Royal United Hospital Bath

We inspected the Royal United Hospitals Bath NHS Foundation Trust as part of our comprehensive inspections programme of all NHS acute trusts.

The inspection was announced and took place between 15 and 18 March 2016. We also inspected the hospital on an unannounced basis on 29 March 2016.

We rated the hospital as requires improvement overall. The effective, and well led key questions were rated as good, caring was rated as outstanding and the safety and responsiveness of the hospital was rated as requires improvement. End of life care within the hospital was rated as outstanding, but critical care services were rated as requires improvement.

Our key findings were as follows:

Safe:

• We rated safety in the hospital as requires improvement. Urgent and emergency care, critical care and maternity and gynaecology were rated as requires improvement. All other services were rated as good.

• There were periods where staffing and skill mix were not as planned by the trust. This was mitigated by higher numbers of healthcare assistants and in some cases supervisory ward sisters acting in a clinical capacity. Nurse staffing and skill mix was assessed and reviewed twice a year using recognised tools to determine staffing levels, in places wards had not been fully engaged with this in the review in August 2015, but were in February 2016. Although there was awareness and systems in place to flex nurse staffing across wards, these were not clear and relied upon the judgement of senior staff rather than being grounded in clear processes. There was, however, a process in place for the authorisation of the use of agency staff and a staffing escalation policy in place. Recruitment was ongoing for nursing vacancies across the trust and the trust was training assistant nurse practitioners in order to provide additional support.

• The trust commissioned a fire safety review in November 2015.Actions were being taken to mitigate the concerns raised. However, these were ongoing and would not be complete until quarter three of the 2016/17 financial year. The trust told us about the actions they were taking and provided  an action plan but this action plan did not clearly show the progress and interim mitigating actions.

• The records maintained regarding the servicing, repair and cleaning of equipment was not always clear and did not provide assurance that all equipment was being regularly maintained. Within maternity services, there were not sufficient numbers of key equipment available, for example epidural pumps.

• In some areas of the hospital, for example in critical care and maternity services, cleaning required improvement. There had also been a higher rate of infections with Clostridium difficile than the hospital target, and also a case of legionella colonisation on one of the wards.

• Openness and transparency about safety was encouraged and embedded across the hospital. Systems were in place for the recording, investigation and learning from incidents. Staff understood their responsibilities to raise and report concerns, incidents and near misses. There was evidence that learning was widely shared across the hospital. However, within critical care not all incidents were reported and had become ‘every day events’.

• When something went wrong, patients received a sincere and timely apology.They were told about any actions taken to improve processes to prevent the same happening again. The majority of staff understood their responsibilities under the Duty of Candour requirement and could provide examples when they had been used.

• Performance showed a good track records and steady improvements in safety.The morality risk was similar at weekends to that during the week within the hospital and the trust scored within the expected range.Rates of new pressure ulcers, falls and catheter acquired urinary tract infections were monitored with no discernible trends. There were techniques in place to help patients avoid harm. These included: the discrete identification of risks on the patient board, for example, their risk of falls and vulnerable pressure areas; and, comfort rounds carried out by staff.

• Medicines were managed effectively throughout the hospital, with secure storage and effective recording where appropriate.

• Records throughout the hospital were stored securely. However, there were some instances where confidential information was not secure if left unattended.

• The completion of records was variable within the hospital. In most areas records were completed and there were clear plans of care and treatment for patients. However, within the emergency department, records were not always completed in order to ensure that it was easy to identify if a patient’s condition was deteriorating.

• In most areas of the hospital there was a proactive approach to anticipating and managing risks to patients. These were embedded and were recognised as being the responsibility of staff. However, in the emergency department, the time taken to triage and assess patients who self-presented at the department (not admitted by ambulance) was not consistently recorded and accurate performance data was not available. This meant we could not be assured that patients were quickly assessed to identify or rule out life or limb threatening conditions to ensure patient safety. We saw examples of patients waiting over an hour for initial assessment. 

• There were clearly defined and embedded systems, processes and standard operating procedures to keep patients safeguarded from abuse. Staff understood the processes and there was evidence of reporting occurring as necessary.

