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University Hospitals Bristol Main Site Outstanding

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Inspection Summary


Overall summary & rating

Outstanding

Updated 2 March 2017

We inspected University Hospitals Bristol Main Site as part of our comprehensive inspections programme of all NHS acute trusts.

The inspection was announced and took place between 22 and 24 November 2016. We also inspected the hospital on an unannounced basis on 1 December 2016.

We rated the hospital as outstanding overall. The effective and well led key questions were rated as outstanding; safety and caring was rated as good; and the responsiveness of the hospital was rated as requires improvement.

Our key findings were as follows:

Safe:

  • We rated safety in the hospital as good, and found safety was good in all the services we inspected.

  • Openness and transparency about safety was embedded in the services we inspected. There was a positive safety culture with good staff involvement. Learning opportunities were identified and shared with staff within their own area and across the trust to support improved safety, and led to changes in practice
  • When things went wrong patients were provided with a timely apology and support. The majority of staff understood their responsibilities under the Duty of Candour requirement and could provide examples when they had been used.
  • Innovation was encouraged, such as SHINE in the emergency department, which provided staff with a simple checklist to ensure patient-safety based actions were completed. Since its introduction there had been no incidents of a deteriorating patient not being identified and then managed.
  • Wards and departments appeared visibly clean. A thorough cleaning programme was in place across the hospital and staff were observed using personal protective equipment to prevent infection. Staff were seen to use hand sanitising gel prior to providing care and treatment to patients.
  • Medicines managed safely and effectively in the services we inspected. Learning was evidenced from incidents relating to medicines, and medicines administration records were fully completed.
  • Nurse and medical staffing levels met national and local guidelines and planned to ensure safe care, and agency staff were only used when required to cover increased demand and vacancies. There were effective handovers and shift changes, to ensure staff can manage risks to patients who use services.
  • Consultant cover in the emergency department did not meet the 16-hours on-site standard and was reduced significantly at weekends. However, junior doctors felt well supported and both the local management team and trust executives were aware of this concern and had actions ongoing to improve the levels of cover.
  • Staff understood their safeguarding responsibilities. Staff were aware of local procedures and knew what to do if they had a concern. In surgery we found examples were staff had taken steps to prevent abuse from occurring and responding to signs of abuse by working with the safeguarding team and local authority to ensure patients were protected. There was lack of clarity around the correct processes to safeguard children between the ages of 16 and 18 years in the surgical trauma assessment unit. There were concerns in this unit around the levels of safeguarding training provided to staff working overnight.
  • Staff carried out comprehensive risk assessments for patients and developed management plans to ensure risks to patients’ safety were monitored and maintained. The World Health Organisation surgical safety checklist was utilised effectively to keep patients safe. However, the environment for patients on the oncology ward presented a potential risk to the safety of patients who may be confused or could not maintain their own safety.
  • Systems to ensure patients’ information was kept safe were not always implemented. Records were found to not be stored securely which could cause a potential breach of patients’ confidentiality in the emergency department, outpatients departments and on medical wards.
  • Mandatory training compliance for nursing and medical staff across the services we inspected were below the hospitals target, including fire, resuscitation and safeguarding training for medical staff. Receptionists in the emergency department had not received any training or guidance to help them identify potentially seriously unwell patients.

Effective:

  • We rated the effectiveness of services within the hospital as outstanding. Urgent and emergency services were rated as outstanding, and medical care and surgery were rated as good. We do not currently rate the effectiveness of outpatients and diagnostic imaging.

