Stoke Mandeville Hospital is part of Buckinghamshire Healthcare NHS Trust and provides a wide range of services to Buckinghamshire and surrounding areas including 24 hour accident and emergency, maternity, cancer care and outpatient services. Services also include the regional burns and plastics units, the specialist spinal unit and is the base for eye care for the area.
Stoke Mandeville, treats over 48,000 inpatients and 219,000 outpatients a year and has 479 beds
We carried out a focused unannounced inspection visit on 6 September 2016. We inspected the medical, surgical and end of life care services provided at this location. During the inspection, we also followed up issues identified at the inspection in February 2014 and March 2015 relevant to the service types inspected.
Overall, medical care, surgery and end of life care were rated as ‘requires improvement’. All the services required improvement to provide safe care. Medical care and end of life care services required improvement to provide effective care and surgery required improvement to provide responsive care. We rated all of them ‘good’ for caring and ‘well led’ services.
Our key findings were as follows:
Are services safe?
By safe, we mean people are protected from abuse and avoidable harm
-
Staff felt confident and able to report incidents. The trust recognised the importance of learning from incidents to improve the care provided to patients. However, staff could not always describe where learning from incidents had changed clinical practice. Staff demonstrated a good understanding of duty of candour and gave examples where they had used this to support patients.
-
Staff did not always follow the trust’s medicine management policies and procedures.For example for controlled drugs orders and monitoring medicine fridge temperatures. Staffing shortages in the pharmacy department resulted in reduced support to departments and we found evidence of some unsafe practices, including out-of-date medicines.
-
In general, all clinical areas were visibly clean. There was some variability in infection control standards. The mortuary trolley was found to be dirty with no agreed cleaning schedule in place and deceased clothing was not appropriately stored while awaiting collection.On ward 8 we found some items of equipment had a layer of dust. Theatre staff did not always collect a new set of scrubs to change into when returning to the operating department from another area in the hospital, in line with the trust’s uniform policy and as good infection control practice. In most areas equipment was labelled to indicate it had been cleaned and was ready for use.
-
Systems were in place to enable staff to assess and respond safely to deterioration in patients’ health. The trust used an electronic warning system to prompt staff to take the necessary action to help prevent further deterioration in patients’ health. Staff completed relevant risk assessments for patients and shared information about patients’ care and treatment needs at handover meetings.
-
In the operating departments, the anaesthetic logbooks were not complete, to provide assurance staff had completed the daily safety checks and equipment was fit for purpose, prior to patients having surgery. On some of the wards, staff had not completed the daily checks on the resuscitation equipment in line with the trust policy, to ensure it was ready for use in an emergency.
-
Overall, staffing levels met the planned levels staffing. The trust achieved this using bank and agency staff for some shifts. Managers followed the trust escalation procedures when they identified staffing shortages for their department. In some areas this meant staff on occasions were under pressure to meet patients’ needs particularly when patients were assessed with high needs and required one to one care.
-
Staff completion ofstatutory and mandatory training was variable and not in line with the trust’s target in some areas, this included safeguarding children and vulnerable adults level 2, duty of candour, infection control, medicines management, basic life support and tissue viability.
-
Patient’s safety and daily staffing information was prominently displayed for patients, staff and visitors to read, as part of the trust’s open and honest approach.
-
Staff were knowledgeable about the hospital’s safeguarding policy and clear about their responsibilities to report concerns.However, not all staff were up-to-date with their level 2 safeguarding children and vulnerable adults training.
-
There was variability in the standard of record keeping.In some areas they were clearly written, and generally well organised. They included information about patients’ medical history and social situation, as well risk assessments, care plans and observations. They also included entries from different disciplines.This was not consistent and we also found records that had not been fully completed. This included no care plan or goals or documentation of how the patient had been involved in this and no record of discharge planning. Some DNACPR forms we inspected were not completed according to national guidelines.
Are services effective?
By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best possible evidence.