Effective:

• We rated the effectiveness of services within the hospital as good .All services that we rate for effectiveness were good with the exception of medical care which requires improvement.

• Patients care and treatment was planned and delivered in line with current evidence-based guidance and standards. We saw good levels of compliance with recognised care pathways, including those for sepsis and stroke care within the emergency department.

• Compliance with protocols and standards was monitored through both internal and national audit. Performance with national audits was mostly in-line with or better than other trusts. For example, the trust was rated C in the Sentinal Stroke National Audit Programme, which placed them in the top 44% of trusts offering stroke care. There was evidence that audit was used to improve performance and practice, for example in the treatment of sepsis in the emergency department. However, improvement was required in the National Diabetes Inpatient Audit from 2015 and the Myocardial Ischaemia National Audit Programme form 2013/2014. Improvements were also required in the audit of compliance with guidance on the termination of pregnancy and the monitoring of rated of infection post caesarean section for learning.

• Patient outcomes were generally good, although patient reported outcome measures (PROMs) for patients receiving surgical treatment for groin hernias and varicose veins were worse than the England average.

• In most areas of the hospital, staff were provided with the training and support they needed to do their job. In the emergency department nursing and medical staff received regular teaching and supervision. They were encouraged and supported to develop areas of interest in order to develop professionally and progress in their careers. However in medical services, there was not a reliable system for staff supervision, and appraisal performance in services for children and young people required improvement.

• Care was delivered in a coordinated way with support from specialist teams and services. There was close, collaborative working across the hospital, for example between the emergency department, stroke team, discharge assessment team, medical nurse practitioner (older person's unit), mental health liaison service and the alcohol liaison service.

• Staff had a good understanding of the Mental Capacity Act 2005. However, for Deprivation of Liberty Safeguards, the trust policy was not in line with the code of practice and stated that for the majority of patients, their stay in hospital would be less than 72 hours so the wider Mental Capacity Act should be applied. For those remaining in hospital for longer than 72 hours the ‘acid test’ for deprivation should be applied.The Deprivation of Liberty Safeguards are applicable to all patients who lack capacity, as set out within the Mental Capacity Act 2005, no matter the length of time they are in hospital.

• Patients were assessed and provided with adequate pain relief most of the time. We saw some examples of where assessed pain levels were not recorded and pain relief was not provided in a timely manner in the emergency department. Additional equipment was required to assist with pain and discomfort during labour and birth.

Caring:

• Overall, caring within the hospital was rated as outstanding. Services for children and young people, and end of life care were rated as outstanding, with all other services rated as good.

• Children and young people were treated as individuals and as part of a family. Feedback was exceptionally positive about the care they received, and praised the way staff really understood the needs of the child and involved the whole family.

• Within end of life care, patients and their families were universally positive about the way they were treated by staff. There was a strong patient-centred culture and staff across the hospital were motivated to provide high quality end of life care and support that promoted patients’ dignity and respect. This was centred around an approach called the conversation project.

• Patients were treated with kindness and compassion. Staff throughout the hospital provided reassurance when patients were anxious and confused. Within services for children, staff were skilled in communicating with children and young people to minimise their anxiety and to keep them informed of what was happening.

• Patients were treated with courtesy, dignity and respect. Patients and their relatives were greeted by staff who introduced themselves with their name and role.

• Across the hospital, patients and their families were involved as partners in their care. Parents, siblings and grandparents were encouraged to be involved in children and young people’s care and treatment.

• Patients understood their care, treatment and condition, worked with staff to plan their care and shared decision-making about their care and treatment. Doctors and nurses took time to explain care in a sensitive and unhurried manner.

• There was a hospital wide approach to initiating conversations with patients and relatives who were making the transition to end of life care.

• However, within critical care there was limited support for patients who stayed on the unit for a long time, in order to keep them in touch with life going on around them. For example, there was not active use or promotion of using quality patient diaries.

• Improvements were required in the number of patients engaging in feedback of experience surveys in maternity services.

• Within outpatient and diagnostic imaging services, staff did not always respect confidentiality when speaking with patients at reception desks.

