Inspection Reports Carried out on 19 November 2012 during a routine inspection Summary of the inspection We issued a warning notice to the trust following our inspection on 5 September 2012. We had found that children on Ward 32 were at risk because there were not enough suitable staff to meet their needs. The notice required the trust to take action by 18 October 2012 to ensure that there were sufficient numbers of suitably qualified and experienced staff at all times. The trust submitted a plan to us setting out the actions they would be taking by this date.
We returned to the hospital on 19 November 2012. The inspection team included a consultant surgeon and a nurse, who were both experienced in paediatric cardiology.
We found that Ward 32 was now designated as a specialist cardiac ward. We were told that the number of beds on Ward 32 had reduced and two high dependency beds created on the Paediatric Intensive Care Unit (PICU). Other developments included a new system for assessing if children could stay on Ward 32 or needed care in a high dependency bed.
Parents on Ward 32 told us that staff were available to them when needed. One parent said “the ward seems quieter than it was in the summer and more controlled”. Staff made comments such as "it feels less anxious" when talking about the changes they had seen on Ward 32.
Overall the risk to children on Ward 32 had reduced because staff were caring for fewer children with a lower level of dependency. We found that the trust had complied with the warning notice.
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Carried out on 5 September 2012 during an inspection in response to concerns What people told us during the inspection We carried out this responsive inspection as a result of concerns raised with the Care Quality Commission about the care and staffing levels on Ward 32. The inspection did not look at the clinical outcomes for children whose stay in hospital included time spent on Ward 32.
Children were cared for on Ward 32 with a spectrum of treatment ranging from medical management, day case /short stay interventions, and pre/postoperative cardiac surgery. Children were treated from the southwest region and South/West Wales regions as part of an established cardiac network.
We contacted commissioners prior to our visit to Ward 32. They raised no concerns with us about the service being provided on Ward 32.
During our visit we focused on Ward 32, but we also spent time on the Paediatric Intensive Care Unit (PICU) so we could understand the working relationship between these two services. Both services were located in Bristol Royal Hospital for Children which is part of the University Hospitals Bristol main site.
During our visit to Ward 32 we spoke with six parents, five registered nurses, two health care assistants and two doctors. The majority of parents we spoke with on Ward 32 told us they had the information they required about their child’s care and treatment. One parent said “This is an amazing place. Lovely staff, lovely doctors. It is reassuring for our child. They really try to be supportive. They treat the whole family. You can ring the ward from home especially in the run up to the operation. Communication is good. There is always somebody you can ask”.
Another parent told us “care is excellent on Ward 32, but the first time we visited Ward 32 which was about a month ago, we were told the wrong information about the operation day. Our child had a cold so they could not operate. We saw five different doctors at the time who gave us different information. The second time our child was admitted we found the communication was much better. The surgeon explained everything he was going to do step by step. We were reassured”.
Staff we spoke with were committed to ensuring that children and their parents were involved in the decision making process about their care and were constantly aware that they needed to ensure dignity and privacy was maintained at all times.
All parents we spoke with on Ward 32 told us that their child had received good treatment and care and they had received good support.
One parent said that their child had never had to wait for feeds. They told us “if my child’s named nurse was busy, then another nurse would take over. It is good team work. They all muck in together. Even after a 12 hour shift, one nurse still came to see me. They wanted to show me how to wind my baby another way. They had agreed to do that earlier in the shift but did not have time”.
Another parent told us “three to four weeks ago there was a bank nurse on duty for two nights as they were short of staff”. They said that “this bank nurse was fine, but there was no continuity or communication. They did not understand our routine and woke us up when myself and child were settled for the night”.
On the day of our visit to Ward 32, parents we spoke with did not report a staff shortage. They did however comment that the staff on Ward 32 were very busy. They also commented on staff shortages on other days they had been present on the ward.