  • Patients had comprehensive assessments of their needs, which include consideration of clinical needs, including both mental and physical health and wellbeing, nutrition and hydration needs.
  • We found there was good multidisciplinary working and people received care from a range of different staff, teams or services, in a coordinated way. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
  • Patients’ care and treatment was planned in line with current evidence based guidance. Clinical care pathways were developed in accordance with national guidelines. Trust policies included reference to NICE guidance and other national strategies. However, the diagnostic imaging service did not always ensure it met best practice clinical guidance for report turnaround time for medical staff requesting diagnostic imaging to be carried out.
  • Patients received care from different teams who worked together to coordinate care. We observed board rounds taking place on wards, which demonstrated effective multi-disciplinary working. For some wards complex discharges were daily occurrences. A multidisciplinary audit programme was in place and actively used by staff to encourage and monitor improved outcomes. There were links with GPs and community providers to ensure safe patient discharge.
  • The hospital achieved good patient outcomes and delivered effective care in the emergency department and medical wards. A programme of local and national audits was used to monitor care and treatment. Some areas showed improvements, including the national stroke audit. In outpatient departments clinics were benchmarked against each other and actions put in place to improve outcomes. Outcomes for people who used the surgical services were mixed. The trust performed well in the bowel cancer audit and the oesophago-gastric cancer national audit and had an improving picture for the national emergency laparotomy audit. However, results were not always in line with the national scores. For example, the trust was performing worse than the national average in some elements of the hip fracture audit, although, the service provided at this trust was relatively small compared to other trusts.  Despite this, mortality rates were better than the England average in all audits we reviewed.
  • Innovative approaches were used to deliver care. This included simple solutions such as a touchscreen guideline system in the emergency department resuscitation area, and the close working relationships with external partners to deliver alternative care pathways and admission avoidance programmes. The SHINE patient safety assessment tool had driven significant improvements and clearly demonstrated improved outcomes.
  • Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
  • Not all staff had received an appraisal in the last year, with particular low compliance in the ancillary staff group. Without an appraisal, learning needs may not be identified and a plan put in place to support staff to develop their practice.

Caring:

  • Overall, caring within the hospital was rated as good. Surgery was rated as outstanding for caring and all other services inspected were rated as good.

  • People we spoke with praised the staff for their kindness and compassion. Patients told us they had been treated with dignity and respect at all times by staff who were respectful and caring.
  • Staff often went out of their way to meet the emotional and physical needs of patients. It was clear they had taken the time to get to know and understand their patients. Staff took the time to ensure patients were comfortable, responding compassionately to patients in pain or distress and giving reassurance and support.
  • We observed doctors and nurses introducing themselves when they met patients and their families for the first time. Patients in the emergency department were addressed by their preferred name. Patients and those close to them were treated as partners in their care and supported to make informed decisions about their care and treatment. We saw examples where relatives and carers were included as part of the care provided for both physical and emotional wellbeing. In outpatient departments staff talked about patients compassionately with knowledge of their circumstances and those of their families. Relatives were encouraged to be involved in care as much as they wanted to be, while patients were encouraged to be as independent as possible.
  • We saw staff from all groups assisting patients and others who were confused or lost in the emergency department in a helpful and supportive manner. One doctor was seen helping a patient to the toilet.
  • Staff in the emergency department had received lots of positive feedback about the compassionate care provided in the form of cards and letters, and these were displayed in the staff room.
  • Patients’ privacy and dignity was respected and staff sought permission before carrying out care and treatment in all the services we inspected. In the emergency department staff used curtains around the bed spaces to provide privacy when assessing and treating patients, and ensured patients’ dignity was maintained when curtains were opened. Patients in the corridor, however, did not have the same provision to ensure their privacy. Staff did their best to ensure confidentiality and privacy in the corridor by keeping conversations as quiet as possible, but because of the close proximity of other patients and relatives conversations could still be overheard.

Responsive:

  • Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. We rated the responsiveness of services within the hospital as requires improvement. Urgent and emergency services were rated as requires improvement. However, surgical services, medical care and outpatients and diagnostic imaging were rated as good.

  • Access and flow was an issue within the hospital. The hospital was consistently failing to meet the national standard which requires 95% of patients to be discharged, admitted or transferred within four hours of their arrival at the emergency department. The emergency department suffered from regular crowding, and this was cited as the department’s greatest risk. Patients spent longer in the emergency department compared to the England average.
  • The emergency department and the trust were working closely with commissioners and partners to address system-wide flow issues and introduce innovative methods to improve patient flow.
  • Waiting times, delays and cancellations were minimal and managed.
  • Referral to treatment times for different specialties within the medicine division were not all within the England standards. Within surgery referral to treatment standards were being met 92% of the time. Where there had been a slip in performance there were clear actions to address these which had been proven to be effective. In the outpatients departments the overall referral to treatment standard on average was slightly worse than the national average.
  • Processes to ensure patients who were medically fit to leave the hospital were not always timely. However, in the majority of cases, reasons for discharge delays were not attributable to the hospital.

  • We found that medical and surgical services were planned and delivered in a way that met the needs of local patients. The hospital offered choice and flexibility to patients and provided continuity of care. New clinics, services and virtual facilities were implemented, to ensure services met patients’ needs. However, sometimes incurred delays due to issues elsewhere.

