Royal Stoke University Hospital

Updated 23 June 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Royal Stoke University Hospital.

We inspected the maternity service at Royal Stoke University Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

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

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

Our rating of this hospital stayed the same. The Royal Stoke University Hospital is rated as requires improvement overall.

The inspection was carried out using a post-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, reviewed policies, care records, medicines charts and documentation.

Following the site visit, we conducted interviews with senior leaders and reviewed feedback from women and birthing people and their families about the trust.

Royal Stoke University Hospital is the main site for maternity services for the trust, with County Hospital providing a full range of antenatal and postnatal services. There were around 6400 over 12 months. It comprises of a delivery suite with maternity theatres, induction of labour beds and enhanced recovery area. There are post and antenatal wards, a midwifery birth centre, a day care assessment area and maternity assessment unit (triage). The service also provides specialist substance misuse clinics, perinatal mental health and lifestyle clinics, fetal medicine and maternal medicine services. These services are available to women and birthing people from across Stoke-on-Trent and Staffordshire.

University Hospitals North Midlands NHS Trust comprises of Royal Stoke University Hospital and a Freestanding Midwifery Birth Unit (FMBU) at County Hospital, Stafford.

At the time of our inspection intrapartum care was suspended at County Hospital, however, all other antenatal and postnatal services at County Hospital were still available.

Demographic data shows a higher proportion of mothers were in the most deprived deciles at booking compared to the national average (18% in the most deprived decile compared to 14% nationally and 17% in 2nd most deprived decile compared to 12% nationally). A report completed in 2022 showed an increase in patient complexity for women using delivery suite services with many of those using the services categorised as moderate and high risk.

Following this inspection, under Section 29A of the Health and Social Care Act 2008, the trust was served a warning notice requiring them to make significant improvements to the safety of the service. The trust wrote to CQC to submit an action plan and confirm the immediate actions taken to improve the safety of the service. The trust has kept CQC informed of progress on improvements. We found that the service had deteriorated since the last inspection on February 2020.

How we carried out the inspection

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

Updated 22 December 2021

Updated 14 February 2020

• The service had enough staff to care for children and young people and keep them safe. Staff knew how to protect children and young people from the risk of abuse. They managed infection prevention and control systems well and most medicines were managed safely. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff exceeded the expectations of children, young people and their families in their passion for patient care. There was a strong, visible person-centred culture where staff genuinely valued their relationships with children, young people and their families. They also extended their compassion towards others outside of their service. Staff recognised and respected the importance of the totality of people’s needs and used innovative methods to support family units during challenging times. Staff consistently supported and empowered children, young people and their families to understand their condition and make decisions about their care and treatment. Staff showed an excellent understanding and a non-judgmental attitude when caring for or discussing children and young people with mental health needs. They worked in a creative and innovative manner to provide exceptional, strong and caring emotional support to children, young people and their families to minimise their distress.
• The service planned care to meet the needs of local people, took account of children and young peoples’ individual needs, and made it easy for them to give feedback. Children and young people could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of the children and young people receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However, we also found:

• Staff were not always up to date with their mandatory training. Improvements were needed to ensure records relating to risk were kept and maintained. Some ligature points were present in the CAU which posed a potential risk to children and young people.
• Assessments that identified if children and young people could consent to their care and treatment were not always clearly documented.
• There was a risk that children and young people’s individual preferences and needs may not be consistently met as these preferences and needs were not always clearly recorded or accessible to staff.

Updated 2 February 2018

Our rating of this service improved. We rated it it as outstanding because:

• Following their previous Care Quality Commission inspection, the leadership team, with the support of the trust, embarked on a transformation programme to address the issues highlighted in all domains.
• Within the safe domain, there were improvements required to increase capacity for level 2 and level 3 patients. This had been achieved by introducing designated units and understanding patient complexity to inform the skills mix and determining nursing requirements. The number of agency staff had decreased and an effective outreach facility helped with access and flow of patients who required the service.
• Local systems and processes reflected a culture of reducing harm and improving. For example, regular audits and reviews, local champions and the introduction of advanced skilled practitioners supported learning.
• The trust had invested in a state of the art electronic patient record system. The technology supported safe management and care of patients. It meant staff could access and update patient information when needed.
• At the last inspection the trust did not contribute cardiac critical care data to the Intensive Care National Audit Research Centre (ICNARC). It had since been introduced, which meant that the information could be used to identify areas for improvements.
• Staff expertise and practical skills were strengthened by the support of a range of practice development nurses, advanced critical care practitioners and quality nurses. There were strong links with local universities and some of the advanced critical care practitioners were honorary lecturers.
• Staff demonstrated compassionate and dignified care for all. We saw this in our observations, discussions with patients and those involved in their care. Patients’ and families religious, emotional, and social needs were considered and the resources provided.
• Critical care was accessible, patients’ needs were catered for and they were also afforded a suitable space to make their experience in critical care comfortable and supportive. There was an access and flow co-ordinator who helped manage waiting times, discharges and to keep delays to a minimum and where possible avoid cancellations.
• The leadership team demonstrated in their transformation work that they were effective and knew what was needed to deliver excellent and sustainable care. They reviewed and evidenced progress against the strategy and plans. This clearly demonstrated their commitment to improvements.
• Excellence was at the heart their achievements. This was demonstrated in their evidenced based approach and research led culture. We saw lots of evidence of innovation and creativity and commitment to research in key areas relevant to critical care.
• There was strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences. There was clear demonstration to commitment to best practice and use of a range of performance and risk management systems and processes. Staff told us that they felt proud to work for the trust and spoke highly of the organisation and culture.