When we visited Ward 32 we found that the trust was not reducing the risk of children receiving unsafe or inappropriate care, treatment and support. This was due to the fact that ‘high dependency care’ was being delivered on Ward 32 without adequate staffing levels over a sustained period of time. The trust had established registered nurse staffing levels, but these did not reflect the high dependency of some children cared for on the ward.
Medical and nursing staff told us about the impact that the current staffing l
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Carried out on 22 June 2012 during a routine inspection What people told us during the inspection We carried out this inspection as part of our scheduled inspection programme. We visited the emergency department, medical assessment unit, ward 51 in the Bristol Heart Institute and the central delivery suite and wards 71, 74 and 76 in the maternity department of St Michael's Hospital.
We spoke with four patients on the medical assessment unit, five patients in the maternity department, five patients, one care worker supporting a patient in the emergency department and three patients on ward 51. We also observed care being delivered in the areas we visited at University Hospitals Bristol Main Site.
Overall people told us they received good care and received the information they needed about their care and treatment.
One person in the emergency department told us “I just came straight in from the ambulance and didn’t have to wait”. They said “on the whole, my treatment has been really good”. Another person we spoke with said they had a quick transfer from the ambulance to the emergency department. They said the staff were marvellous.
All five of the people we spoke with said that staff kept them informed of what was happening, although one person said that as the department got busier they had to ask.
One relative said that care on the medical assessment unit had been superb and staff had explained things to them. Another relative of a patient on the medical assessment unit contacted us following our inspection to tell us their concerns about the care provided to their family member following our inspection and a previous inspection. The concerns raised were not observed by us during out inspection and we advised the person to complain directly to the trust.
Patients on ward 51 told us the staff were very good on the ward. One person who had been a patient for five days said "so far I'm impressed".
Patients we spoke with in the maternity department felt that they had received good treatment and care. One woman on the transitional ward was completely satisfied with her care apart from one nurse/midwife making her feel pressurised into continuing breast feeding when she had already been supported by another midwife into undertaking a mixture of breast and formula feed as was her choice.
We found that the trust was non- compliant with outcome 13: Staffing. This was only for the regulated activity maternity and midwifery services. The trust provided evidence that they had a staffing level of one midwife to 38 births. Senior staff told us on the day of our inspection that they had a staffing level of one midwife to 39 births. The national guidance for midwifery staffing levels in a hospitals setting is one midwife to 28 births. We saw that staff were not able to take breaks in a timely manner. Staff throughout the maternity department said that although they were able to provide a safe service to all their patients they did not have time to give the extra care and support that some women might need. For example, staff having discussions about psychological issues or concerns that the woman might have in relationship to her birth, the baby or general care. One patient we spoke with said that she had not been shown how to bath her baby prior to leaving the hospital.
We observed patients in all areas we inspected, being supported in a professional manner. Patients were informed of their treatment. We saw that consent for surgical procedures was gained from patients. We were told that within the emergency department consent was sought verbally.
Staff spoken with were committed to ensuring that women in the maternity unit were involved in the decision making process about their care and were constantly aware that they needed to ensure dignity and privacy was maintained at all times.
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Carried out on 10 May 2012 during a check to make sure that the improvements required had been made What people told us during the inspection We carried out this review to follow up on the improvement actions served following our review of the Histopathology service at the trust published in September 2011.
We spoke with four consultant histopathologists, one consultant surgeon, one consultant radiologist, one consultant oncologist, four cancer nurse specialists and the Joint Clinical Lead for Cellular Pathology.
We found that the trust had made improvements and were now compliant with all of the outcomes reviewed.
Processes had been put in place to ensure attendance of the core members of the multidisciplinary team (MDT) at meetings and the trust had audited compliance with this. The audit of compliance demonstrated high levels of attendance of core members of the MDT between December 2011 and March 2012.
A new policy for the management of discrepancies in cellular pathology had been put in place to clarify the procedure and criteria for reporting incidents relating to discrepancies in opinion of histopathology reports. We saw that there were low levels of discrepancies and subsequent issue of supplementary histopathology reports between July 2011 and January 2012.