  • The medical wards were creative to ensure patient flow through the hospital was maintained and was responsive to the ever-changing demand. There was a constant oversight by senior staff, of how different departments were managing flow, to ensure staff across all areas of the hospital prioritised patient safety, whilst maintaining the flow of patients through the hospital.
  • The flow of patients through the medical division was monitored and actions taken to minimise the numbers of patients being cared for on wards other than those related to their medical condition/specialty. These patients were known as medical outliers. The hospital ensured outlying patients received the care and input from nursing and medical staff, relevant to their medical condition/specialty.
  • The radiology department was slightly below the national standard of 90% of patients referred by the cancer referral process to be seen within two weeks. However; the diagnostic and imaging department was above the national average for the percentage of patients seen within six weeks.
  • Patients were not always able to locate the outpatients and diagnostic imaging departments because they were not clearly signposted. A wide selection of information leaflets were available to patients; however, they were not available in other languages.
  • The parking facilities did not always meet the demand leaving patients unable to find a space in a timely manner.
  • There was good support for patients living with dementia or learning difficulties, and translation services were available for patients whose first language was not English. Reasonable adjustments were made for people living with dementia or with learning difficulties including use of the ‘this is me’ document and access to activities for stimulation. There were access to dedicated teams for dementia, learning disabilities and psychology which were always available.
  • In response to the last inspection and feedback from patients, each outpatient department had introduced waiting time boards which displayed the waiting times for each clinic for that day.

Well led:

  • We rated the well led domain as outstanding. Urgent and emergency services and surgery were rated as outstanding; and medical care and outpatients and diagnostic imaging were rated as good.

  • The leadership, governance and culture promoted the delivery of high-quality person centred care. There was a clear statement of vision and values within the trust which was driven by quality and safety. We found clear statements of vision and values for medical care, surgery, and outpatients and diagnostic imaging, which were driven by safety and quality. The strategies and supporting objectives were stretching, challenging and innovative whilst remaining achievable. The emergency department strategy had not yet been drafted and agreed, although there were programmes of work underway which showed progress towards achieving the department’s vision.
  • Staff understood the vision and strategy and their role in in delivering it. They were proud to work for the hospital and patient focused. Staff demonstrated a kind culture, both to patients and relatives, and to each other.
  • Governance structures were complex to follow. However, the board and other levels of governance within the hospital functioned effectively and interacted well. Staff told us their responsibilities were clear and quality, performance and risks were understood and managed. Risks were escalated when needed and the information communicated to the hospital board flowed well. Processes were in place to monitor, address and manage current and future risk. Performance issues and concerns were escalated to the relevant committees and board. There was a continued focus and drive to improve safety and quality through excellent governance and leadership.
  • Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired culture and to motivate staff to succeed. Leaders understood the challenges to good quality care within and outside the organisation, and there were collaborative relationships with stakeholders.
  • Staff felt leadership was good and divisional lead staff were accessible. Staff told us they felt supported and heard, and there was a collective culture of openness to drive quality and improvement. Leaders and staff demonstrated the participation and involvement of patients who used the service was important to them.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture. There were high levels of constructive engagement with staff. Where there had been a poor culture identified innovative and effective actions were put into place to resolve them.
  • Innovative approaches were encouraged and supported, and these had a clear focus on patient safety, quality and performance, from staff led forums to improve the efficiency of work streams to research in pioneering research techniques. Changes were monitored effectively to evidence the improvements to patient care the changes had.
  • Leaders demonstrated a drive for continuous learning and improvement through the ongoing evaluation and monitoring of the service and by delivering projects and innovative developments aligned to this.
  • The management and governance of current performance of staff mandatory training did not ensure all staff were fully training. For medical staff, this included fire, safeguarding and resuscitation training.
  • The medical division had recognised a risk in the acute oncology service at night, concerning both staffing levels and a lack of suitably skilled triage staff. However, sufficient action was required to minimise the risk to patients in both the service provision and staffing provision.