Responsive:

• Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. Urgent and emergency services, medical care, surgery, critical care and outpatients and diagnostic imaging were rated as requires improvement. However, services for children and young people, and maternity and gynaecology were rated as good and end of life care was rated as outstanding.

• Access and flow was an issue within the hospital. Although patients arriving by ambulance received an assessment within eight minutes of being admitted to the emergency department, the hospital consistently failed to meet the standard for 95% of patients to be discharged, admitted or transferred within four hours of arrival. There had been a worsening trend since October 2015 with the worst performance in January 2016 at 71.8%. The average for the year (stated in data in January 2016) was 86.6%. Despite this there were no patients who waited in the department for longer than 12 hours on a trolley. A , although patients did remain in the department overnight when there were no beds available in the hospital, the 12 hour standard was not breached.

• However, this was not solely an emergency department problem. The flow of patients throughout the hospital from admission to discharge was not efficient. Patients sometimes stayed in hospital longer because ward teams were not able to arrange transfer to community hospitals or to easily access packages of social care in the community.

• There were a number of initiatives ongoing in the hospital to improve the flow of patients. For example, there was a ward flow pilot project to streamline the process of transferring patients from the medical assessment unit to speciality wards. The emergency surgical ambulatory unit had reduced the need for patients referred by their GP to the hospital to be admitted to the hospital.

• There were long waiting times, delays and cancellations of operations within the hospital. Access to routine specialist treatment was greater than the 18 week standard across surgical specialties and in gastroenterology, cardiology and dermatology. From May 2015 when the standard was abolished, timely access to these services deteriorated further. The short stay surgical unit had been used as an escalation ward since December 2015, in order to accommodate the demand on services across the hospital.This had an impact on the number of elective operations that the hospital could perform.

• Within outpatient services, 14 out of 31 specialty departments were breaching the national standard for patients to receive their outpatient appointment within 12 weeks of referral, in order that treatment can start within 18 weeks.However, the trust met the national cancer waiting time standards.

• Due to pressure on services, we found that patients were being moved between wards at night. Data collected showed that the number of patient moves after 10pm had reduced between October and November 2015.This occurred in surgical and critical care services.In addition patients in critical care experienced delays in being discharged from the unit because of pressure on services elsewhere in the hospital.These delays were worse than the national average. However there were fewer urgent operations cancelled due to the lack of an available critical care bed.

• Most services in the hospital were responsive to people’s individual needs. There were very good facilities for patients living with dementia in all areas. For example within outpatients there was a sensory box in place to support patients using distraction therapy. There was good support for patients living with a learning disability and their families and carers in all areas. However within critical care, there were no follow up clinics or psychological support for patients following discharge from the unit, no high or low-level communication aids for patients and there were limited facilities for relatives on the unit.

• Within maternity services, there was good access and flow, although gynaecology services were affected by the access and flow issues in the rest of the hospital.There was however, room for significant improvement in the provision of specialist bereavement services for maternity patients and their families experiencing loss. Staff were not trained in this and the designated areas identified to care for bereaved women and their families lacked privacy, space and facilities.

• Services for children and young people were tailored to meet their needs and delivered in a flexible way. Although facilities within the areas of the hospital designated for children and young people were good. Other areas, including the theatre recovery rooms were not child friendly.

• The responsiveness of end of life care within the hospital was outstanding. There was an individual approach to the planning and delivery of end of life care. The trust worked with services in the local community to provide continuity of care where possible. Rapid discharge was provided for patients when the appropriate packages of care were available in the community. The trust engaged commissioners and community services in driving improvements in end of life care.

• Complaints were managed effectively across the hospital. There were no barriers to making a complaint, they were handled in an open manner and opportunities for learning and improvement were acted upon.

Well Led:

• We rated the well led domain as good. All services within the hospital were rated as good with the exception of critical care which was rated as requires improvement.

• 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. Some departments, for example the emergency department, had created mission statements.

• There were effective governance frameworks throughout the hospital, risks were identified and the majority were mitigated effectively. Leaders were aware of challenges to patient care within services and identified plans for improvement. Cross department and directorate working was evident in ongoing work to improve the flow of patients through the hospital and out into the community. Partnership working was evident.

