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

Updated 2 July 2018

Staffordshire and Stoke-on-Trent Partnership NHS Trust delivers a wide range of community health and adult social care services across a diverse population of over 1.1 million within the geographical boundaries of Staffordshire County Council and Stoke on Trent City Council, covering both urban and rural areas.

For adult community services we inspected the regulated activities across 12 teams within Staffordshire that provided community adult nursing under the trusts registration. The nursing teams we visited were based at; Rising Brook Health Centre (Stafford), Greyfriars Therapy Centre (Stafford), Moorlands House (Leek), Milehouse Primary Care Centre (Newcastle under Lyme), Wombourne Clinic (Wombourne), Bilbrook House (Codsall), Sandylane Health Centre (Rugeley), Meir Primary Care Centre (Stoke on Trent), Bentilee Neighbourhood Centre (Stoke on Trent) and Merlin House (Tamworth). Some of these bases hosted more than one team. Each team or service had a team leader who provided day-to-day operational leadership. The team leads were managed by neighbourhood managers who were in turn managed by area managers.

Services we inspected were provided in people’s own homes, residential homes and within clinics.

During the two weeks leading up to our inspection we held seven staff focus groups where we spoke with a total of 54 members of community nursing staff from across Staffordshire.

During our inspection, we spoke with 27 patients, 14 carers or relatives and 51 community based staff (including administrators, nurses, therapists and community nursing managers). We also spoke with the Director of Nursing and the Head of Quality Governance. We looked at 45 sets of patient records.

The trusts community nursing teams completed 614705 face to face contacts between 1 March 2017 and 28 February 2018. 583482 visits were made between 8am and 6pm and 37413 of these visits were made between 6pm and 8am. A total of 31223 patients received care from community nursing teams in same time frame.

There had been recent changes to the service with a separation of social care staff from within the teams.

Updated 2 July 2018

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

Updated 2 July 2018

Good

Overall rating for this core service

When we last inspected this core service in 2015 we found that the trust were in breach of a number of Regulations. These breaches meant people had been or had been at risk of receiving unsafe, ineffective and unresponsive care. At that time, effective systems were not in place to ensure the service was consistently well-led. At that inspection, we rated the core service as inadequate and we served a Warning Notice to the Trust on 15 December 2015 informing the trust of the improvements they were required to make.

At this inspection, we focussed on how community nursing services operated within the trust as the concerns we found at our previous inspection mostly centred around these services.

At this inspection, we found significant improvements had been made and we identified no regulatory breaches. We found that:

• Incidents were reported, investigated and learnt from across the trust.

• Staff understanding of the duty of candour was much improved since the previous CQC inspection in 2015 (the duty of candour regulation under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires health service bodies to act in an open and transparent way with people when things go wrong).
• Staffing levels were sufficient to keep patients safe.
• Medicines were recorded and administered as per national guidelines.
• Patient records were, in the majority, well completed and contained sufficient information to keep patients’ safe.
• Patients received care and treatment that was evidenced based and met best practice guidelines.
• Staff was appropriately qualified and competent at the right level to provide the care that patients required.
• There were improved arrangements for staff supervision and appraisal.
• There was a multidisciplinary collaborative approach to care and treatment.
• There were appropriate systems in place to monitor and improve quality and patient outcomes.
• Staff could access the information they needed to assess, plan and deliver care to patients in a timely way.
• Consent to care and treatment was obtained in line with legislation and guidance including the Mental Capacity Act 2005.
• We found that the trust used do not attempt cardio pulmonary resuscitation (DNACPR) records and staff had appropriately completed them.
• People were supported and treated with dignity and respect and they were involved as partners in their care.
• Staff provided people and their families/carers with emotional support and promoted self-care and independence where possible
• Feedback from people who used community nursing services was positive about the way they had been treated by staff.
• We observed caring and compassionate interactions between patients and we saw that staff were consistently respectful and kind.
• Suitable leadership structures were in place to provide staff with the support and guidance they required.
• Staff described their team leaders and managers as approachable and accessible.
• Staff shared and followed the trusts values, vision and strategy to promote patient centred, high quality care.
• Effective systems were in place to ensure that patient safety and the quality of care was consistently assessed, monitored and managed to ensure safe and effective care was delivered.
• We found a positive shift in staff culture. Staff felt able to report safety concerns and felt empowered to make innovative changes to the way they worked to improve patient care and staff morale.

However;

• We saw some examples whereby patient care plans were incomplete or had not been updated appropriately. Furthermore, we saw that within the majority of records we looked at, demographic information had not been consistently completed.

• During this inspection, we found that mandatory training compliance varied between areas as of March 2018. In particular we saw compliance against the trust targets for fire safety training and basic life support training was consistently not met in all community nursing teams. Overall, mandatory training compliance was lower within community nursing teams located within North Staffordshire than those located within South Staffordshire.
• Some investigation reports following incidents that had caused moderate harm to patients did not have an action plan attached to show how future harm could be prevented.

Updated 11 May 2016

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.

Updated 11 May 2016

Overall we rated dental services at this trust as good. Patients’ were protected from abuse and avoidable harm. Systems for identifying, investigating and learning from patient safety incidents and infection control procedures were in place. The environment and equipment were clean and well maintained.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practises within the service. The service was able to meet the needs of the patients who visited the clinics for care and treatment because of the flexible attitude of all members of the service.

The patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion and of effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the clinics we visited the staff responded to patients' needs. Effective multidisciplinary team working ensured patients were provided with care that met their needs and at the right time. Through effective management of resources, delays to treatment were kept to reasonable limits.

Organisational, governance and risk management structures were in place. The operational management team of the service were visible and the culture was seen as open and transparent. Staff said that they generally felt well supported and that they could raise any concerns.

Updated 11 May 2016

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.

Updated 2 July 2018

When we last inspected in 2015 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 (EOLC) services or to identify and manage risk. There was no overall vision, with no board leadership. Records were not always fully completed ‘do not attempt cardio pulmonary resuscitation’ (DNACPR) Order recording systems were not operating effectively.

The previous CQC inspection of this core service, conducted in November 2015, was rated inadequate because:

Safe was rated as requires improvement, effective was rated as inadequate, caring was rated as good, responsive was rated as requires improvement and well-led was rated as inadequate. A warning notice was issued in November 2015.

Overall we saw the service had made significant progress and had addressed the majority of issues raised within the 2015 Warning Notice, however, there was still more to be done but we saw the service and the trust had sight of these and were working to improve them.

There is now an EOLC vision and the director of nursing was now the executive board member providing leadership and in line with the trust-wide End of Life Care strategy. The service fast tracked patient’s home as per their wishes in the last days of life and followed clinical quality indicators set by commissioners.

As found at the last inspection, EOLC patient records were not always fully completed for example the spiritual needs and carer support section. However, we found that DNACPR order recording was much improved. Systems were in place to establish patients’ mental capacity and to make decisions about their welfare and care were followed. We observed and heard that all staff caring for EOLC 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 leads and specialist nurses.