We saw several areas of outstanding practice including:

  • In times of crowding the emergency department was able to call upon pre-identified nursing staff from the wards to work in the department. This enabled nurses to be released to safely manage patients queueing in the corridor.
  • The audit programme in the emergency department was comprehensive, all-inclusive and had a clear patient safety and quality focus.
  • New starters in the emergency department received a comprehensive, structured induction and orientation programme, overseen by a clinical nurse educator and practice development nurse. This provided new staff with an exceptionally good understanding of their role in the department and ensured they were able to perform their role safely and effectively.
  • In the emergency department the commitment from all staff to cleaning equipment was commendable.
  • The comprehensive register of equipment in the emergency department and associated competencies were exceptional.
  • Staff in the teenagers and young adult cancer service continually developed the service, and sought funding and support from charities and organisations, in order to make demonstrable improvements to the quality of the service and to the lives of patients diagnosed with cancer. They had worked collaboratively on a number of initiatives. One such project spanned a five year period ending May 2015 for which some of the initiatives were ongoing. The project involved input from patients, their families and social networks, and healthcare professionals involved in their care. It focused on key areas which included: psychological support, physical wellbeing, work/employment, and the needs of those in a patients’ network.
  • The use of technology and engagement techniques to have a positive influence on the culture of an area within the hospital. There were clear defined improvements in the last 12 months in Hey Groves Theatres.
  • The governance processes within the division to ensure risks and performance were managed.
  • The challenging objectives in the strategy and how they are used to proactively develop the quality and the safety of the service.
  • The use of innovation and research to improve patient outcomes and reduce length of stay. The use of a discrete flagging system to highlight those patients who had additional needs. In particular those patients who were diabetic or required transport to ensure they were offered food and drink.
  • The introduction of IMAS modelling in radiology to assess and meet future demand and capacity.
  • The use of in-house staff to maintain and repair radiology equipment to reduce equipment down time and expenses.
  • The introduction of a drop in chest pain clinic to improve patient attendance.

However, there were also areas of poor practice where the trust needs to make improvements. Importantly, the trust must:

  • Ensure all medicines are stored correctly in medical wards, particularly those which were observed in dirty utility rooms.
  • Ensure records in the medical wards and in outpatient departments are stored securely to prevent unauthorised access and to protect patient confidentiality.
  • Ensure all staff are up to date with mandatory training.
  • Ensure non-ionising radiation premises in particular Magnetic Resonance Imaging (MRI) scanners restrict access.

In addition the trust should:

  • Ensure chemicals are stored securely at all times in the emergency department and on medical wards.
  • Ensure checks of the equipment in the emergency department’s resuscitation area are recorded consistently.
  • Ensure patients in the emergency department have access to call bells at all times.
  • Ensure reception staff are able to recognise patients who attend the emergency department with serious conditions and need urgent referral to the triage nurse and provide a formalised process for summoning help.
  • Continue working towards providing 16-hours on-site consultant cover in the emergency department, and increase consultant cover at the weekend.
  • Ensure the emergency department is accessible to wheelchair users and the layout of the reception desk allows staff to interact with wheelchair users whilst sat at the desk.
  • Ensure the emergency department develops and formalises its vision and strategy.
  • Ensure staff in the emergency department are up-to-date with their mandatory training, including safeguarding adults and children.
  • Work with commissioners and the local mental health service provider to ensure mental health patients arriving at the emergency department receive the care they require in a timely manner.
  • Ensure all staff working in the emergency department and medical staff receive an annual appraisal.
  • Ensure clear signage and equipment is in place for staff, patients and visitors to wash their hands when entering a medical ward area.
  • Ensure the environment in the oncology department and ward keeps patients safe and comfortable, especially for patients who may be confused or cannot maintain their own safety.
  • Ensure access to the staff room on the medical assessment does not allow access to unauthorised people.
  • Take remedial maintenance action to ensure the heating system on ward D703 maintains a suitable and safe temperature for staff and patients.
  • Ensure staff have a greater understanding and awareness of the intercom system on the Hepatology ward, to ensure safe and prompt access to the ward and confidentiality of patient information.
  • Ensure medical doctors’ inductions are undertaken in scheduled blocks and planned so doctors do not start work on the wards without an induction.
  • Ensure clear signage and equipment is in place on medical wards to advise staff, patients and visitors to wash their hands when entering a ward area.
  • Ensure delays in the provision of take home medicines do not delay patients.
  • Ensure medical records are legibly and fully completed. This includes patient risk assessments.
  • Audit records in the cardiac catheter laboratory to ensure they are fully complaint with the World Health Organisation surgical safety checklist for all surgical procedures.
  • Address the risk in the acute oncology service where patients may be placed at risk by reduced staffing levels at night due to admissions of emergency oncology patients. There should be suitably skilled staff in place at night to ensure safe triage advice is given to patients accessing the emergency oncology service. Whilst the trust recognised these risks, sufficient action should be taken to minimise the risk to patients in both the service provision and staffing provision.
  • Ensure pain audits are established to monitor if pain was managed effectively for patients with an ability to express their pain.
  • Continue to monitor staff’s use of the Abbey Pain Scale to ensure patients with cognitive impairment in the specialised services division have an effective tool to assess their pain needs.
  • Continue to ensure all efforts be made to maintain flow through the hospital and patients be nursed on the correct wards to meet their needs.
  • Reduce the risk on the hepatology ward in relation to lone working practices, when accompanying patients off the ward at night to smoke.
  • Improve the level of safeguarding training for staff working overnight in the surgical trauma assessment unit.
  • Improve compliance for mandatory training in surgical areas.
  • Improve patient outcomes to bring them in line with the national average for the hip fracture audit and improve the National Emergency Laparotomy Audit.
  • Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
  • Monitor the World Health Organisation (WHO) Surgical Safety Checklist is always used in the appropriate area as a checklist when carrying out non-surgical interventional radiology.
  • Provide leaflets within outpatient departments are available in different languages
  • Check local and national diagnostic reference levels (DRLs) are on display as stated in Regulation 4(3)(c) of IR(ME)R 2000 and IR(ME) amendment regulations 2006 and 2011.

