The Royal Stoke Hospital is part of University Hospitals of North Midlands NHS Trust. The trust was created on 1 November 2014, following integration with Stafford Hospital from the Mid Staffordshire NHS Foundation Trust. The hospital is based in Stoke on Trent and provides general acute hospital services as well as some specialised services.

We recognise that the leadership of the new trust has had the significant task of bringing together two organisations at a challenging time. We have seen that progress has been made but there is still more to be achieved.

We inspected this service in April 2015 as part of the comprehensive inspection programme. We inspected all core services provided by the trust at both hospital sites.

We visited the hospital on 22, 23 and 24 April 2015 as part of our announced inspection. We also visited unannounced to the trust until Tuesday 5 May 2015. Our unannounced visit included A&E, Medical Care Services and Critical Care.

Overall we have rated this hospital as requiring improvement. We saw that services were caring and compassionate. We saw a number of areas that required improvement for them to be assessed as safe and effective. We saw that leadership of services also required improvement at both a local and an executive level. The responsiveness of services was assessed as inadequate.

Our key findings were as follows:

• Staff were caring and compassionate towards patients and their relatives, we saw a number of outstanding examples of good care right across the hospital.
• There was a strong culture of incident reporting and staff were encouraged and supported by their managers to engage in this. This made staff feel empowered.
• Achieving safe staffing levels was a constant challenge for the organisation and there was a heavy reliance on agency and locum staff to support this.
• Systems and processes did not support patients flow through the organisation.

We saw several areas of outstanding practice including:

• A range of initiatives in services for children and young people to enhance their patient experience

• Diagnostic imaging services had received accreditation from the Royal College of Radiologists through the imaging services accreditation scheme (ISAS).
• The hospital Alcohol Liaison team had reduced hospital stay for patients with alcohol related issues by an average of 1 day per patient. This equated to 2762 hospital days saved during the last two years.
• A specialist one stop clinic had been developed for women with substance misuse issues where they could obtain the script for their medicines and then see the consultant and specialised midwife for their antenatal care.

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

Importantly, the hospital must:

• Review systems and processes to ensure patients flow through the organisation in a timely manner
• Address high waiting times in the emergency department
• Review the capacity and adequacy of the critical care services.
• Review the sustained use of recovery to accommodate critically ill patients
• The hospital should review staffing arrangements in medicine and the emergency department to ensure there are sufficient numbers of nurses and that the planned and actual staffing levels for each shift are displayed.
• The hospital should ensure that resuscitation trolleys throughout the hospital are appropriately stocked and are checked as regular intervals
• There must be sufficient and appropriately experienced staff to provide safe and effective patient care.
• There must be appropriate systems in place and available to respond to deteriorating patients and the outreach team must be able to provide a service to all parts of the hospital.
• Implement the individualised care plan as soon as possible so that patients who are actively dying are supported holistically.
• Improve must be made to the discharge process for patients who wish to go home to die so that fast track discharges can be completed within 48hrs.
• Patients preferred place of death should be recorded and monitored so that the hospital can meet patients’ choices.
• The hospital must review the sustained use of recovery to accommodate critically ill patients
• The hospital must review arrangements for gynaecology patients to ensure they are provided with a safe service and are cared for by staff with the relevant skills and expertise.
• Out of hours medical cover and arrangements for emergencies in critical care must be reviewed.
• Multi-disciplinary working in critical care must be reviewed to ensure that effective working arrangements are in place.
• Patients who appear to lack capacity should be assessed appropriately when decisions about their care are being discussed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

During our inspection we visited the Emergency Department, the Frail Elderly Assessment Unit (FEAU), two elderly frail wards and two orthopaedic wards. We spoke with patients who had dementia or possible dementia and their relatives. We also looked at the care records of seven patients with dementia, and we spoke with the staff who were on duty in all of the areas we visited.

We saw that patients were assessed and placed on an appropriate ‘dementia’ or ‘possible dementia’ care pathway. This pathway sets standards of care and treatment to ensure that patients received the right care when they needed it.

We saw that patients were kept safe because their risks were appropriately managed by the staff. Staff worked closely with other providers and services to ensure that specialist assessments were completed and safe hospital discharges were facilitated.

Patients and their relatives told us they were treated with care and compassion. One patient said, “The staff here are wonderful. Everyone has been wonderful”. We saw that staff provided care in a responsive and unrushed manner. One relative told us, “They’ve saved her life. They wouldn’t leave her, the nurse was pumping her full of fluids. It could have gone either way but now my relative is great”.

The service was well led. A plan was in place to improve dementia care and systems were in place to assess and monitor the improvement plan.

We carried out this inspection as part of our schedule of inspections. We wanted to see what life was like for people who used the service. We also wanted to see whether the trust had made any improvements since we last visited.

A team of seven inspectors carried out the visits over two days visiting eight wards. This included visiting the elderly care unit, a medical ward, a gastroenterology ward, a renal ward, a short stay ward and the medical assessment ward. We also visited the new accident and emergency centre.

We spoke with a total of fourteen visitors and thirty four people who were using the service.

The first day of the visit was unannounced. This means that the service did not know that we were coming.

An expert by experience took part in this inspection and talked to people using the service, their visitors and staff who work for the service. An expert by experience is some one who uses services, or has had experience of services. They are people of all ages, with different experiences and from diverse cultural backgrounds. Our expert by experience took some notes and wrote a report about what they found; we have included their observations in the main body of this report.

