noted that from May
2016 to February 2017 the trust was consistently above
• The medical services were part of the medical business the ceiling target for agency expenditure. In view of the
unit, which included general medicine, endoscopy, expenditure for agency staffing (£1,138,444 for February
cardiology, geriatric medicine, endocrinology, 2017), the sustainable delivery of quality care was put at
gastroenterology, rehabilitation, respiratory and stroke risk by the financial challenge.
medicine.
Leadership of service

55 Stepping Hill Hospital Quality Report 03/10/2017

 Medicalcare
Medical care (including older people’s care)
• Staff stated that the executive team and board members Public engagement
were accessible.
• Business and operational plans for Stockport NHS
• Ward staff felt well supported by their line managers and
Foundation Trust were available online to the public via
the senior leadership team. However, senior nurses did
their website and gave information about performance
not feel supported by nursing managers. Most staff felt
and strategic plans for the Trust.
confident to raise issues with line managers and felt
• The trust’s website contains a wide range of information
managers responded positively when concerns were
including policies and procedures, condition specific
shared.
advice and information about the hospital.
• All staff we spoke with were aware of the whistleblowing
• Information on how patients, carers and relatives could
policy.
provide feedback to the trust were available on the
• Leaders were sighted on the challenges to good quality
website. This included a number of ways to give
care and were able to identify actions needed to
feedback including an automated web form.
address them.
• The trust used social media sites to engage with the
Culture within the service public, such sites were maintained, up to date and
utilised regularly.
• Staff told us that senior leaders got ideas from ‘the
• Stockport NHS Foundation Trust appointed three young
ground up to make improvements’, which helped them
members of the public to act as youth ambassadors to
to feel valued.
represent the views of younger people in decision
• Operational staff told us that managerial changes had
making about the trust.
improved the culture.
• The trust has around 17,500 public and staff members
• Staff felt encouraged to raise issues and concerns and
who provided input into trust decisions, take part in
felt confident to do so.
surveys, elect governors and receive a member’s
• We observed staff teams working collaboratively and
newsletter.
sharing responsibility to deliver care.
Staff engagement
Equalities and Diversity – including Workforce Race
Equality Standard • Staff told us that they received regular email
communication from the trust providing updates on
• The trust had recently published and equality, diversity
changes and improvements.
and inclusion report which was available on the
• There were regular staff engagement meetings and
website. This showed how the trust were meeting its
offers and opportunities to meet with the senior team.
obligations under the Equality Act (2010).
• The trust’s workforce was fairly representative of the Innovation, improvement and sustainability
growing ethnic diversity in the local community,
• Patient surveys recorded via IPads enabled the trust to
religious beliefs, sexual orientation and the population.
view results daily by clinical area.
However, in common with most health organisations,
• The trust had introduced an improving wound care
women make up the majority of their workforce.
diploma devised and agreed by the newly formed
• The trust was in the lowest 20% of trusts across the
Wound Care Steering Group, chaired by the district
country when staff were asked if they had experienced
nursing service.
discrimination at work but there were some patterns of
difference across equality groups. During our inspection
we asked staff about this and no one we spoke with felt
that they had been discriminated against. The trust had
a Workforce Race Equality action plan to address this.

56 Stepping Hill Hospital Quality Report 03/10/2017

 Outstandingpracticeandareasforimprovement
Outstanding practice and areas for improvement

Outstanding practice
• The trust had introduced an improving wound care
diploma devised and agreed by the newly formed
Wound Care Steering Group, chaired by the district
nursing service.

Areas for improvement

Action the hospital MUST take to improve • The trust must address the delayed transfers of care
and formulate an action plan outlining how it will
• The trust must ensure that records are securely stored.
address this issue within a reasonable time period.
• The trust must ensure there is an adequate skills mix
• The trust must ensure nursing intervention records are
on all medical wards and that staff have the right level
consistently completed.
of competence to effectively nurse the patients they
• The trust must ensure that thickening powder is
are asked to care for.
securely stored.
• The trust must do all that is reasonably practicable to
• The trust must ensure that patient’s dignity is
ensure there is safe staffing on the medical wards.
preserved at all times across the medicine division.
• The trust must ensure that patient risk assessments
are completed and updated at regular intervals. Action the hospital SHOULD take to improve
• The trust must ensure that it is compliant with the
• The trust should ensure there are regular morbidity
Mental Capacity Act and that all staff have the required
and mortality meetings across the medicine division.
level of training in this area.
• The trust should consider implementing clear
• The trust must ensure that its mandatory training
guidance for senior staff to use when making
reporting systems are accurate and reflective of the
judgments about staff moves.
training needs and requirements of all staff.
• The trust should ensure that where audit findings fall
• The trust must ensure all staff are up to date with their
below the trust’s expected standards, action plans to
mandatory training.
address this are created and monitored.
• The trust must ensure that at all times there is a
• The trust should improve the appraisal rate for the
suitably trained member of staff on each medical ward
medicine division.
and unit that has current adult life support training.
• The trust should ensure the proportion of patients
• The trust must ensure there is consistent
seen by a cancer nurse specialist is above audit
categorisation of the same type of incident in the
minimum standard of 80% for lung cancer.
trust’s incident reporting system.
• The trust should ensure that patients’ discharge
• The trust must ensure safeguarding training levels for
summaries are published within 48 hours.
staff are in accordance with the trust’s own policy and
best practice guidance.

