Archived: Staffordshire & Stoke-on-Trent Partnership NHS Trust

Letter from the Chief Inspector of Hospitals

The Staffordshire and Stoke on Trent Partnership NHS Trust provides community health and adult social care services and is responsible for adult social and community healthcare within Staffordshire, and community healthcare in Stoke-on-Trent. It also provides health and care services in the community, including community hospitals, health centres, nursing homes, schools, prisons and in a patient’s own home.

Staffordshire and Stoke on Trent Partnership NHS Trust currently provides Sexual Health Services in Shropshire, Telford & Wrekin and Leicestershire.

It serves a population of more than 1.1 million people and employs more than 6,000 staff.

We inspected this trust as part of our comprehensive inspection programme. We visited the trust on 2 to 6 November 2015; additionally we carried out unannounced visits to a number of locations.

During our announced visit we carried out a full inspection of the trust testing whether services are safe, effective, caring, responsive to people’s needs and well led. We looked at all the services it provided. We inspected community inpatient services; services for adults; services for children, young people and their families; end-of life-care services; sexual health services and dental services. The CQC also inspected adult social care provided by the trust at a number of locations. These reports have been published and services were rated as Good at Living Independently Staffordshire - Lichfield & Tamworth, Living Independently Staffordshire – Moorlands and Requires Improvement at Brighton House Care Home.

Following our visit, we remained concerned about a number of services that the trust provided and we issued it with a warning notice setting out areas where it needed to make immediate, significant improvements to services. We received an action plan from the trust setting out the steps it intended to take with regard to the immediate issues we raised.

In 2014, three whistle-blowers independently contacted the Care Quality Commission (CQC) to share concerns about the trust. Specifically, they raised concerns about a poor leadership culture; unsafe staffing levels and, resulting from this, patient safety. We carried out an unannounced visit to a targeted area of the trust (community inpatients and community services for adults) over one day in November 2014. We looked only at whether the services were safe and well led.

We published our report from this inspection. We said that the trust must review its staffing levels in community adult nursing; must ensure staff were engaged in change and improvement programmes; and must improve communication and engagement with staff.

The Staffordshire and Stoke on Trent Partnership NHS Trust created a role of ‘Ambassador for Cultural Change’. This innovative role was designed to allow the staff voice to be heard and concerns from staff to surface in a way that focused on the topic rather than the individual, protecting the identity of any staff member wanting to remain anonymous. This initiative received significant national attention. We saw that not all staff were happy with this role. They were often guarded and concerned they might not have the full protection promised. While some staff engaged with the Ambassador for Cultural Change many felt that the actions from this did not follow on as expected.

Overall, we rated the trust as inadequate for Well Led. We rated the trust as Requires Improvement for Safe, Effective and Responsive, and we rated it as good for Caring.

Overall, we rated the trust as Requires Improvement.

Our key findings were as follows:

• There were significant staffing shortages in community services for adults. This led to poor and unsafe practices, for example, we saw some shifts with no trained nurse on duty.

• Staff in community services for adults were under significant workload pressure. We did not see adequate action from the senior management or the trust executive to manage the significant issues that threatened the delivery of safe and effective care. Staff morale was low.

• Services in the community for adults were inequitable between North and South of the trust’s area. We identified this along with poor staffing, in our 2014 visit; in our 2015 visit, we found this had not improved.

• Due to increased demand, patients visits were frequently cancelled or if the day staff could not visit they were handed over to the night staff. In some cases, they could not see the patients either, so handed them back to the day staff.

• Handover between community nursing teams was inadequate and in some areas carried out by answerphone. The trust did not collect any data on the number or frequency of cancellations.

• The ‘do not attempt cardio pulmonary resuscitation’ (DNACPR) order recording system was not operating effectively; practice varied across the trust and was unsafe. DNACPR documentation was poorly completed.

• We found poor prescribing practices in end-of-life care. There were no formal arrangements in place to support and oversee the prescribing practice and competence of the palliative care nurse consultants.

• There was no credible statement of vision or strategy for end-of-life care services. Systems and processes to assess, monitor and improve the quality and safety of end-of-life care services were not sufficiently established or operated.

• There was limited data on patient outcomes. Staff told us they were too busy to monitor this information. The trust did not collect data on some routine areas of provision (for example, responding to urgent and routine appointments) and was, therefore, unable to assess how well it was meeting peoples' needs.

• Compliance with mandatory training and staff appraisal were below the trusts target.

• Appointment systems in Sexual Health services do not enable people to access service when they need to; there are long waiting times in some areas and no action to address this. Test results were not always shared in a timely way.

• The trust had not undertaken a full analysis of staff requiring safeguarding training for children above level 1 reflecting the requirements of the Intercollegiate Document on safeguarding children and young people. Not all staff working with children were trained to the required level to ensure they were able to fully protect vulnerable children. 

• Staff were not well engaged with the trust’s overall vision and strategy; many staff said they were too busy. Some staff told us senior managers were less visible to the clinical teams within the service.