Updated 2 February 2018

Our rating of this service improved. We rated it as good because:

• We saw staff were aware of how to report incidents and provided examples of incidents they would report. We saw changes to practice had occurred following incident investigations.
• Documentation had improved since our previous inspection in 2015. We saw improvements with the recording of Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) decisions.
• We saw improvements with the use of individualised care plans as these were used for all patients and were highlighted for staff with colour coded materials.
• We saw that there had been improvements with the prescribing of anticipatory medicines for patients since the last inspection.
• End of life care training formed part of staff mandatory training; ensuring staff were familiar with the processes to follow for the identification and care of patients at the end of life.
• Specific equipment regularly used with patients at the end of life, such as syringe drivers, was readily available which was an improvement since the previous CQC inspection.
• Staffing within the specialist palliative care team, mortuary team and bereavement teams was sufficient to meet the needs of patients.
• We saw the trust had improved their results within the National Care of the Dying Audit for Hospitals; and had action plans to address areas where performance indicators had not been met.
• The end of life care service followed guidelines set by the National Institute of Health and Care Excellence (NICE) regarding end of life care.
• Staff were caring and compassionate in their approach to patients and relatives. Staff made effort to protect privacy and dignity, even when patients were located within a ward bay rather than a side room.
• The purple bow scheme assisted staff to be responsive to patient and relative needs, and to provide a service over and above what is normally offered to patient visitors. This supported a positive experience for patients at the end of life, and their relatives.
• The end of life care service was recognised at trust board level, and had a trust strategy to support its delivery. Staff were aware of the end of life care objectives and sought to achieve these within their day to day roles.

However:

• We saw that staff did not undertake Mental Capacity Act assessments with patients who were identified as potentially lacking capacity when completing DNACPR forms.
• We saw staff training in, and availability of, the end of life care specific individual care plans had been rolled out across Royal Stoke hospital during 2017 prior to our inspection. However, we saw that not all information was always completed such as sections covering the spirituality needs of patients.
• We saw that the trust failed to meet four out of five clinical indicators as part of the ‘End of life care: Dying in hospital’ audit, 2016.
• The trust did not monitor patients achieving their preferred place of care, or patients achieving rapid discharge.
• There was no local risk register for the end of life care service; instead one risk was identified for the service on a corporate register.

Updated 23 June 2023

Updated 14 February 2020

We rated it as requires improvement because:

• People could not always access services when they needed it and receive the right care promptly. Waiting times from referral to treatment were not always in line with good practice for some clinics.
• Systems to manage performance and risk were not always effective in identifying and escalating relevant risks and performance issues or in identifying actions to reduce their impact.
• Although staff completed and updated risk assessments for each patient and removed or minimised risks. Staff were unaware of whether there was a policy to guide them in identifying and quickly acting upon patients at risk of deterioration.
• There was a lack of effective monitoring of patient outcomes. This meant they could not be used to improve services.
• The fracture clinic waiting room was not big enough for the amount of people attending clinics.

However;

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Updated 2 February 2018

• The service did not manage patient safety incidents well. While staff recognised incidents and reported them appropriately and managers investigated incidents, lessons learned were not shared effectively with the whole team and the wider service.
• Not all areas of the service’s premises were suitable, and some equipment was stored inappropriately.
• Managers were not achieving the trust’s target to appraise staff’s work performance through supervision meetings with them to provide support and monitor the effectiveness of the service.
• People could not always access the service when they needed it. Waiting times for some kinds of treatment were worse than other, similar services in England. People whose operations were cancelled for non-clinical reasons did not always have them completed within 30 days of the cancellation.

Updated 22 December 2021