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Salisbury District Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 7 April 2016

Salisbury NHS Foundation Trust provides care to over 240,000 people across Wiltshire, Dorset and Hampshire. This includes general and acute services at Salisbury District Hospital with specialist services including burns, plastics, cleft lip and palate, genetics and rehabilitation serving over three million people. In addition the Duke of Cornwall Spinal Treatment Centre serves South England’s population of 11 million people.

Salisbury Hospital has 464 beds and is staffed by approximately 4054 members of staff. They provide care to around 240,000 people across Wiltshire, Dorset and Hampshire.

CQC uses an intelligent monitoring model to identify priority inspection bands. This model looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations. Against this the trust was judged as a low risk, at level six (the lowest level) which it had been at since 2013.

We inspected this trust as part of our programme of comprehensive inspections of acute trusts. The inspection team inspected the standard eight core services as well as an additional service, the spinal service.

Overall, this trust was rated as requiring improvement. We rated it as requiring improvement for safety, being responsive to patients needs and for being well led and good for providing effective care and being caring.

Our key findings were as follows:

Safety

  • Nurse staffing levels in emergency and urgent care, surgical wards, services for children and young people, including the neonatal unit, critical care, maternity and the spinal unit were not always meeting national guidelines or recommendations.This was a risk to patient safety.

  • General infection rates in the Trust were low. There had been no new Methicillin Resistant Staphylococcus Aureus (MRSA) since October 2014. Rates of Clostridium Difficile were below the Trust trajectory as at October 2015. However there were occasions where inspectors found variable compliance with infection control procedures such as wearing of gloves and aprons. In a minority of areas equipment was found to be dusty and in one area a commode was found to be dirty.

  • The trust was not meeting its target of 85% for the percentage of staff receiving mandatory training.

  • In some areas it was found that resuscitation equipment was not being checked every day as required.

  • Patient records were not consistently written and managed appropriately. In particular, in the medical services, there was poor documentation of patient’s weight and the management of intravenous cannulas and catheters. Charts were not kept secure and confidential at all times.

  • In the emergency department patients did not always receive an initial clinical assessment by a healthcare practitioner within 15 minutes of arrival.

  • Patients whose condition deteriorated were appropriately monitored with action taken as required.

  • There was a strong culture of reporting and learning from incidents. Staff understood their responsibilities to raise concerns, record safety incidents and near misses and to report these appropriately. Staff received feedback and lessons were learnt to improve care. There was a culture of being open and the duty of candour was well understood.

Effective

  • In the majority of services, patient needs were assessed and care and treatment delivered in line with legislation, standards and evidence based practice. Performance in national audits was generally the same or better than the national average.

  • Mortality rates were as expected at 107 as measured by the Hospital Standardised Mortality Ratio (July 2015) and 107 for the Summary Hospital-level Mortality Indicator (March 2015).

  • Themajority of staff and teams worked well together to deliver effective care and treatment. Maternity services and theatres could do more to improve multidisciplinary working.

  • The majority of staff received an annual appraisal. Improvements were needed to ensure the records about who had received an appraisal were robust.

  • Consent and knowledge of the mental capacity act was good however the recording of this needed improvement.

Caring

  • Staff provided kind and compassionate care which was delivered in a respectful way.

  • The need for emotional support was recognised and provided by a clinical psychology service.

  • In the spinal treatment centre some patients felt ignored and isolated, however also in this unit there were examples of staff going the extra mile such as arranging a wedding to take place in the unit for one patient.

  • The majority of feedback from patients and relatives was extremely positive and although the response rate for the friends and family tests were below the national average the number of patients who would recommend Salisbury Hospital exceeded the national average.

Responsive

  • Patient’s individual needs were not consistently met. In spinal services there was disparity between the experiences of some patients, whist some made good use of the gardens and away days others felt lonely and bored.

  • Spinal patients waiting for video-urodynamics and outpatients experienced unacceptable waits for appointments and there was little risk assessment of the patients who were waiting.

  • The trust did not provide mental health services. Vulnerable patients in the emergency department with mental health needs, particularly children and adolescents who required assessment by a mental health practitioner, did not always receive a responsive service from the external mental health provider teams.

  • The environment for children in the emergency department was not appropriate, with them being cared for in the adult area.

  • The trust was not consistently maintaining single sex accommodation.

  • Patients living with dementia were generally well supported.

  • The investigation of complaints was comprehensive however there were areas that could be improved. These related to working with other organisations to provide a single response when required, the development of action planning and learning after the investigation.

  • Overall the trust performed well in meeting national targets, including the time patients spent in the emergency department and referral to treatment times.

  • The Benson bereavement suite facilities, and sensitive care provided to maternity and gynaecology patients and their relatives experiencing loss were outstanding. These services had been developed with the full involvement of previous patients and their partners.

Well led

  • The trust had a governance framework which supported the delivery of care although there were some areas of weakness. The trust had recently undertaken a self- assessment against Monitor’s quality governance framework however this had not clearly identified weaknesses or areas for improvement. A review had been undertaken to support board development. Additionally, an externalreview of the board assurance framework had beencompleted inMay 2015 with 'substantial assurance' being attained.