We saw that the trust had taken steps to reduce the workload of consultant histopathologists through the recruitment to vacant posts within the trust and the creation of a new consultant histopathologist post. We also saw that the trust had committed to review workload within the histopathology service with a view to further recruitment. Three out of the four consultant histopathologists we spoke with said their workloads were more manageable than last year. However, one consultant histopathologist said their workload had increased in number and complexity. The consultant histopathologist did not know whether their workload was within the Royal College of Pathologists guidance.
The trust was in a position to provide raw data to evidence the ongoing review of workload within the histopathology service. At the time of our inspection there was further work going on in this area and we will continue to monitor this with the trust.
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Carried out on 20 March 2012 during a themed inspection What people told us during the inspection 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 treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.
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Carried out on 13 December 2011 during a check to make sure that the improvements required had been made What people told us during the inspection We carried out this review to follow up on the compliance action for outcome 5 "meeting nutritional needs" which we served on the trust following the Dignity and Nutrition review carried out in May 2011.
We reviewed five wards across University Hospitals Bristol NHS Foundation Trust Main Site, including two children's wards and three adult wards. These wards provided surgical and medical care and included an acute ward for patients who had suffered a stroke.
We spoke with 18 people who were using the service (and their parents on the children's wards), 23 members of staff, observed the care on the wards during the lunchtime period and reviewed the care records of 17 people who use the service.
People on the adult wards told us staff within the trust supported them with their nutritional needs. One person, who had some paralysis in their left side and was unable to cut meat or butter toast, said staff always help with cutting food or opening packages of marmalade. They also said staff make sure they have the help they need at mealtimes.
People told us they had enough to eat and drink. One person said "actually they give you too much, I waste an awful lot". Another person said "I'm a very small eater and they want me to put on weight". She said that staff make sure she has a meal which is at a size she will eat rather than being overwhelmed by. We saw that this person was given a snack in the middle of the morning in addition to their main meals. A third person said "staff are caring and ask if I've had enough. They also ask my opinion about the food".
One of the people we spoke with missed meals over four consecutive days whilst they were waiting to have their surgery. This was in preparation for their surgery. On each day when it became apparent that the surgery was not going to take place the person was offered a choice of sandwiches to eat. They told us they were not offered a hot meal but they were happy with sandwiches. None of the other people we spoke with had missed a meal.
People who used the service told us they could ask for additional food if they were hungry.
We spoke with five young people and their parents on the children's wards. They told us that staff checked whether they had enough to eat and drink, although this may be through observation rather than directly asking. Four out of six of the young people we spoke with said that they had been asked about their food preferences on admission. We found that four of the young people had missed a mealtime whilst in hospital. Three of them were offered a meal on their return to the ward and were given a choice. One young person was told there was no other food available and had to wait until teatime for their next meal. Their parents told us they were not happy about this because the young person was hungry.
We observed people on both adult and children's wards were supported and encouraged to eat in a positive and respectful manner. For example, one young person did not fancy their meal when it arrived and staff asked them what they would like. Staff prepared cheese on toast as requested by the young person.
We found that care plans were not always fully completed and gave limited information to support staff in meeting people’s nutritional needs. However, staff that we spoke with had good knowledge of the needs of the people for whom they were caring. We also saw staff were meeting people's nutritional needs by supporting and encouraging them in their eating.
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Carried out on 18 and 19 May 2011 during an inspection in response to concerns What people told us during the inspection We carried out this review to follow up on the concerns raised following the publication of the Histopathology Independent Inquiry Report which published in December 2010 and also in response to an additional case of misdiagnosis which was reported to us by the trust. We have also had concerns raised by members of the public about the provision of histopathology services at University Hospitals Bristol NHS Foundation Trust.
This review was focused on the delivery of histopathology services and the diagnosis of cases through the multi-disciplinary team (MDT) meetings.
We found that the trust had implemented an action plan following the Histopathology Independent Inquiry Report which they had made progress with. However, further actions were still to be implemented.