57 Stepping Hill Hospital Quality Report 03/10/2017

 This section is primarily information for the provider

Requirement notices
Requirementnotices
Action we have told the provider to take
The table below shows the fundamental standards that were not being met. The provider must send CQC a report that
says what action they are going to take to meet these fundamental standards.

Regulated activity Regulation

Treatment of disease, disorder or injury Regulation 10 HSCA (RA) Regulations 2014 Dignity and
respect
1. Service users must be treated with dignity and
respect.
2. Without limiting paragraph (1), the things which a
registered person is required to do to comply with
paragraph (1) include in particular— a. ensuring the
privacy of the service user;
b. supporting the autonomy, independence and
involvement in the community of the service user;
c. having due regard to any relevant protected
characteristics (as defined in section 149(7) of the
Equality Act 2010) of the service user.
The trust was not always ensuring the privacy of the
service users it was providing care for.

Regulated activity Regulation

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care and
treatment
1. Care and treatment must be provided in a safe way for
service users.
2. Without limiting paragraph (1), the things which a
registered person must do to comply with that
paragraph include—
a. assessing the risks to the health and safety of service
users of receiving the care or treatment;
b. doing all that is reasonably practicable to mitigate any
such risks;
g. the proper and safe management of medicines;

58 Stepping Hill Hospital Quality Report 03/10/2017

 This section is primarily information for the provider

Requirement notices
Requirementnotices
h. assessing the risk of, and preventing, detecting and
controlling the spread of, infections, including those that
are health care associated;
The trust was assessing and responding to risks to the
safety of service users. The trust was not at all times
managing medicines safely.

Regulated activity Regulation

Treatment of disease, disorder or injury Regulation 17 HSCA (RA) Regulations 2014 Good
governance
1. Systems or processes must be established and
operated effectively to ensure compliance with the
requirements in this Part.
2. Without limiting paragraph (1), such systems or
processes must enable the registered person, in
particular, to— a. assess, monitor and improve the
quality and safety of the services provided in the carrying
on of the regulated activity (including the quality of the
experience of service users in receiving those services);
b. assess, monitor and mitigate the risks relating to the
health, safety and welfare of service users and others
who may be at risk which arise from the carrying on of
the regulated activity;
c. maintain securely an accurate, complete and
contemporaneous record in respect of each service user,
including a record of the care and treatment provided to
the service user and of decisions taken in relation to the
care and treatment provided;
d. maintain securely such other records as are necessary
to be kept in relation to— i. persons employed in the
carrying on of the regulated activity, and
ii. management of the regulated activity;
The trust was not monitoring and mitigating risks to
service users effectively. Records were not always
maintained and stored securely.

59 Stepping Hill Hospital Quality Report 03/10/2017

 This section is primarily information for the provider

Requirement notices
Requirementnotices
Regulated activity Regulation
Treatment of disease, disorder or injury Regulation 18 HSCA (RA) Regulations 2014 Staffing
1. Sufficient numbers of suitably qualified, competent,
skilled and experienced persons must be deployed in
order to meet the requirements of this Part.
There were not always sufficient numbers of suitably
qualified persons deployed across the medical and
urgent care area. This was observed to have a direct
negative impact on patient care and experience.

60 Stepping Hill Hospital Quality Report 03/10/2017

 This section is primarily information for the provider

Enforcement actions
Enforcementactions
Action we have told the provider to take
The table below shows the fundamental standards that were not being met. The provider must send CQC a report that
says what action they are going to take to meet these fundamental standards.

61 Stepping Hill Hospital Quality Report 03/10/2017

 This section is primarily information for the provider

Enforcement actions (s.29A Warning notice)

Enforcementactions(s.29AWarningnotice)
Action we have told the provider to take
The table below shows why there is a need for significant improvements in the quality of healthcare. The provider must
send CQC a report that says what action they are going to take to make the significant improvements.

Why there is a need for significant Where these improvements need to

improvements happen
Start here... Start here...

62 Stepping Hill Hospital Quality Report 03/10/2017