CQC reports significant improvements at Mid Staffordshire NHS Foundation Trust, but says further work needed

27 July 2010

The Care Quality Commission (CQC) today (Tuesday) acknowledged significant improvements at Mid Staffordshire NHS Foundation Trust and announced that it would lift five of the six conditions imposed on its registration.

Publishing a review of care at the trust, which evaluates progress in implementing recommendations from the March 2009 investigation report, CQC said standards had improved significantly. It said the trust is listening and responding to concerns raised by patients, mortality rates are declining, there are more nurses and patients are generally positive about their care.

However, a number of important improvements remain outstanding. Nurses reported difficulty in accessing equipment to prevent pressure sores, some patients are waiting too long in A&E and there are a lot of nurses absent due to sickness in some areas of the trust.

CQC has been monitoring progress at the trust very closely. It published reviews of progress in July and December. In April, when it introduced a tough new system of registration, Mid Staffordshire was one of 22 trusts found not to be meeting essential standards of quality and safety. It was registered on the condition that it made improvements within strict deadlines.

As part of this recent review, CQC conducted announced and unannounced inspections during March and April, including an unannounced visit at A&E during the night. CQC interviewed more than 50 patients, spoke with staff, observed clinical care, reviewed documentation and talked with local patient groups and other NHS bodies.

Based on its findings, CQC will lift five conditions relating to:

• staffing levels. The trust reduced its vacancy rate from 11% in January to 7% in March. There are more nurses on the wards and it is continuing to examine nurse-patient ratios closely.
• how the trust monitors and assesses the quality of care being provided on the wards. Good clinical governance structures are now in place. For example, the trust now reviews every patient death to identify any problems with care.
• training staff to use equipment. An audit showed that 88% of nurses were competent in using all essential medical equipment and the trust has implemented a training programme to address outstanding concerns
• managing patients in A&E. Patients have very good access to senior doctors in A&E and the department has made some positive changes, including  ‘minors’ and ‘majors’ areas, an observation unit and a surgical assessment unit. However, during inspections, CQC identified two very ill patients who had been in the A&E department for 12 hours. Both had received treatment to stabilise their condition, however CQC said this was too long for patients to be managed in the A&E department. While evidence shows that this is the exception, rather than the norm, it is still unacceptable and CQC raised its concerns with the trust immediately. CQC has lifted this condition, but it will continue to monitor this aspect of care closely.
• ensuring all medical equipment is in working order and properly maintained. CQC found that the trust has processes in place to ensure that equipment is maintained, but there needs to be better systems for checking that processes are working in practice. In addition, CQC observed patients who were at risk of developing pressure sores but who did not have access to pressure-relieving devices and this was also raised as an issue by staff. This is not acceptable and the trust must ensure that sufficient pressure-relieving devices are routinely available. While CQC has lifted this condition, it will continue to monitor this closely.

The sixth condition relates to supporting workers through effective supervision and appraisal and has a deadline of 30 June. CQC did not assess compliance with this condition as part of this review, but will do so in August. At the same time, it will review whether improvements have been sustained and check progress in other planned improvements.

Andrea Gordon, CQC regional director in the West Midlands, said: “I’m sure this has been a long, hard year for everyone at the trust. The problems were huge and the programme of reform was ambitious. But it has certainly paid off. This is a very different trust to the one we saw a year ago. There is a culture of openness and accountability. Safety is very squarely at the top of the agenda and patients have the opportunity to take concerns directly to the board.

“But there is still a lot to be done. There are still instances where care is not to the standard it should be. The trust has 28 days to improve its systems for monitoring and ensuring equipment is well maintained. In addition it must ensure that essential equipment is routinely available to those patients at risk of developing pressure sores. It’s almost there, but almost isn’t good enough. We also want to see further improvements in A&E, specifically an improvement in managing the time that patients wait in A&E.”

Dr Gordon added: “There was never going to be wholesale change overnight, but the trust has certainly come a very long way in one year. We will continue to scrutinise standards very closely to make sure that progress isn’t lost.

 “We’d like to thank all of the patients, carers, staff and local groups who gave us frank and honest accounts of care at Stafford Hospital. It’s obvious that everyone is very committed to improving their local hospital and that can only help drive change faster.”

Summary of findings

1. Action by the board to oversee the quality of safety of clinical care

Progress:

• The board is promoting a culture of openness. Each meeting begins with a patient giving a description of their care and serious incidents are discussed in public sessions.
• Clinical directors review all patient deaths
• The board scrutinises monthly mortality data
• The trust can demonstrate how it learns from serious incidents
• Governance and audit arrangements are in place to check whether policies are being put into practice on the wards
• Risks are monitored and reduced

Areas for improvement:

• There has been very good work, but the trust needs an overall strategy for how it will get information from patients and how it will use it to improve services.
• The management of complaints must improve. Complaints need to be dealt with on time and any themes from need to be routinely reported throughout the trust and to the board
• Clinicians need to scrutinise their own clinical outcome data (for example, mortality rates for individual clinicians)
• Processes for clinical audit need to be embedded
• The trust needs better processes to ensure medical equipment is maintained

2. Standards of care

Progress:

• The experience of patients has improved, with patients providing generally positive feedback about communication, management of pain and nutrition.
• The majority of patients were positive about their care. Of the 46 patients surveyed, 33 were positive about their care, five people provided mixed comments and eight had an overall negative experience. During inspections, CQC spoke to 51 patients and their carers. Of these 47 made positive comments, three mixed comments and one was negative overall.
• Patients could reach call bells and staff provided help when they rang
• Patients were positive about the food and had access to water
• Patients were clear about the plan for their care
• Matrons were working on the wards one day a week and staff reported that this had a positive impact
• There were low levels of healthcare-associated infections over the last year

Areas for improvement:

• There is still a minority of patients reporting negative experiences
• Patients are assessed for risk, but care plans did not always outline how the risk would be minimised
• Some patients who were at risk of developing pressure sores did not have access to necessary equipment, such as pressure-relieving mattresses

3. A&E Department

Progress:

• Patients have access to senior doctors
• There is strong leadership by clinicians
• There are enough staff, including nurses
• Patients needing emergency surgery are better managed and there is a new surgical assessment unit
• Improved clinical audit programmes to monitor how policies are put into action

Areas for improvement:

• Waiting times are still too long. More work is needed to ensure patients are stabilised and moved to the most appropriate setting as quickly as possible
• More work is needed to ensure patients with medical emergencies are transferred quickly to the acute medical unit
• The trust must continue to improve the way it develops and approves clinical protocols

4. Staffing and capacity

Progress:

• The trust has filled many nursing vacancies. The vacancy rate dropped from 11% in January to 7% in March
• In order to fill vacant shifts, the trust previously used 30% bank staff (staff from other parts of the trust) and 70% agency (nurses from an external company). It now uses 70% bank and 30% agency. Bank staff are preferred because they are more familiar with the hospital and cost less than agency staff.
• There are more nurses on the wards
• There is good access to training
• Staff have access to advice about critical care when they need it
• There is better use of theatre space so patients needing emergency surgery can be treated quickly

Areas for improvement:

• The must continue to fill vacant posts and analyse patient-nurse ratios
• The trust must address high rates of absence due to sickness, which exist in some parts of the trust. In March, the absence due to sickness was as high as 15% in some areas
• There is not yet a formal structure in place for supervision of staff
• The trust should review its consultant and medical cover at night for surgical patients
• There have been significant improvements, but theatres are not always available for surgery when they are needed.

Ends

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Notes to editors