• Infection prevention and control procedures were good. We saw staff adhere to handwashing procedures and the use of hand gel. We saw that nursing and medical staff washed their hands and used hand gel between patients.

• Staff were caring and supportive of their patients. Despite the challenges in some areas with workload, staff put their patients at the heart of their work.

We saw several areas of outstanding practice, including:

• The trust recently set up a palliative care contact centre in the North division to improve care for patients needing palliative or end-of-life care. This drew on services from a range of local providers to meet individual patient needs.
• We saw that services in the trust’s community dental health services were good in all areas.
• The staff on Bennion ward at Bradwell Hospital had introduced many dementia care initiatives, including:
• staff wearing theatre scrubs on night duty to mimic nightwear so that patients living with dementia were encouraged to sleep, and night time care plans.
• A reminiscence room with pictures and books.
• A garden shed had been changed into ‘The Bradwell Arms’ where patients, in better weather, would be able to play darts and cards.

However, there were also areas of poor practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure staffing levels in community adult nursing are sufficient to ensure that patients receive safe and effective care in a timely way and that this is continually reviewed using a systematic approach to determining the number of staff and range of skills required.

• Review caseloads and workloads of staff in the community adult teams to ensure that the significant issues that threatened the delivery of safe and effective care and addressed and mitigated.

• Ensure that DNACPR practice across the trust is consistent, the effectiveness of the DNACPR policy and procedures and regularly reviewed and audited.

• Review the nurse consultant prescribing procedures for pain management in end-of-life care services, ensuring that more effective systems of support and clinical supervision are put in place.

• Develop a vision and strategy for end-of-life care services which sets out the objectives and plans for the service and reflects the local health economy needs. The strategy should be embedded in the organisation and shared widely with staff so they understand it. Leadership of end-of-life care services should be clarified and clearly articulated to all staff.

• Develop a training needs analysis and clear plan to ensure all relevant staff in all services are trained to level 3 in adult safeguarding and child protection to comply with requirements of the

• Review appointment processes in sexual health services to ensure that patients and the public are able to access services in a timely manner.

• Ensure that patients and the public are not put at risk by ensuring that all post-test contact systems within sexual health services have sufficient staff to ensure late or missing results are identified.

At the end of the inspection, we issued the trust with a warning notice served under Section 29A of the Health and Social Care Act 2008. The warning notice related to consent, systems to assess, monitor and mitigate risk, systems to assess, monitor and improve the quality and safety of services and Duty of Candour.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Substantial staff shortages meant that patients were at increased risk of avoidable harm. Poor staffing levels in some parts of the service had a significant impact on its ability to provide safe care. Due to these poor staffing levels, uptake of mandatory training was below trust target levels, and documentation, including risk assessments, were not kept consistently up-to-date.

Staff reported incidents and felt supported to do so, but learning was limited and not always shared. Staff understanding of the Duty of Candour regulations was mixed. Not all staff had an understanding of the meaning of Duty of Candour.

Care and treatment reflected current evidence-based practice but there was limited data on outcomes of care for patients. Staff told us they did not have the capacity to collect relevant information.

The service had not met its target on completion of staff appraisals, and access to clinical supervision was limited for nursing staff. Staff said there were opportunities for training and development but demand on services meant that opportunities to attend training were limited.

We observed staff gaining consent to treatment and care verbally but this was not consistently recorded. Staff awareness of the Mental Capacity Act was patchy and the service had not ensured that staff were fully aware of their responsibilities under the legislation.

Although targets had been set for responding to urgent and routine appointments, the service did not routinely collect data on performance against these targets, so it could not determine if it was responding to peoples' needs.

Although staff were clear on the purpose and vision for the service, the values were not widely shared and there was no clear strategy. Staff did not feel supported by senior managers and felt they did not understand the daily challenges staff faced. Community nursing teams showed a strong patient focus, but many staff described a culture of fear and anxiety about the safety of the service. Managers in the service were sighted on a number of challenges facing the service but had not taken effective steps to address then or monitor activity to measure the impact. The delivery of high-quality care was not assured by the leadership, governance and culture of the service. We found there were inconsistencies with effective leadership across adult community services.

People were supported and treated with dignity and respect and they were involved as partners in their care. Feedback from people using services was positive about the way they had been treated by staff.

The vision and strategy for the service were not developed, leaders were unable to articulate the key elements of the strategy and how it aligns with the trust-wide vision and strategy. Risk registers did not reflect some of the key issues facing the service.

There is an increased risk that children and young people (CYP) are at risk of harm because there is limited assurance about training for staff. The trust had not met its target of 90% of all staff completing mandatory training; this included level one child protection training. The trust was unable to confirm the number of staff who were up to date with level two and level three child protection training.

The trust had also not achieved its target for staff appraisals, meaning that staff may not have their learning needs identified and/or be supported to undertake training and development.

There were no care pathways or arrangements for transition to adult services for children with complex needs and access to electronic patient information was poor, systems to manage and share patients' records were not always effective.

Children, young people and their families were treated with dignity and respect and were involved as partners in their care. Information about care and treatment was delivered in a way that children understood and so could make informed choices. Care and treatment followed evidence based practice and outcomes for patients, where available were good. We saw effective multi-disciplinary working and good arrangements around consent.