We spoke with 14 patients within the Haematology and Oncology Centre about the care that they had received, their pathway through diagnosis, the discussions they had had with clinicians and other healthcare professionals, information they had received about their treatment and diagnosis and if they had any concerns about the service.
People told us that they were very satisfied with the care that they had received from diagnosis through to their treatment. People told us that they had received adequate information about their diagnosis and treatment and that staff of all levels had been willing to answer any questions that they had. However, one person told us that their appointments with the consultant could be quite rushed not leaving time for all of the questions they had to be answered. Most people told us that they are given options for treatment which they were able to discuss with their consultant.
We were told by patients that there was plenty of literature to assist in increasing their knowledge about their condition and we saw evidence of this in place within the Haematology and Oncology Centre.
We spoke to a variety of staff (17 in total) including Cancer Nurse Specialists, Consultant Surgeons, Consultant Oncologists, Consultant Radiologists, Consultant Histopathologists, Matrons and members of the senior management team of the trust.
They told us that they all felt supported in their role and that they had all received appraisals.
We found that there were systems in place within the trust to assess and monitor the quality of services and that the trust had recently commissioned two reviews of governance systems by Audit South West and by an independent consultant. These reviews made recommendations for improvements which the trust were acting upon.
We found that core members of the multi-disciplinary team (MDT) meetings were not always in attendance as required by trust policies. The trust is monitoring the attendance at MDT meetings.
We found that the trust works in cooperation with other trusts to ensure that people receive safe and coordinated care, treatment and support where more than one provider is involved, or they are moved between services.
We found that staff in the Histopathology Department had high workloads. We reviewed the Consultant Workload Data for the year 2010-2011. We reviewed the figures against the Royal College of Pathology guidance on staffing and workload within histopathology and cytopathology departments (June 2005). The data showed that most consultant histopathologists within the department were working in excess of the number of unweighted specimens recommended by the Royal College.
We found evidence that staff are supported in their role and had access to professional education and continuing professional development. We found that staff had received appraisals but that some were more detailed and meaningful than others.
We found that Histopathologists are undertaking External Quality Assurance (EQA) Schemes which are appropriate to their practice.
We saw that histopathology reports were documented in line with that expected. The trust is also reviewing the style of hist
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Carried out on 5 May 2011 during a themed inspection What people told us during the inspection Most patients and their relatives told us that they were satisfied with the care and treatment they received at University Hospitals Bristol Main Site. They said they had been treated with courtesy and respect and that their privacy and dignity had been protected.
People told us that all staff explain and ask if it is alright before they help or provide any care. One patient said “Yes they do. They are respectful of our privacy. Yes they do always draw the curtains”. People told us that care is given in a respectful way but that they sometimes feel that some staff don’t like giving care or are shy.
We observed personal care being provided behind closed curtains including examinations and discussions with medical staff. Some of the discussions could be heard throughout the bay area on the day of our visit.
Most people told us that they had received information about the care and treatment options available to them although some didn’t feel that they had received enough information. People told us that they had not received information about the facilities available within the hospital or about what will happen when they leave the hospital. People told us that they understood the information that was given to them and that staff take time to ensure that you understand. One person said “the staff don’t really have much time to talk to you unless you need a lot of care.”
People told us that staff respond to their needs quickly enough during the day time but that at night they feel that they are short staffed and that it takes longer for somebody to come and help them.
Most people told us that they were asked what they liked to be called but that in some cases staff did not use this name to address them. One person told us that they had not been asked what they liked to be called but that it didn’t matter.
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Carried out on 12 and 14 October 2010 during a check to make sure that the improvements required had been made What people told us during the inspection We found that people who use the services feel that on the whole the food that they receive is good. The people we spoke to felt that the staff encourage and support them in eating and some had been given information about their nutrition following their discharge from hospital.
Some people that we spoke to said that they did not receive the food that they ordered but received an alternative, although this was not always a suitable substitute for that ordered.
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