• Clinical and internal audit processes were well embedded and had a positive impact on quality governance.

• There was an open culture within the whole hospital. People were encouraged to report incidents.There was a culture of safe innovation, with staff telling us of the “Dragon’s Den” approach to pitching areas for improvement to the trust board.

• Leadership within directorates was visible and staff felt supported in their roles.

• However, the critical care service lacked senior nurse leadership as there had been no matron in post for over a year prior to our inspection. Although there was support from the clinical lead, senior sister and senior manager providing temporary oversight, the unit was not performing as it should without the guidance of its most senior nursing post. The unit was not always benefitting from the wider experience and skills of trust-wide teams. The leadership did however, promote the delivery of safe patient care and there had been improvements in safety and quality measurement and governance arrangements. There had also been measurable and valuable innovation and change within the unit following audit, research and investigations into best practice.

We saw several areas of outstanding practice including:

• The emergency department had developed guidelines on the management of patients during periods of high demand when flow out of the department is limited. The guidelines aim to reduce the patient safety risks associated with overcrowding by minimising the number of ambulance-borne patients with undifferentiated diagnosis waiting in the corridor for assessment. The document also describes measures to maintain the comfort and dignity of patients waiting in the corridor. 

• SSSU and SAU had Project Search Students. This programme provided a mixture of structured work placements and classroom learning for young people living with learning disabilities. It was evident that the students were part of the team and had a clear set of tasks and structure to their daily routine.

• The Surgical Assessment Unit operated an Emergency Surgical Ambulatory Care Unit (ESAC). As part of a Quality Improvement Project (QUIPP 5.8) it was recognised that patients waiting for emergency surgical procedures such as hernia and abscesses (category C and D as classified by NCEPOD), were not being managed properly. These patients were often starved and cancelled at the end of an emergency theatre lists due to running out of theatre time. The ESAC had two dedicated surgeons, which operated a booked emergency list, which focused on these patients and had eight spaces. It had its own dedicated ultra sound equipment, room and a Sonographer who has a dedicated inpatient clinic for two hours a day, Monday to Friday.

• The ESAC unit was run by two band seven Nurse Practitioners Monday to Friday. The Nurse Practitioners also ran a Nurse Led Clinic, which managed complex dressings, and an Accelerated Discharge Programme, which aimed to get patients home sooner but still give them the support and treatment required as an outpatient rather than inpatient.

• There was outstanding caring to children, young people, their parents and the extended family.

• Frontline staff and senior managers were passionate about providing a high quality service for children and young people with a continual drive to improve the delivery of care.

• There was excellent local leadership of the children’s service. Senior clinical managers were strong and committed to the children, young people and families who used the service, and also to their staff and each other.

• The trust had run The Conversation Project, which was an initiative to improve communication between staff, patients and relatives about care for the dying patient.

• The trust had implemented new documentation called The Priorities of Care for recording a personalised care plan for the dying patient.

• We observed and heard numerous examples of outstanding, compassionate care provided by nursing, medical and cleaning staff for patients at the end of their lives from both the patients and their relatives.

• We saw some outstanding practice within the outpatients department, in how staff treated and supported patients living with learning difficulties. This included providing double appointments, rearranging appointments out of hours so patients with anxiety problems could be seen without other patients around. We saw how carers were fully involved where appropriate including working with them and the patient during potentially intimate examinations.

• The orthopaedic and fracture clinic had a sensory box that could be used for patients with dementia, learning difficulties and children. The box had a range of sensory objects as well as appropriate picture books. Staff told us they use the box regularly as part of distraction therapy.

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

Importantly, the trust must:

• The trust must continue to work in collaboration with partners and stakeholders in its catchment area to improve patient flow within the whole system, thereby taking pressure off the emergency department, reducing overcrowding and the length of time that patients spend in the department.

• The trust must take steps to ensure that the emergency department is consistently staffed to planned levels to deliver safe, effective and responsive care.

• The trust must take steps to ensure that all staff in the emergency department are up-to-date with mandatory training.

• The trust must monitor and report on the time to initial assessment of patients who self-present in the emergency department.

