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The Care Quality Commission checks whether hospitals, care homes and care services are meeting government standards. Visit our website at www.cqc.org.uk.

Royal United Hospital Bath NHS Trust

  • Directors Offices, Royal United Hospital, Combe Park, Bath, Somerset, BA1 3NG

  • Read more information about this hospital...

Type of service
Hospital

Specialisms/services
Assessment or medical treatment for persons detained under the Mental Health Act 1983, Diagnostic and/or screening services, Management of supply of blood and blood derived products, Nursing care, Services for everyone, Surgical procedures, Termination of pregnancy, Treatment of disease, disorder or injury

Local Authority Area
Bath & N E Somerset

These checks were made using our new inspection model for NHS hospitals. If we are taking enforcement action, we highlight it below.
Click on each area to read a summary

Summary of inspection on 5-6 and 14 December 2013

The Royal United Hospital Bath NHS Trust (RUH Bath) provided acute treatment and care for a population of around 500,000 people in Bath and the surrounding towns and villages of North East Somerset, North and West Wiltshire, Somerset (Mendip) and South Gloucestershire. The trust provided 595 beds and a comprehensive range of acute services, including medicine and surgery, services for women and children, accident and emergency services, and diagnostic and clinical support services. The trust had an annual budget of around £230 million and employed 4,600 staff.

We chose to inspect the RUH Bath as one of the Chief Inspector of Hospital’s first wave inspections because we were keen to visit a range of different types of hospital, from those considered to be high risk to those where the risk of poor care was likely to be lower. From the information in our Intelligent Monitoring at this time, the RUH Bath was considered to be a medium-risk trust.

The trust had faced significant challenges in the past year, particularly over the last winter period of December 2012 to March 2013:

  • There was a high demand for trust services and the trust did not have sufficient capacity to cope with emergency admissions. The trust had three periods of ‘black escalation’ in January, February and March 2013. Patients were waiting in the corridors of the accident and emergency (A&E) department for treatment. The day surgery unit was being used for overnight stays. The trust received £2.35 million of NHS winter pressures funding to improve services.
  • The NHS patient safety indicators on falls, catheter and urinary tract infections, blood clots and pressure sores were above the national average and incident report rates were low compared with other trusts.
  • Elective surgical procedures were being cancelled and patients had long waiting times for surgery; this was worse than other trusts.
  • The staff survey results identified that the level of staff engagement was in the bottom 20% of trusts.
  • Patient complaints and concerns increased during this time.
  • The trust was not meeting standards and there were compliance actions following several CQC inspections for respecting and involving service users, care and welfare, safeguarding, and assessing and monitoring the quality of service provision.
  • We served a Warning Notice after our inspection in June 2013 because the trust did not meet standards for Regulation 20 (1) (a) and (2) (a) (b) (Records) of the Health and Social Care Act 2008.
  • In 2012, the trust had gained approval to be a foundation trust from the strategic health authority. The initial assessment with the healthcare regulator, Monitor, was between November 2012 and March 2013, and the trust was focused on this corporate, financial and governance challenge on service provision.

The trust also had positive areas of practice:

  • Surgical procedures were safe and the trust had not had a ‘never event’ for 18 months.
  • Infection control rates were similar to those of other trusts.
  • Overall mortality rates were similar to those of other trusts. The hospital standardised mortality ratio (HSMR) is a measure for deaths in hospital for specific conditions and procedures. This was significantly lower than other trusts and there was no difference between weekday and weekend mortality.
  • The trust participated in national clinical audit and could demonstrate many areas where national guidelines were adhered to.
  • The trust was supportive of innovation in services, for example, in dementia and end of life care.
  • Patient feedback from surveys and NHS Choices was largely positive.

During this inspection, we inspected services in A&E, medical care, surgery, critical care, the children’s centre, end of life care and outpatients. We did not inspect maternity services because these were part of Great Western Hospitals NHS Foundation Trust.

From this inspection, the trust has demonstrated that it could lead significant change effectively. It had been open and transparent with partners about challenges and funding had been used to support innovative changes. It had engaged the national Emergency Care Intensive Support Team (ECIST) to change services in both the trust and across the local health and social care community to improve the management of patient admissions and discharge. The changes had significantly improved how the trust managed the demand for its services and ensured that patients received good quality and safe care. Staff told us there had been a tangible shift in culture over the past few months from a corporate to a patient focus, and the trust was in a better position to manage winter pressures and unexpected demand for services.

Patients received safe and effective care. Surgical services were safe, for example, and infection rates were similar to those of other trusts. Patients were being treated according to national guidelines and clinical outcomes for them were good. Patients told us staff were caring and that they were treated with dignity and respect. Services were more responsive to patients’ needs and the trust had made changes to improve how it handled and responded to complaints. The trust was making progress in providing a seven-day service, and new models of care in A&E, medicine and surgery had meant patients were receiving quick and effective treatment and their length of stay in hospital was reduced. The environment on two wards, Combe Ward and the neonatal unit, had been redesigned and refurbished to reduce anxiety and improve the comfort of patients with dementia and of children and parents, respectively.