  • Make improvements on the follow up backlog waiting list to meet people’s needs and minimise risk and harm caused to patients through excessive waits on follow up of outpatient appointments and  the reporting of images.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 2 March 2017

Effective

Outstanding

Updated 2 March 2017

Caring

Good

Updated 2 March 2017

Responsive

Requires improvement

Updated 2 March 2017

Well-led

Outstanding

Updated 2 March 2017

Checks on specific services

Medical care (including older people’s care)

Good

Updated 2 March 2017

We rated this service as good because:

  • There was a good incident reporting culture and staff were encouraged to report incidents. Learning from incidents had led to changes in ward practice.
  • Safety was monitored and actions taken to improve safety.
  • Staffing levels were in line with the hospital’s staffing measurement tools.
  • Feedback from patients and those close to them was positive. Patients’ emotional and social needs were valued and this was demonstrated in the way staff cared for patients.
  • The service was flexible and creative to ensure flow was maintained. The systems put in place to support the patients on outlying wards ensured they were seen by the right medical team every day, and their care was always overseen by the medical team.
  • Work had taken place to deliver services that met the needs of patients living with dementia.
  • Patients’ care and treatment was planned in line with current evidence based guidance.
  • Patients had comprehensive assessments of their needs. Patients had their pain assessed regularly and managed promptly. Their nutrition and hydration was assessed and monitored.
  • A programme of local and national audits was used to monitor care and treatment was being provided in accordance with national guidelines. Some areas showed improvement, including the national stroke audit.
  • Learning needs of staff were identified and training put in place to meet those needs.
  • Patients received care from different teams who worked together to coordinate care. There were links with GP’s and community providers to ensure safe patient discharge.
  • When patients who needed specialist community support were discharged, effective links were made with community services.
  • Whilst care was provided seven days a week, ward rounds by medical staff did not take place every day. However, access to medical care was always available.
  • Discharge delays, transfers and bed moves were all monitored to ensure they did not negatively impact on patients.
  • Complaints were handled in accordance with trust policy, and improvements were made in response to complaints.
  • There was a clear, overarching statement of vision and values for the medicine service, which was driven by safety and quality. Staff understood the vision and strategy and their role in in delivering it.
  • Risks were escalated when needed and the information communicated to the hospital board flowed well. Processes were in place to monitor, address and manage current and future risk.
  • Leaders understood the challenges to good quality care within and outside the organisation, and there were collaborative relationships with stakeholders.
  • Staff felt leadership was good and divisional lead staff were accessible. Leaders and staff demonstrated the involvement of people who used the service was important to them.
  • The hospital had forged strong links and worked closely with the voluntary sector.
  • Leaders demonstrated a drive for continuous learning and improvement through the ongoing evaluation and monitoring of the service and by delivering projects and innovative developments.