• The trust must take steps to improve record keeping within the emergency department, so that patients’ records provide a contemporaneous account of assessment, care and treatment.

• The trust must take steps to ensure that patients in the emergency department receive prompt and regular observations and that early warning scores are calculated, recorded and acted upon.

• The trust must take steps to improve recording of pain assessment scores and pre-hospital medication and ensure that patients attending the emergency department who need it receive prompt and appropriate pain relief.

• The trust must take action to ensure that staffing reviews are robust and reflect accurate and comprehensive data for all medical wards. The trust must continue to mitigate the risks associated with less than planned staffing levels to ensure safe staffing on medical wards for every shift

• The trust must take action to ensure that relevant staff are aware of the major incident protocol.

• The trust must take action to improve the safe storage of medical notes on the surgical wards.

• The trust must employ an experienced nurse to the post of critical care matron, a post that has been vacant for 15 months.

• The trust must ensure the approved operating policy for critical care is understood and followed by hospital staff when considering moving nursing staff to work on other wards. Review nursing staff levels so they meet recommended guidance for critical care to enable the supervisors/coordinators, protected staff, and clinical educators to fulfil their roles.

• The trust must review the incident reporting procedures within critical care to ensure staff are aware of what constitutes an incident, staff are enabled to report all incidents, and they receive feedback and follow-up from those they report.

• The trust must ensure all areas of the critical care unit are clean, tidy and organised to allow good cleaning to take place.

• The trust must review the equipment on the critical care unit to ensure all maintenance and servicing is up-to-date and then accurately recorded. Ensure all equipment and medicines are checked as required and stored safely, preventing the risk of tampering, and to meet legal requirements.

• The trust must ensure the access and flow of patients in the rest of the hospital reduces delays from critical care for patients admitted to wards. Reduce the number of patient discharges at night.

• The trust must make sure policies, guidance and protocols for providing care and treatment within critical care are reviewed and up-to-date with best practice at all times.

• The trust must ensure there are specialist bereavement staff and an appropriate environment to effectively provide care and support for bereaved gynaecology and maternity patients and their families.

In addition the trust should:

• The trust should continue to develop cooperative relationships between the emergency department and other specialities within the hospital and work towards meeting internal professional standards.  

• The trust should continue to work with partners to improve the responsiveness of out of hours support for adults, children and young people with mental health issues.

• The trust should continue to work with partners to improve the responsiveness of the patient transport service.

• The trust should ensure there is a reliable system of staff supervision for clinical staff.

• The trust should ensure patient records are stored securely on the cardiac ward.

• The trust should ensure staff are compliant with safeguarding children level two and safeguarding adults level two training.

• The trust should take action to improve the performance of the diabetes service, particularly with regard to prescription errors and the number of patients seen by a multidisciplinary foot team within 24 hours.

• The medical division should ensure specialty clinical governance meetings occur frequently.

• The trust should ensure improvement plans to address difficulties of flow within the medical service proceed and the impact of these changes are critically monitored.

• The trust should ensure re-assessments of risk of venous thromboembolism are consistently completed.

• The trust should ensure staff identify review dates and stop dates for antibiotics prescribed.

• The trust should ensure that actions resulting from external reviews, for example fire safety reviews, are clearly documented and acted upon in a timely manner.

• The trust should make sure chemicals and substances that are hazardous to health (COSHH) are secured and not accessible to patients and visitors on the surgical wards sluice area.

• The trust should continue with their action plan to reduce their RTT in all surgical specialities.

• The trust should continue to recognise and address issues with nursing staff shortages on the surgical wards.

• The trust should make sure medical staff on the surgical wards are up-to-date with their mandatory and statutory training and meet trust targets.

• The trust should review the chairs in the admission suite as they were of the same height, which could make it difficult for patients with limited mobility.

• The trust should reduce the number of bed moves after 10pm on the surgical wards.

• The trust should make sure a doctor prescribes all oxygen therapy before being used.

• The trust should make sure all operations and procedures are included on consent forms prior to the start of the procedure/operation, especially for those who lack capacity to make the decision.