The CQC standards identified in the Warning Notice, and all but one of the compliance actions from our inspection in June 2013, had now been met. The Warning Notice has now been lifted.

We also identified a number of areas where the trust needed to improve. Staffing levels were safe but needed to improve in some areas, particularly in the critical care and neonatal units. Incident reporting had improved but information was not shared effectively so that staff could learn from mistakes. Patients were safeguarded, but more staff need appropriate safeguarding training to protect children, and some staff needed a clearer understanding about the rights to independence of patients who are at risk of wandering. Staff were caring, but at busy times in busy areas, such as admission and short stay wards, patients’ care needs were not always being met. Patients still had long waiting times for some planned surgery and outpatient appointments, and there were discharge delays for some patients with complex needs. The trust needed to engage with staff in lower pay bands who spend much of their time with patients and in patient areas, such as cleaners, who told us they did not feel valued or listened to. The trust was well-led but it needed to further improve how it assessed and monitored its quality and safety procedures. We identified actions for the trust to take to improve its services.

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Background information for inspection on 5-6 and 14 December 2013

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Inspection areas

Summary of inspection on 5-6 and 14 December 2013

Patients received safe care and were protected from risks, and incident reporting had improved. Services had changed to cope at busy times and patients who were transferred to non-specialist wards were managed appropriately. The trust was taking action to address staffing levels to ensure patient care needs were met; this was particularly required in the critical care and neonatal units. Infection rates were similar to those in other trusts and the environment was clean. Most equipment was checked as required and medicines were prescribed and administered correctly. Some staff did not have up-to-date training in safeguarding children and some needed a clearer understanding about the rights to independence of patients who are at risk of wandering. Patient records had improved and included accurate and appropriate information.

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Summary of inspection on 5-6 and 14 December 2013

Patients’ care and treatment were effective. National guidelines and best practice were applied and monitored, and outcomes for patients were good overall. Staff worked in multi-disciplinary teams to coordinate care around a patient, and end of life care was integrated with GP and community services. Staff were supported to innovate services and develop their clinical skills. However, some training for staff working with children needed to improve.

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Summary of inspection on 5-6 and 14 December 2013

People at our listening events had mixed views about the care and services they had received. Most people who contacted us to share their experiences were concerned about poor care and the loss of dignity and respect. However, during our inspection, we observed that staff were caring and patients confirmed this, saying also that staff were compassionate and treated them with dignity and respect. Staff in the critical care team provided outstanding emotional support. There were instances though, at busy times, and in busy areas such as admission and short stay wards, when patients’ care needs were not met and this was a concern. Patients had a good choice of meals and were supported to eat and drink appropriately. They did not have mixed-sex accommodation.

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Summary of inspection on 5-6 and 14 December 2013

Demand for trust services last winter meant that the trust was not meeting waiting times in A&E and bed occupancy was at a level that had had an impact on the quality of care. This had now improved but there were still long waiting times for some elective surgical procedures and outpatient appointments. The trust had already started work on developing seven-day services and this was improving patient diagnosis and treatment. Care was improving for patients who were vulnerable as a result of their experiences, although the transfer of elderly patients at night was a concern. Discharge was better coordinated in the hospital but needed to improve by engaging with community partners to reduce delays. The trust was developing a more open culture in how it handled complaints but there were still some delays in responding to patients when a compliant was investigated. Information and translation services were available.

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Summary of inspection on 5-6 and 14 December 2013

The trust was clear about its clinical and governance strategies and was developing its approaches to improve its performance and monitoring arrangements. There had been a renewed focus on patient quality and safety issues and these were being managed more effectively alongside corporate and financial challenges as the trust aimed to achieve foundation trust status. There were, however, gaps in monitoring and the trust needed more information on service risks and quality. Staff told us they were proud to work in the trust and most felt valued by the trust leadership. Staff were involved in innovative projects and service development, and the trust had radically changed and developed services to cope with demand. The leadership team was improving its engagement and communication to ensure they were listening to patients and staff about their concerns and experiences.

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Checks on specific services

Summary of inspection on 5-6 and 14 December 2013

Patients received safe and effective care. Their safety was a high priority and risks to patients were identified and managed effectively. There were good clinical outcomes for patients. Patients with mental health needs were waiting too long for assessment out of hours and at weekends, although efforts were being made to improve this. Staff were compassionate and caring and patients’ feedback was good. The A&E department was well-led and the staff in the department worked as a strong and cohesive team. The trust had taken a whole-hospital approach to managing demand for services and staff in the department were confident that winter pressures would be better managed in 2014.

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Summary of inspection on 5-6 and 14 December 2013

Patients received safe and effective care. There were good outcomes for patients and the trust had improved its record-keeping to ensure patients received appropriate and safe care. Staffing levels on medical wards, particularly in the medical admissions unit (MAU), was a concern. The trust was actively recruiting staff but current levels were having an impact on patient care. Staff were caring and most patients said they had been well cared for and staff were attentive. There were some concerns, however, when staff were busy, and in busy areas such as MAU when patient care needs were not always met. The care and treatment of older patients, especially those with dementia, was improving. Patients’ discharge was well supported but there were delays for some patients with complex needs. The service was well-led and staff told us of their pride in working for the hospital. They said they felt better prepared to deal with service demands and winter pressures.