However:

  • Systems were not always reliable to keep patients’ information safe. Records were consistently seen to not be stored securely.
  • Not all medical staff had completed mandatory training in line with the trust’s targets.
  • Doctor induction was undertaken in scheduled blocks. Should doctors start work in between those blocks, they may work for a period of time without induction.
  • There were gaps in information being monitored in specific areas of care, such as pain audits to establish if pain was managed effectively. The cardiac catheter laboratory used a World Health Organisation surgical safety checklist for all surgical procedures. However, these records were not audited to ensure they were all fully completed.
  • Not all staff had received an appraisal in the last year. Without an appraisal, learning needs may not be identified and a plan put in place to support staff to develop their practice.
  • The management of risk did not protect staff on the hepatology ward. This related specifically to lone working practices when accompanying patients off the ward at night who wanted to smoke.
  • The division had recognised a risk in the acute oncology service at night, concerning both staffing levels and a lack of suitably skilled triage staff. However, further action was required to minimise the risk to patients in both the service provision and staffing provision.

Urgent and emergency services (A&E)

Good

Updated 2 March 2017

  We rated this service as good because:

  • There was a multidisciplinary audit programme in place which was actively used by staff to encourage and monitor improved outcomes.
  • Innovative approaches were being used to deliver quality care. In particular a new patient safety assessment tool, known as SHINE, had driven significant improvements and clearly demonstrated improved outcomes.
  • There was a strong multidisciplinary approach to patient care and this included staff within and external to the department, including partner organisations.
  • There was a real focus on staff learning and development. Staff were supported and sponsored by the department and the trust to complete additional relevant qualifications.
  • Staff demonstrated a clear understanding of consent and best interest decision practices and records evidenced these were being followed.
  • There was a continued focus and drive to improve safety and quality through excellent governance and leadership.
  • Leaders were respected by their teams and truly encouraged a supportive, open and honest culture amongst all staff.
  • Innovative approaches were encouraged and supported, and these had a clear focus on patient safety, quality and performance.
  • There was an extremely positive safety culture, with all staff taking an interest and personal responsibility with regard to patient safety.
  • Learning opportunities were identified and these were actively shared with staff to support improved safety. The use of simulation training to further embed learning was an excellent tool.
  • Medicines were managed safely and securely. Incidents relating to double administrations had led to new stickers being implemented to highlight pre-hospital medicines administration to staff.
  • Nursing staffing levels met national guidelines and additional nurses were called upon from the wards to support the department in times of crowding.
  • People were treated with dignity and respect and staff were mindful of confidentiality and privacy.
  • Staff took time to ensure patients and their relatives understood their care, diagnosis and treatment plans.
  • The emergency department and the trust were working closely with commissioners and partners to address system-wide flow issues and introduce innovative methods to improve patient flow.

However:

  • The trust was consistently failing to meet the national standard which requires 95% of patients to be discharged, admitted or transferred within four hours of their arrival at the emergency department.
  • The emergency department suffered from regular crowding, and this was cited as the department’s greatest risk. This was on the corporate risk register.
  • Wheelchair users and patients with mental health conditions were not having their needs met.
  • Patient privacy and confidentiality could not be maintained in the corridor when the department was crowded.
  • Not all staff had received an appraisal in the last year, with particular low compliance in the ancillary staff group.
  • Consultant cover did not meet the 16-hours on-site standard and was reduced significantly at weekends. However, junior doctors felt well supported and both the local management team and trust executives were aware of this concern and had actions ongoing to improve the levels of cover.
  • Receptionists did not receive any training or guidance to help them identify potentially seriously unwell patients and there was no formalised procedure for calling for help in the event of a patient deteriorating in the waiting room. However, while this presented a risk to patients awaiting triage, no incidents of harm had been reported.

