All inspections: Royal Stoke University Hospital

University Hospitals of North Midlands NHS Trust provides a general acute hospital services for over 1.1 million people in Staffordshire, South Cheshire and Shropshire. The trust provides a full range of hospital services. The trust also provides specialised services for three million people across a wider area, including neighbouring Counties and North Wales.

The Emergency Department (ED) at the Royal Stoke University Hospital is open 24 hours a day, 7 days a week. The trust is a major trauma centre and receives patients by helicopter as well as land ambulance. There is also an urgent care centre located adjacent to the main waiting area but does not provide a 24 hours service.

We carried out an unannounced visit on 14th March with a follow up announced visit on 26th March of the Emergency Department only under the winter pressure inspection programme.

We spoke with various members of staff, patients, relative and carers. We reviewed 10 sets of patient records.

We rated the service as Requires Improvement because:

There were significant handover delays for patients arriving by ambulance and for those who self-presented to the emergency department.

Not all patients were seen in a timely way

Not all risk assessments were completed

We carried out an unannounced visit on 14th March with a follow up announced visit on 26th March of the Emergency Department (ED) only under the winter pressure inspection programme. The Royal Stoke University Hospital provides a range of NHS hospital services. The ratings for ED remained the same as Requires Improvement. The rating from ED has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at University hospitals of North Midlands NHS trust.

We spoke with various members of staff, patients, relative and carers. We reviewed 10 sets of patient records. We rated the service as Requires Improvement because: There were significant handover delays for patients arriving by ambulance and for those who self-presented to the emergency department. Not all patients were seen in a timely way. Not all risk assessments were completed.

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.

We inspected the medicine core service and urgent and emergency care 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.

The trust provides a full range of hospital services including urgent and emergency care, critical care, medical care, surgery, end of life care, maternity and gynaecology, and outpatients services at both hospitals. Services for children and young people are provided at Royal Stoke University Hospital and County Hospital.

In addition to these services, the trust is also a tertiary centre on the Royal Stoke site for trauma, cardiology and spinal care.

Royal Stoke Hospital: The Royal Stoke Hospital is a large acute hospital in Stoke on Trent. They offer several secondary care services including medical care, maternity, surgery and children and young people services. The hospital is also a regional trauma centre and offers direct major trauma care to patients from across the region and north Wales.

The Emergency Department (ED) at the Royal Stoke Hospital is open 24 hours a day, seven days a week. The trust is a major trauma centre and receives patients by helicopter as well as land ambulance. The helipad where patients were brought in was outside the green ambulance entrance. Due to the COVID-19 pandemic, the department had changed the layout to adhere to recommended infection prevention and control guidance. The department now consisted of:

Six triage cubicles.
Seven trolley spaces in the ambulance assessment.
High risk ambulatory with five treatment rooms
Medium risk ambulatory with four treatment rooms and four trolley’s.
Medium risk majors with 15 cubicles and one side room.
High risk majors with 16 enclosed cubicles and three side rooms.
Medium risk resuscitation (resus) with eight enclosed cubicles. One bay is set up as a trauma bay and one set up for paediatric patients.
High risk resus with 10 enclosed cubicles. One cubicle was reserved for paediatric patients.
Children’s ED had one triage, one escalation room, separate waiting rooms (high and medium risk), four cubicles, two treatment rooms and three escalation bays.

At the time of our inspection, patients with minor illness, injuries or ailments were redirected to alternative treatment facilities. There was also an urgent care centre located adjacent to the main waiting area. This was managed separately by another provider and therefore did not form part of this inspection.

During the inspection, we visited the emergency department. We spoke with 48 staff including registered nurses, health care assistants, reception staff, medical staff, and senior managers. We spoke with eight patients. During our inspection, we observed care and treatment and reviewed 26 sets of patient records.

We also carried out a short notice announced inspection of medicine core service because of several serious incidents relating to falls and pressure ulcers had been reported to us.

Medical services at Royal Stoke Hospital were last inspected in 2019 where it was rated as requires improvement overall. Please refer to our previous trust and location reports for details of regulatory action taken.

During our inspection, we visited the frail elderly assessment unit, acute medical unit, respiratory ward and general medicine wards.

We spoke with 60 staff including, doctors, allied health care professionals, health care support workers, ward managers, sepsis leads, matrons, nurse practice educators, discharge coordinators, a safeguarding lead, a mental health lead, a chief dietitian, a clinical lead for speech and language therapy, head of therapies, the acting associate director for medicine, the medicine divisional chair and the deputy associate chief nurse for medicine. We also spoke with ten patients about their care and treatment.