We spoke with a total of nineteen staff members. This included a consultant, a trainee doctor, reception staff, health care support workers, nurses, physiotherapists, an alcoholic liaison nurse, matrons, a discharge liaison nurse, the chief nurse, associate chief nurse (quality & safety) and the chief executive.

Prior to our inspection visits we had contacted other agencies to see whether they had any recent information which would help us to assess the trust’s compliance. These agencies included Staffordshire and Stoke on Trent local involvement network groups (LINKS) who had visited various wards as part of their “enter and view” programmes. LINKS are made up of individuals and community groups, such as faith groups and residents' associations, working together to improve health and social care services.

Staff from the primary care trust for Stoke on Trent and Staffordshire (PCT) had also carried out visits to the trust.

The majority of the people we spoke with were happy with their care and treatment. They said, “People here are technically professional and genuinely care about a patient, that’s across the board, ten out of ten”. Another person said of the staff, “Incomparable experience the NHS staff are beyond compare.”

The majority of visitors we spoke with were also complimentary about the services their relatives had received. A visitor told us, “My relative is receiving excellent care”.

As part of our assessment of compliance we held a meeting with the trust to discuss mortality outliers. A mortality outlier is where a hospital trust has a higher number of deaths in a specific area than the national average for hospital trusts. In the respect of this trust there were four mortality outliers. With each case, we had one or several responses from the trust that significantly failed to satisfy our requirements. We therefore requested a meeting to discuss this and have included the outcome in this report under outcome 16.

A brand new hospital has been built for this trust as part of their “fit for the future” campaign. At the time of our visit most of the wards and departments had already moved and the hospital was now located over one site. There was only the renal unit left to move. Building of the new site continues and is due to be completed in 2014.

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

We carried out this inspection to see if the trust had made the necessary improvements since our last review earlier this year. We had previously assessed the trust as not being compliant in outcomes 4, 11, 16 and 21 and we had told them that they needed to improve in these areas.

We carried out unannounced visits to the hospital on 12, 13 and 14 October 2011. This included an evening visit to the accident and emergency department (A&E).

We visited the A&E department and assessment wards. We also visited the elderly care and surgical units.

As part of this review we obtained information from other involvement groups who had an interest in the service.

These included local involvement networks (Links) and the overview and scrutiny committee (OSC).

Links are groups of individual members of the public and local voluntary and community groups who work together to improve health and social care services. To do this they gather the views of local people.

Overview and scrutiny committees (OSC) for health and social care have statutory responsibilities to scrutinise health and social care services in order to recommend improvements to care. They gather evidence and information from a variety of sources, including the views and experiences of people using services and local communities.

To help us to understand the experiences people have as patients, we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. Some people using the service were able to tell us about their experiences and we also spoke with visitors and other health professionals.

We involve people who use services and family carers to help us improve the way we inspect and write our inspection reports. Because of their unique knowledge and experience of using health and care services, we have called them experts by experience. Our experts by experience are people of all ages, from diverse cultural backgrounds who have used a range of health and/or social care services.

An expert by experience took part in this inspection and talked to the people who used the service and their visitors. They looked at what happened in the wards and what it was like to be a patient. They took some notes and wrote a report about what they found and details were included in this report.

Overall we found that the trust had made improvements to all of the outcome areas we had asked them to. The trust had worked hard to bring about these improvements and had changed systems and documentation and introduced more quality monitoring at ward level. This had had a positive effect on improving outcomes for people using the service.

The trust was confident that these improvements would continue to take effect as the hospital moves over to the new site and that the systems they had introduced would continue to be rolled out across all areas.

We identified some concerns for some individual patients during our inspection and we highlighted these to the trust following our visits.

Patients and their visitors were very complimentary about the staff who looked after them. They said, “The staff are always approachable and will try to help you and make time for you, but they are always very busy”.

They told us that staff treated them with dignity and respect in circumstances that were often “busy and chaotic”.

Patients referred to staff as “kind” and “patient”.

Staff who work for the service including nursing, medical staff and paramedics told us that they thought the new procedures introduced in A&E were, “much better” and that people were triaged and seen, “more quickly” than before.

People waiting in A&E told us that they had been offered regular drinks. Patients admitted to the admission wards told us that they were given plenty of drinks and meals (where people were not nil by mouth).

Three of the thirty patients we spoke with had experienced long periods of waiting but each one of these people had only positive comments about the care and support they had received from staff whilst they were waiting.

Two out of the thirty people we spoke with told us that they did not know what was happening to them and they didn’t know who to talk to about this. The other people felt that they had been supplied with sufficient information and that staff had been, “very helpful”.

Patients across the trust felt that their personal and care needs were being met well by the staff. They felt that staff were attentive and people described care as “excellent”, “fantastic” and “couldn’t have done any more”.

Two patients and one visitor highlighted concerns about the nursing care they/their relative had received and we have raised this with the trust.

Our rating of services improved. We rated it them as good because:

• We rated safe and responsive as requires improvement, effective and well-led as good, and caring as outstanding. All ratings improved, apart from safe which stayed the same.
• Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
• We saw the trust had taken steps to improve patient flow through both hospitals, including a range of initiatives in the Emergency Departments and in medicine.
• Processes around the management of medicines had been improved in some areas.
• Staff were very caring and compassionate, universally put the patient first despite facing huge pressure on capacity.
• Staffing levels had improved and the trust had less reliance on temporary workers.
• Services in critical care and end of life care had been transformed since our last inspection.