-
Staff planned and delivered people’s care and treatment in line with current evidence based guidance, standards and best practice across the medical and surgical services. While there was some evidence of evidence-based care for end of life care this was not constantly applied across the hospital. For example the trust did not have a protocol for withdrawal of treatment, which was not in line with national guidance
-
The hospital participated in national and regional audits and undertook a local audit programme. For the surgical services results from these audits showed patient outcomes were in keeping with the national average. The results of a number of national audits showed medical services performed worse than the national average. For example, the results of the myocardial ischaemia national audit project (MINAP) national audit 2013/14, National Institute for Cardiovascular Outcomes Research (NICOR) heart failure audit and National Diabetes Inpatient Audit (NaDIA) and national inpatient falls audit showed performance worse than the England average.
-
Staff assessed and managed patient’s pain appropriately and had access to the acute pain service for advice and support. However, for patients receiving end of life care staff did not use a standardised pain assessment tool to ensure staff delivered a consistent approach to pain measurement or management.
-
Patients told us they had made an informed decision to give consent for surgery. The most recent informed consent audit showed medical staff were not completing all consent forms and patient care records to the expected trust and national standards.
-
There was some variability in staff awareness of their responsibilities regarding the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLs). Patient’s capacity was not always formally assessed and decisions were made on behalf of patients who were deemed to lack capacity.
-
Multi-disciplinary working was embedded across all the wards. Staff worked effectively within their team and with other teams to provide co-ordinated care to patients, which focused on their needs.
-
The hospital had systems in place to ensure they provided care for inpatients seven days a week. This included access to on-call theatre and diagnostic imaging staff in an emergency and consultants carried out ward rounds seven days a week. The hospital performed above the national and regional average for most standards set out in the NHS services, seven days a week guidance.
-
Staff had good access to training and professional development. The specialist palliative and end of life care staff were skilled and competent to perform their roles effectively. End of life care was not included in the hospital’s core training package for all staff which was not in line with national guidance. The trust did not provide standardised or formal training in end of life care for porter or mortuary staff.
Are services caring?
By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect.
-
In all areas, patients and relatives were positive about the caring attitude of staff, their kindness and their compassion. All patients we spoke with would recommend the service to their friends and family.This was supported by data collected for the Friends and Family Test.
-
Staff took time to ensure patients and their relatives understood their care and treatment. Patients told us they felt involved in their care and understood their treatment plans. Medical and nursing staff showed sensitivity when communicating with patients and relatives.
-
Staff we spoke with valued and respected the needs of patients and their families. Patients’ emotional, social and religious needs were considered and were reflected in how their care was delivered.
Are services responsive?
By responsive, we mean that services are organised so they meet people’s needs.
-
The trust worked in partnership with local commissioners to plan and deliver services, to meet the needs of local people. This recognised the local geography, population and neighbouring services.
-
There were services to improve the access and flow of patients through the hospital, to promote shorter lengths of stay. The trust is an integrated trust which provides acute and community services. This facilitated the development of improved pathways of care, for example the respiratory pathway and the creation of the division of integrated elderly and community care.
-
Patients had timely access to emergency treatment and the trust was taking action to minimise the waiting time for elective surgery.
-
Staff took account of the needs of different people, including those with complex needs, when planning and delivering services. Staff showed good understanding and made reasonable adjustments to meet patients’ individual needs. However, patient assessments, measuring the suitability of the environment for people with dementia and people with a learning disability, were consistently low scoring. There were adequate facilities to meet individual’s spiritual and cultural needs.
-
Ward staff and the discharge team started to consider and plan patient discharges from the date of admission. The trust worked with partners to improve the coordination of patient discharges and transfers to remove barriers to delays where possible. Trust data showed a significantly higher percentage (44.2%) of patients waiting for a residential home placement, contributed to the delayed transfers of care, compared with the national average of 10.2%.
-
In the surgical division, there was a significant backlog of patients requiring pre-operative assessment. The division had not achieved 90% of patients being seen and admitted within 18 weeks of referral.
-
The trust operated a rapid discharge home to die pathway which served to discharge a dying patient who expressed wanting to die at home within 24 hours. However, there were some external delays with funding and care packages for patients with complex needs and patients who expressed a wish to die at home, did not always get to do so.
-
Complaints were investigated thoroughly to improve the quality of care.
Are services well led?
By well led, we mean that the leadership, management and governance of the organisation assured the delivery of high-quality person-centred care, supported learning and innovation, and promoted an open and fair culture.