• The trust should make sure all equipment in theatres has the date of the last service recorded on them.

• The trust should repair all the equipment that was broken or damaged in theatres.

• The incident reporting system should be able to provide analysis of trends in incidents to staff to allow actions to be taken quickly to address any areas needing to be improved.

• The trust should display avoidable patient harm data within critical care so it shows long-term results and is meaningful to visitors.

• The trust should complete the process of otherwise good mortality reviews within critical care services to demonstrate the implementation of actions and responsibility for their delivery.

• The trust should make sure all confidential information relating to patients in critical care is secure.

• The trust should review and risk-assess the provision of the critical care outreach team service or its equivalent, which was not being provided as recommended in best practice, with appropriately trained staff for 24 hours a day. Ensure there is a formal handover between the outreach team and hospital-at-night team.

• The trust should ensure sufficient allied health professional staff are used or employed to meet the rehabilitation needs of patients in, or being discharged from, critical care at all times.

• The trust should review the use of link roles for critical care staff to better embed this practice.

• The trust should look to reference the guidance by The Law Society in its policy relating to deprivation of Liberty, and ensure there is flexibility within the policy when applying the 72-hour rule.

• The trust should look to provide an assessment for patients in critical care for any poor psychological outcomes or acute psychological symptoms, and provide support in line with National Institute for Care Excellence (NICE) guidance CG83.

• The trust should develop and implement approved strategies for patients admitted to critical care to keep them in touch with life around them. Improve the quality of communication aids for patients.

• The trust should improve the quality and quantity of information provided to patients and visitors to critical care on both printed and electronic format.

• The trust should look to analyse and determine how to reduce noise levels within the critical care unit.

• The trust should progress the business care to provide patients with a consultant-led follow-up clinic for critical care.

• The trust should ensure the critical care unit looks outside of itself to the wider hospital experienced specialist teams for input into patient care and meeting the needs of patients and their visitors.

• The trust should produce a meaningful vision and strategy for the unit with action plans designed to improve quality and performance of the service.

• The trust should provide effective use and management of the critical care risk register.

• The trust should find a solution to the continuing poor relationship with the bed management/site team and ensure all sides understand and empathise with the pressures and risks to each other’s services.

• The trust should improve direct feedback to the critical care unit from visitors and patients to capture their views and deliver services to meet their needs.

• The trust should ensure appropriate standards and auditing of cleanliness and infection control within the maternity and gynaecology services.

• The trust should ensure there is enough obstetric equipment to provide epidural pain relief and to monitor the foetal heart during labour.

• The trust should ensure there is evidence that all equipment on the delivery suite had been serviced and checked as required.

• The trust should ensure the safe storage of medical records on Charlotte ward.

• The trust should ensure clear, written evidence in records to identify if maternity care should be midwife or consultant led.

• The trust should ensure the obstetric consultant staffing complies with Royal College of Obstetricians and Gynaecologists (Towards Safer Childbirth, 2007) recommendations on staffing for a unit of this size.

• The trust should ensure effective systems are in place which evidence one to one care was provided to women in established labour 100% of the time.

• The trust should ensure gynaecology patients are supported by specialist trained nursing staff at all times.

• The trust should ensure systems are in place to effectively monitor and review patients for post-operative infection rates following a caesarean section.

• The trust should ensure there is regular audit and evaluation of the termination of pregnancy services to ensure and full compliance with national guidance and recommendations.

• The trust should make sure all confidential records are stored securely on the children’s wards.

• The trust should ensure all areas used by children are child friendly and should particularly consider improving the environment for children in the theatre recovery rooms.

• The trust should make sure appraisal rates are closely monitored and actions taken to improve performance for the staff on the children’s wards.

• The trust should ensure discharge summaries are completed in an appropriate time frame.

• Several outpatient areas were breaching their waiting time targets and had long follow-up appointment waiting lists. We acknowledge the work the trust had done to resolve these issues, but the trust should continue to work on this area and make sure patients are seen in a timely way.

• The trust should make sure that clinic letters are typed and sent to GPs within the trust target.

Professor Sir Mike Richards

Chief Inspector of Hospitals