Surgery

Outstanding

Updated 2 March 2017

We rated this service as outstanding because:

  • There was a good culture of incident identification, reporting, investigation, and sharing of learning throughout the surgical division. There were many examples shared with inspectors of learning from incidents both in their own area and from the wider trust.
  • Staffing levels were good with only occasional use of agency staff. Where there were shortages of staff there was a quick response to rectify this. This resulted in safe staff management and handover from staff to manage risks.
  • Risks were managed and responded to effectively both on the wards and in theatre. Learning from a never event was fully integrated into the surgical safety checklist. On the wards we saw comprehensive risk assessments, which included physical and mental health, to ensure the safe care and treatment of patients.
  • Staff worked effectively together as a multidisciplinary team and worked together in a coordinated way for the patients best interests. This included working between teams and services.
  • Mortality rates were consistently better than the national average in all the audits we looked at.
  • Feedback from patients and their families was almost entirely positive. Patients we met spoke positively of the service they received and of the compassion, kindness and caring of all staff. Staff ensured patients experienced dignified and respectful care.
  • Although slightly limited, reasonable adjustments were made for patients living with dementia or with learning difficulties including use of the ‘this is me’ document and patient access to activities.
  • Leadership in the trusts surgical services was enthusiastic and staff were motivated to succeed. A strong governance structure aided managers to proactively review performance and risks and were reviewed to reflect best practice.
  • We saw an innovate method of engaging staff through the use of the ‘Happy App’ and proactive engagement with staff. We found because of this the culture of engagement had developed to be positive. Staff were proud to work at the hospital.

However:

  • Not all staff within the surgical service had received recent mandatory training to keep patients safe. There were a number of staff who had not completed all of the required training for resuscitation, safeguarding, fire, manual handling and infection control.
  • The service was planned and delivered in a way which met patient’s needs. However, some patients had long waiting times to have their surgical procedure due to a high level of medical outliers on surgical wards and staff shortages in some specialties. This was particularly apparent in the cleft palate service and the dental service.

Intensive/critical care

Good

Updated 2 December 2014

Critical care services were judged to be good in the safe, effective, caring and well-led domains. The responsive domain required improvement.

The trust’s adult critical care services had a good patient safety record and performed better than other comparable trusts. We saw that there was a culture of learning from incidents and complaints. Risks were being managed appropriately. Staff were encouraged and supported to be involved in quality improvement projects and we were shown several examples of innovation. Arrangements for medicines were generally appropriate, but some improvements were needed.

Patients and relatives told us that staff were mostly caring and compassionate. There was appropriate medical cover for critical care wards and CICU. The imminent plan to recruit more experienced nurses will give greater assurance of the ongoing safety in both critical care and CICU.

Changes within the last 12 months to the leadership of both the critical care unit and CICU had been positive and were leading to improved opportunities for staff and an improved skill mix for nurses, which will enhance patient care. Clinical leadership from consultants within critical care was also seen to be good. However, there was a lack of clarity around governance arrangements from CICU consultants.

The forthcoming opening of the new critical care unit (ward 600) will provide both staff and patients with an improved care and working environment. There will be improved facilities for visitors and additional quiet rooms, which will afford greater privacy for distressed and grieving relatives. The new unit will provide one additional bed compared with current availability. It is highly likely that problems will continue relating to access to critical care beds, resulting in cancelled operations and delays in transfer to critical care due to the lack of available suitable beds.

Maternity and gynaecology

Good

Updated 2 December 2014

The maternity and family planning services were found to be good in the safe, effective, caring and responsive domains and outstanding in the well-led domain. The maternity services provided care and support in accordance with recommended guidance. Audit systems in place meant that practices were monitored continuously and action was taken when improvements were required. Staff were confident in reporting incidents, telling us that they had confidence that any lessons learned would lead to the necessary change in practice.

There were times when records were left unattended on the postnatal ward, meaning that confidentiality of information was not always assured.

The services had enough resources, including equipment and staff, to meet the needs of women, although the midwife-to-women in labour ratio was lower than the recommended level. On occasion, sanitary bins on the postnatal ward were overflowing and domestic staff on the labour ward had not always cleaned a room within the set timescales. Staff told us that discussions were ongoing with outside agencies who were involved in the provision of domestic staff.

Staff at all levels undertook the required training and assessments of their competencies were ongoing. Midwives had regular supervision of their practice. Staff reported that they had opportunities to develop their skills.

Women’s individual needs and level of risk were taken into account when planning their care. As a regional referral centre, the maternity services worked with a range of other services to ensure that women’s plans for their pregnancy were carried out where possible.

Feedback from women and their families was positive about the services they received, the level of support and information they received and the way in which their dignity and privacy were maintained.