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Summary of inspection on 5-6 and 14 December 2013

Patients received safe and effective surgical care. There were good safety checks and management of risks to patients. The reporting of incidents to learn from mistakes was improving. Cleanliness and infection control were good. The surgical environments were well managed, but some areas could have been better maintained. Equipment was usually available when needed, although some checks were not done as required. Staff were caring and services were responding to patients’ needs. However, levels of nursing staff sometimes delayed surgery and delayed patient transfers between theatre, recovery and ward areas. There were some concerns, when staff were busy, and in busy areas such as the short stay surgical unit, when patients’ care needs were not always met. Staff had improved their understanding and approach to the care of people who were vulnerable, such as patients with a learning disability or dementia. They were dedicated, and most teams worked well together to coordinate patient care. Staff told us they were proud of the work they did.

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Summary of inspection on 5-6 and 14 December 2013

Patients received safe and effective care although staffing levels in the critical care unit needed to improve to reduce the pressures on staff. Obtaining patient consent was done well but capacity to consent to care and treatment was not documented appropriately. Clinical outcomes for patients in the unit were good and often above the national average. The consideration and compassion shown by staff to their patients in critical care were outstanding. Staff morale was improving and there was effective team working, although training and professional development needed to improve. There was an unacceptably high level of delayed discharges because of capacity problems elsewhere in the hospital, and this added to the pressures on the unit. The trust was taking action to manage risks, but national delays to recruiting staff had not been effectively communicated to staff. Staff told us risks were now being managed effectively.

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Summary of inspection on 5-6 and 14 December 2013

Children received safe and effective care in the children’s centre. Staffing arrangements were flexible to meet the needs of children, and children’s care and treatment followed best practice guidance. Staffing in the neonatal unit needed to improve to meet intensive care standards, and the supervision of children in A&E needed to improve. Parents told us staff were caring and the nurses were described as “attentive” and “very helpful”. The service was responsive to children’s needs and parents praised the neonatal unit and commented on how it created a feeling of calm and wellbeing. Staff engaged well with the children and treated them with dignity and respect. Staff told us they felt supported and took pride in their work, although in some areas they needed further specialist training. Risks needed to be better monitored to demonstrate that these were being managed effectively.

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Summary of inspection on 5-6 and 14 December 2013

Patients received safe and effective end of life care. Their care needs were being met and the service was integrated with GPs and community services, which supported effective discharge arrangements and care at home. Most patients and their families were positive about the care and support they received, and said they were treated with dignity and respect, from reception staff through to consultants. Staff had appropriate training and supported patients to be fully involved in their care and decision making. The service was well-led and staff were dedicated to improving standards of end of life care across the hospital.

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Summary of inspection on 5-6 and 14 December 2013

Patients received safe and effective outpatient care and staff were caring. However, staff throughout the outpatient services did not demonstrate a robust understanding of the Mental Capacity Act (2005) in relation to consent from adults who were vulnerable. Patients’ waiting times were within national targets, although some patients waited longer for appointments at the pain management clinic and some patients waited a long time for consultations when clinics were busy. Patients told us that the breast care clinic was outstanding. The outpatient clinics were managed differently by departments and information on quality and safety was just beginning to be shared. The trust had commissioned work to review and further improve outpatient services.

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application/pdf icon Quality report published 6 February 2014 706.47KB

Latest Inspection

The latest check of this hospital was carried out on 5-6 and 14 December 2013 using our new inspection model.

application/pdf icon Quality report published 6 February 2014 706.47KB

Inspection Reports

Carried out on 17 and 18, 19, 20 June 2013 during an inspection to make sure that the improvements required had been made
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287.6 KB
Carried out on 4 and 5, 6 February 2013 during an inspection in response to concerns
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226.47 KB
Carried out on 4 October 2012 during a routine inspection
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55.35 KB
Carried out on 21 March 2012 during a themed inspection
Carried out on 11 November 2011 during a routine inspection
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101.32 KB
Carried out on 22 February 2011 during an inspection in response to concerns
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78.48 KB

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What our icons mean

All standards were being met when we inspected the service. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.
At least one standard in this area was not being met when we inspected the service and we required improvements.
At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.


What does a grey cross mean

At least one standard in this area was not being met when we inspected the service and we required improvements.

What happens next
The service will tell us how it is making improvements. Once we are happy that the improvements have been made, we will update our judgement to show a green tick. Other times, we may have to carry out a 'follow-up' inspection to check improvements.


How can I get more information
Our inspector's report will give you more information about why the service received a grey cross. You can also contact the service directly or visit its website for more details on any improvements it has made.



What does a red cross mean

At least one standard was not being met when we inspected the service and we took enforcement action.

What happens next
The type of enforcement action we take depends on the seriousness of our inspector's findings, and the service must make improvements before we update the judgement on our website.


How can I get more information
Our inspector's report will give you more information about why the service received a red cross. You can also contact the service directly or visit its website for more details on any improvements it has made.