Incidents were reported and investigated and there was evidence that learning from incidents took place. The trust had met the 2015 trajectory target in response to the National Health Visitor Implementation Plan.

CYP services were planned and delivered in a way that met the needs of the local population. Services were flexible and the needs of different people were taken into account. We found a positive, patient-focused culture, leaders were supportive and staff felt valued.

We observed exceptional multi-disciplinary team (MDT) working in the hospitals with professionally managed, patient focussed, MDT meetings and discussions. Patients told us they were treated with kindness and compassion; their dignity had been respected. We were told that patients and those close to them received the support they needed to cope emotionally with their care, treatment or their life changing condition.

We found all areas to be clean, well maintained and tidy. We saw that the trust followed local and professional guidance and the staff were familiar with the policies and procedures. Patients reported that they received sufficient and appropriate pain relief and their nutritional state had been assessed and monitored as part of their care.

The community services were planned and delivered to meet the needs of the local population with patients' expectations being considered in ‘goal’ planning meetings. People with complex needs were assessed and supported by specialist teams of staff including therapists and communication assistance. We saw dementia friendly environments supporting patients and those close to them with diversional therapies and specialist advice.

We heard that when complaints were received these were discussed at ward meetings. We heard that staff and patients listened to each other and independence was promoted in line with the community hospital values. Staff told us they were proud to provide high quality, safe services. We heard how the ward staff promoted their patients' returns home by meeting and planning with community care workers, patients and their carers. The ward managers told us they worked well in supporting each other. Monthly staffing levels were published for the community hospital wards, including the actual staffing levels. We saw that staffing was assessed to the shift-by shift service need, taking into account the demand on the service.

The safety performance at the hospitals was displayed at ward level, staff told us they were encouraged to report all incidents however shared learning had not been encouraged.

We saw a high number of missed medication doses on the wards which were not reported as per trust policy. The documentation did not explain the reason for the omission in all cases.

In the minor injuries clinic at Leek Moorlands we found that patients may be unobserved for up to 40 minutes in the waiting area whilst other patients were triaged. The site had no security personnel and the nursing staff described vulnerable situations when they had called the police to escort unwanted visitors out of the department. Medical and nursing staff told us that during the ‘out of hours’ period they felt vulnerable; they had experienced, on a few occasions, when timely emergency assistance for patients had been delayed or not been available.

The mandatory training target of 90% was not met overall in any area. Ward managers were aware of the shortfall in training levels which was mainly due to staff not being available with short and long term sickness.

Systems or processes were not sufficiently established or operated to effectively ensure the trust was able to assess, monitor and improve the quality and safety of End of Life Care services or to identify and manage risk. There was no overall vision, no executive board member providing leadership and no recognition of the trust-wide End of Life Care strategy group.

The service did not achieve many of its key performance targets in 2014/15, including fast tracking patients home in the last days of life and clinical quality indicators set by commissioners. The service carried out very few local clinical quality audits during 2014/15.

End of Life Care patient care plan records were not always fully completed and progress notes did not always match the relevant goal on the plan. The ‘do not attempt cardio pulmonary resuscitation’ (DNACPR) Order recording systems were not operating effectively; practice varied across the trust and did not protect patients from the risk of avoidable harm. Systems in place to establish patients’ capacity and to make decisions about their welfare and care were not always followed.

All staff caring for End of Life Care patients treated them and their relatives/carers with kindness, respect and compassion. Relatives caring for patients in their own homes were very positive about the support they received from community nurses supported by palliative care lead and specialist nurses.

The trust had not undertaken a full analysis of staff requiring safeguarding training for children and young people above level 1. Staff working in sexual health services were not trained to the required level to ensure they were able to protect vulnerable children and young people. The service had failed to meet its own targets for staff mandatory training.

Patients who attended the service in Leicester and provided positive test results for sexually transmitted infections were not always contacted within the advised two-week response time. As patients were advised, that “no news was good news”, this put patients and others at risk as it could result in infected patients having unprotected sex and passing on an infection.

Services operated on a walk-in basis and appointments were available on request. At busy times, the service employed a triage system but this was not done systematically, there was no standard operating procedure. The number of patients turned away and rescheduled appointments were not monitored to ensure patients were able to access services in a timely manner and the service was able to respond to patient need.

Governance systems and processes did not operate effectively, some systems to monitor performance and safety issues were not in place. Staff based outside Staffordshire did not feel part of the trust. Staff satisfaction was mixed, not all staff felt engaged and teams did not always work cohesively.

However, we also saw that staff demonstrated a caring, inclusive, compassionate attitude. Patients and carers felt engaged and involved in their care and treatment. Patients were satisfied with the care they received. There was access to emotional and psychological support for patients. Treatments followed recognised pathways and best practice in line with national guidance. Staff followed best practice guidance when obtaining consent and dealing with young people. Infection prevention and control measures were in place. Systems were in place to ensure medicines were managed, stored and administered or prescribed safely.