Leadership in the maternity and family planning services was outstanding. There was a high level of satisfaction amongst staff. There was evidence of strong collaboration and support across the service. Staff spoke of an open, supportive and friendly culture, with “great teamwork”. Leadership was encouraged at all levels within maternity services. Staff were able to input ideas and were empowered to find and implement solutions.  The team worked cohesively with open communication and all members of the staff team felt they were able to speak up and were listened to. This led to a highly functional team.

The service had a proactive and well-defined governance structure. Meetings existed that oversaw activity, performance, quality, safety, audit and risk. Issues were escalated within the trust, as required.

There was strong engagement with patients and a focus on gaining greater involvement in the MSLC from patients groups who represented the local population using the service.

Continuous improvement was embedded within the service with multidisciplinary working parties empowered to develop, discuss and test new ideas and guidance. Innovative approaches were adopted to resolving challenges.

Services for children & young people

Good

Updated 2 December 2014

Services for children and young people were found to be good. Children received good care from dedicated, caring and well-trained staff who were skilled in working and communicating with children, young people and their families.

Patient outcomes were routinely better than expected which was demonstrated through independent benchmarking. There was evidence of staff being involved in the development and review of policy, procedures and implementing a change practice, where improvements in outcomes were required. There was a strong commitment to the skills knowledge and competence of all staff.  The trust had developed a Paediatric Faculty of Education at the hospital to develop the skills, competence and knowledge of staff. Transitional care was outstanding, young people had been involved in the development of the service and planning occurred from an early stage.

 Children and their families were actively involved in their care and treatment and their feedback regularly sought and listened to.

The arrangements for safeguarding were excellent and staff told us about the open culture that encouraged them to report issues as they arose. Following a successful recruitment campaign, wards were staffed with well-trained and competent staff.

The majority of comments from parents, children and young people were very positive. They thought the staff were brilliant and the facilities excellent.

End of life care

Good

Updated 2 December 2014

The specialist palliative care team had developed a range of tools and processes in order to deliver, monitor and evaluate care in line with current best practice. They regularly reviewed patients within multidisciplinary forums to promote coordinated, safe and effective care. Care records demonstrated that potential problems for patients were identified and planned for in advance with action plans. This information was recorded clearly in care plans.

We found that end of life care was effective and responsive to individual patient needs, particularly in the last days and hours of life. Improvements were needed to identify patients who were potentially in their last year of life in order to better plan care. End of life patients were not always able to be in their preferred place of care as the discharge-planning process was not fully effective. Intermediate improvements were required to the mortuary facilities while the planned redevelopment of this facility were completed.

All the patients and relatives we spoke with told us that they had been involved in decisions, care was good and staff were respectful and kind. Staff throughout the trust valued the expertise and responsiveness of the specialist palliative care team.

Outpatients

Good

Updated 2 March 2017

We rated this service to be good because:

  • There was a good incident reporting culture and openness and transparency were encouraged. Lessons learnt were shared in both outpatients and diagnostic imaging to make sure action was taken to improve not just the affected service.
  • There were clearly defined systems and processes to keep people safe and safeguarded from abuse. All staff we spoke with had a good awareness of safeguarding legislation and what to do if they had any concerns.
  • People’s care and treatment in both outpatients and diagnostic imaging was planned and delivered in line with current evidence based guidance, standards, best practice and legislation. We saw evidence of audit to ensure that practice was monitored ensuring consistency
  • Feedback from patients and relatives had been consistently positive. They praised the way the staff really understood their needs and involved their family in their care. Patients were treated as individuals.
  • We found although people were waiting too long for appointments, there were innovative approaches to the appointment booking systems and the management of the capacity and demand of outpatient’s and diagnostic imaging clinics.
  • In response to the last inspection and feedback from patients, each outpatient department had introduced waiting time boards which displayed the waiting times for each clinic for that day.
  • Services were planned and delivered in a way that met the needs of the local population and took into account patient choice.
  • There was a clear statement of vision and values, driven by quality and safety. It was translated into a credible strategy for outpatients with defined objectives that were regularly reviewed and relevant.
  • Staff and patients were engaged in how care was delivered. Staff felt as if they were active contributors to how the service was developed.

However:

  • Some medical records were not being stored securely in outpatient departments.
  • There was a backlog of appointments and high levels of referrals meaning people were not able to access the services for assessment, diagnosis or treatment when they needed.
  • We found doors to the MRI scanners were unlocked and were accessible to patients in the main waiting area.