We reviewed the care records of 12 patients and reviewed staff training records, and governance records, such as minutes of meetings, audit information and relevant policies and procedures.

Our rating of services went down. We rated them as Requires Improvement because:

Our rating of safe was Requires Improvement overall. Risks within the emergency department were not always identified and escalated appropriately. We were not assured that all patients allocated to wait on the corridor were safe. Not all staff had completed all of the required mandatory training. Not all staff had training on how to recognise and report abuse. However, despite the low training figures, staff we spoke with were knowledgeable on how to recognise and report abuse. Both nursing and medical staff throughout the core service did not meet the trusts targets for safeguarding training. The service did not always have enough nursing staff with the right qualifications, skills and experience to keep patient's safe from avoidable harm and to provide the right care and treatment on all wards. Staff did not always undertake observations of patients’ vital signs in a timely manner. Risk assessments relating to patient malnutrition were not undertaken in line with the trust target
Our rating of effective was Requires Improvement overall. The service did not always provide care and treatment based on national guidance and evidence of its effectiveness. The service did not always ensure staff were competent for their roles. Managers sometimes appraised staff’s work performance to provide support and monitor the effectiveness of the service. Staff did not always assess and monitor patients regularly to see if they were in pain. Staff did not always understand their roles and responsibilities under the Mental Capacity Act 2005. They did not always know how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
Our rating of caring was good overall. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment. Staff cared for patients with compassion however, patient dignity was sometimes compromised.
Our rating of responsive was requires improvement overall. People could not always access services when they needed. The service treated concerns and complaints seriously however, complaints were not always responded to within appropriate time frames or learning effectively shared.
Our rating of well led was requires improvement overall. Not all managers had the right skills and abilities to run services providing high-quality sustainable care. Departments did not always have effective systems for identifying risks.

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.

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.

We asked people who use the service (patients) about how well the hospital provided information to them on their care and treatment and how well their dignity and privacy was respected when being treated in the hospital. In general, people felt that they were given information but that there were areas for improvement. More information was needed to explain what would happen when discharged from hospital and in busy areas such as A&E, people felt that they were not always supplied with enough information about what to expect.

People we spoke to on wards told us that they were able to express their views and confirmed that they felt informed and that nursing and medical staff had explained treatment, procedures and care to them. Patients on wards generally felt that staff had time to answer questions and queries. They also felt that staff had treated them with consideration and their privacy had been respected. Patients accommodated on wards also told us that staff made time to talk to them and provided plenty of information about their condition and any tests and treatments. They said that discharge had been discussed with them and arrangements made for care at home. They told us that they were treated with respect and that visitors were made to feel welcome.

Overall patients were very satisfied with the nursing, medical care and treatment they were receiving in the hospital. In A&E, there was dissatisfaction with long waits in holding wards and corridors. In these areas patients felt that they were waiting around for too long, not given enough information and that there was a lack of patient confidentiality and dignity. We heard that where admission to a ward from the accident and emergency department was delayed, equipment they had been assessed for, such as pressure relieving mattresses, was not always available.

Everyone we spoke with during our visits were happy with the way that they were treated by the staff who work for the trust. Patients and their representatives were complimentary about staff attitude towards them and told us that staff were 'caring', 'respectful', 'considerate' and 'polite'. Patients on the wards confirmed they would be happy to raise concerns and that they would speak to staff in the first instance.

Patients were generally aware of the information provided in the bedside book and that this included information on raising concerns. However none of the patients and visitors we met with on A&E were clear about how to raise concerns.

In respect of the meals served at the hospital, a number of patients we spoke with expressed dissatisfaction with these. We were made aware that patients are not always given a choice for each meal that takes into account their individual preferences and needs.

Royal Stoke University Hospital

All Inspections

During an assessment of Urgent and emergency services

During an assessment of the hospital overall

7 March 2023

During an inspection looking at part of the service

4 October 2022

During an inspection looking at part of the service

24 and 25 August 2021

During a routine inspection

05 Jun to 01 Aug 2019

During a routine inspection

3 October to 16 November

During a routine inspection

21 April 2015

During an inspection of this service

April 2015

During a routine inspection

11 December 2013

During a themed inspection looking at Dementia Services

20 July 2012

During an inspection looking at part of the service

20 March 2012

During a themed inspection looking at Termination of Pregnancy Services

10 January 2011

During an inspection looking at part of the service

18, 29 January 2011

During a routine inspection