-
Staff enjoyed working at the hospital and told us they found managers and their team supportive. There was a clear sense of teamwork and collaboration between wards and members of the multidisciplinary team. Staff told us there was an open and transparent culture within the hospital.Most staff felt the leadership of the trust and within the division were visible and supportive.
-
There was a clear governance structure in place, which linked in with the trust’s overall governance structure.Meetings took place at all levels of the divisions and were well attended by members of the multidisciplinary team (MDT) staff reported on quality, safety and performance. However, minutes of all meetings at all level were not always recorded and therefore it was not always possible to evidence what had been discussed.We identified a number of concerns around staff not following practices designed to keep patients safe which had not been identified by the trust.
-
There was a local and a national audit programme and staff had knowledge of the audits that directly linked to their clinical area. The clinical governance teams had an oversight of audit performance and there was evidence of improvement in clinical audit results.
-
Systems were in place to gather patient feedback and departments and the division had used this feedback make changes to services. The trust had set up a patient panel to ask for opinions and suggestions in what mattered to them regarding developing plans for end of life care. The trust had not audited the views of the bereaved as recommended by the National care of the Dying audit hospitals) NCDAH) 2014/15.
We saw several areas of outstanding practice including:
However, there were also areas of poor practice where the trust needs to make improvements.
Importantly, the trust must ensure:
-
Pharmacy staffing is provided to planned levels so that medicines management is safe and clinical pharmacy support is available to departments.
-
Staff comply with all aspects of the trust’s medicine management policy and associated standard operating procedures.
-
The management of controlled drugs is improved and staff comply with the misuse of drugs regulations.
-
All medicines are stored within the manufacturer’s recommended temperature ranges and that records are maintained to demonstrate that medicines are safe for administration to patients.
-
Daily checks of the anaesthetic machines and resuscitation equipment are completed and documented to confirm the equipment is safe for use.
-
All patients thought to lack capacity to make decisions about their care and treatments have a formal assessment of their capacity.
-
There is a clear process in placewith clear accountability for the cleaning of the mortuary trolley.
-
Suitable sealed storage is in place for deceased patients’ belongings in the bereavement office.
-
The new end of life care plans “Getting it right for me” and the associated “Getting it right for me patient held record” are used by clinical staff for all end of life care patients in the trust.
-
Patients who are subject to deprivation of liberty have current and valid authorisation documentation in place.
-
The end of life care strategy is completed and published and all clinical staff are aware of this strategy.
-
The use a standardised pain assessment tool across the hospital to ensure end of life patients have their pain accurately assessed and responded to.
-
A protocol for withdrawing treatment as recommended in the 2015 National Institute of Clinical Excellence guidelines is in place and clinical staff are trained in its use.
In addition, the trust should also ensure
-
The pharmacy service does not supply out of date British National Formularies.
-
Audits completed by the pharmacy service are used to drive improvements and progress should be demonstrated over time.
-
All staff working in theatres comply with the trust’s uniform policy, in particular changing their scrubs, if they leave and then return to theatre.
-
The standard of record keeping is monitored through regular audits and action taken for areas of non- compliance.
-
All staff understand the Mental Capacity Act (2005) and are confident to apply this in the clinical setting to safeguard patients.
-
Compliance with the trust informed consent audit shows continued improvement, with further action taken to address areas of non-compliance.
-
Minutes are recorded for all meetings held within the division of surgery and critical care, with an action log included to provide assurance that concerns are being addressed.
-
Medical records are maintained securely on care of the elderly wards.
-
Staffing levels are as planned to meet all patients’ needs.
-
Staff on ward 8 comply with infection control procedures to reduce the risk of infection.
-
The high proportion of delayed transfers of care attributed to patients waiting for a residential home placement is reduced.
-
Advanced care plans are fully documented in order to comply with patient’s wishes.
-
Porters, cleaners and mortuary staff receive standardised formal end of life care training.
-
The views of bereaved relatives is obtained to make care change to improve to the service
-
All staff are aware of the up to date list of telephone numbers for calling different faith ministers to visit the hospital out of hours.
-
Information leaflets regarding advance care planning, what happens when someone dies and how to register a death are printed and distributed in all the clinical departments, with a named lead responsible for ensuring they are accessible for patients and families and are up to date.
Professor Sir Mike Richards
Chief Inspector of Hospitals