County Hospital

Updated 23 December 2022

We inspected the medicine core service on the 4 October 2022. This was a follow-up focused inspection in response to a warning notice issued in 2021 whereby we notified the trust that the Care Quality Commission had formed the view that the quality of health care provided in relation to medical staffing in urgent and emergency care at the Royal Stoke University Hospital and the risk management of patients with mental health needs medicine at County Hospital required significant improvement.

Updated 23 December 2022

Updated 2 February 2018

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

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

• 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 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.
• 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.
• 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 (NCDHA); 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 Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) forms.
• 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.
• We saw variable completion of individual care records for end of life patients.
• 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 14 February 2020

We rated this service as good because:

• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well.
• Staff assessed risks to patients, acted on them and kept good care records. 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 monitored the effectiveness of the service and 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. 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. Some 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.

However:

• Not all staff had training in key skills.
• Not all staff were up to date with their appraisals.

Updated 14 February 2020

We previously inspected this service jointly with diagnostic imaging and are not therefore able to compare the ratings. 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.

• There had been issues with chemotherapy treatments not being on transports from Stoke. This meant the trust could not be assured that patients’ medicines would be available in a timely way at all times.
• Systems to manage performance and risk were not always effective. The risk register was not effective in identifying and mitigating risks to patient care and treatment. Therefore, we were not assured that all patient risks had been identified and acted upon.
• Some incidents were not reported on the electronic incident reporting system. For example, staff requiring to stay beyond their working hours to ensure patients were chaperoned whilst waiting for transport. There were discrepancies in the recording of ‘near misses’ on the electronic incident reports, these are incidents which might have resulted in harm to a patient.
• Although, staff told us how they would respond to an emergency involving a child or young person, there was no policy staff were aware of in regards to a deteriorating child in the main outpatients department. This meant staff did not have clear guidelines for managing a paediatric emergency.
• There was a lack of records audits for County Hospital, this meant the trust could not be assured that patient records were full and complete. Staff in the outpatients ‘hub’ told said consultants occasionally omitted the time to next booking from patients paper based outcomes forms. Staff at the hub told us they had been advised to put these patients on the six week waiting list. This meant administrative staff were making decisions about when some patients should attend their next appointment.
• Not all leaders were visible and approachable for staff. Most staff we spoke with described local leaders as present and approachable. Local managers told us senior managers were accessible and visible. However, some staff told us it was difficult for staff based in County Hospital to access senior managers that were based at Royal Stoke Hospital
• There was a lack of effective monitoring of patient outcomes at County Hospital. This meant audit findings could not be used to improve services. The outpatients’ dashboard did not gather information on patient outcomes.
• The governance structure for all outpatients services was not always clear and consistent. Governance was devolved to divisions and each care division operated independently. County Hospital was under represented at some governance meetings
• Although staff said the trust promoted a culture of outpatients across sites being ‘one team,’ this was not fully embedded. Some staff told us there was a ‘them and us’ culture between Royal Stoke Hospital and County Hospital. Although most staff said this was improving.

However:

• The service had enough nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
• The service provided mandatory training in key skills to all staff and made sure staff completed it.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
• The service controlled infection risk well.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• The service made sure staff were competent for their roles.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Staff cared for patients with compassion. Staff were mindful of the emotional wellbeing of patients and took steps to support patients and families where necessary.
• The service was inclusive and took account of patients’ individual needs and preferences.
• It was easy for people to give feedback and raise concerns about care received.
• Staff were committed to continually learning and improving services.

Updated 22 December 2021

Updated 14 February 2020

Our rating of this service went down. We rated it as requires improvement because:

• The service did not make sure all staff completed mandatory training in key skills. Staff did not update all risk assessment documentation completely and consistently. There was not enough of all suitable equipment for resuscitation of children.
• There was a lack of effective monitoring of care and treatment. Staff did not consistently document capacity assessments or information relating to pain relief. Not all clinical staff completed training on the Mental Capacity Act and Deprivation of Liberty Safeguards. Data provided by the trust below showed low completion rates of staff appraisals.

However:

• 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. 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 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.

We rated safe and effective as requires improvement and caring, responsive and well-led as good.