  • Risk registers did not consistently identify all risks, mitigating actions or where it did the actions had not always been taken or where they had the risk had not been updated.

  • One of the strengths of the trust was that staff had a strong sense of respect for each other and communicated well, however we heard of informal conversations between staff that lacked documentation to support an audit trail for decisions and actions.

  • The trust had experienced a deficit for the first time in its history and staff were anxious about the future. A recovery plan was in place.

  • There was an extremely positive culture in the trust, staff felt respected and valued. Many staff had worked in the trust for a considerable number of years and knew each other well. They frequently referred to themselves as being like a family and were very supportive of each other.

  • Staff at all levels were very positive about the trust as a place in which to work and this was supported by the staff survey results (2014). Staff had contributed to the development of the trust values and lived these in their work. Staff spoke of being proud of working at the trust, were passionate about providing the best care they could.

  • The chief executive had a very high profile in the trust and was known by all staff. Staff felt they were listened to and supported by their managers who were visible in the clinical areas.

  • There was a stable executive team with all posts filled on a substantive basis.

  • The Governors were fully engaged with the Board, felt supported in their roles and could see their influence when issues were raised.

  • Although in the staff survey there had been some reports of discrimination from staff from black, minority and ethnic groups this was not the experience of those spoken with during the inspection who reported feeling supported.

  • Innovation and improvement was encouraged and rewarded. There were award ceremonies at which innovative and caring practice was shared and recognised, this was well publicised and appreciated by staff who were proud of their colleagues achievements. Participation in research was good and increasing.

We saw several areas of outstanding practice including:

  • The surgery wards had identified link roles for staff in varied and numerous relevant subjects. A nurse and a healthcare assistant had been assigned together to the link role.

  • The surgery and musculo-skeletal directorates had regular specialty meetings. A member of the care staff who would not otherwise attend these meetings joined the meeting each time to provide a ‘sense-check’. They listened to the content, decided if it made sense and properly described the state of their service.

  • There was an outstanding level of support from the consultant surgeons to the junior and trainee doctors and other staff including the student nurses.

  • The maternity services strived to learn from investigations in order improve the care, treatment and safety of patients. This was evident with the robust, rigorous and deep level of analysis and investigation applied when serious incidents occurred. For example, the reopening of a coroners case as a consequence of the maternity service investigations. Further evidence of this was available in meeting minute records. In addition, a wide range of staff demonstrated that learning from incidents was a goal widely shared and understood.
  • The Benson bereavement suite facilities, and sensitive care provided to patients experiencing loss were outstanding. These services had been developed with the full involvement of previous patients and their partners. The facilities were comfortable and extensive, enabling patients and their families’ privacy and sensitive personalised care and support.
  • In the services for children and young people a mobile APP was produced in conjunction with a regional neonatal network to provide information and support for parents taking their babies home.

  • Sarum Ward staff worked across the hospital working with a variety of teams to improve services for children and young people. Examples were of developing a DVD for pre-operative patients, using child friendly surveys in other areas of the hospital, supporting any staff with expertise on the needs of children and young people.

  • Nurse led pathways were being used. In one example a nurse led pathway was in place for early arthritis, this pathway had been ratified by the Royal College of Nursing. The pathway was evidence based that showed the quicker patients were diagnosed with arthritis, the quicker treatment could be started and the quicker patients could go into remission. This service came top in a national audit for patients with early arthritis. Staff had presented their service at national and international conferences including the Bristol Society of Rheumatology conference in 2015.

  • We observed excellent professionalism from staff in outpatients during an emergency situation. Staff attended to the patient that needed immediate help and support. Staff also cared for and supported the other patients who had witnessed the emergency. Patients were moved away from the emergency into another department and kept informed of what was happening and offered lots of reassurance. When the emergency was over, patients were shown back into the waiting area with explanations on the subsequent delay to the clinic.

  • The outpatients departments monitored how often patients were seen in clinics without their medical records. From January to July 2015 123,548 sets of patients notes were needed for the various clinic appointments across the trust. Out of these, 115 sets of notes could not be located for the appointment. The department identified that this was because the notes had been miss-filed, staff had not used the case note tracking properly or the notes were off site for another appointment. Overall, patients’ medical notes were found for 99.91% of appointments, which was a small increase from the previous two years. This showed that there was an effective system in place for making sure patients’ medical notes were available for their outpatient’s appointments. Where they were not available, a reason was identified to try and reduce the likelihood of the issue happening again.

  • In the spinal centre there were examples of care where staff went above and beyond the call of duty. One example of this was where a patient got married in the spinal centre. Staff went with the patient’s partner to collect and prepare food and on the wedding day was picked up by a member of staff in their classic car. The couple were then allowed the use of the discharge accommodation after the wedding.

  • The ‘live it’ and ‘discuss it’ sessions were fully integrated into the spinal treatment centre. We observed one session where patients and relatives were given opportunities to discuss their concerns as a peer group as well as to professionals and ex-patients. It was clear that patients and their carers were being supported through a difficult time and were being educated on important topics preparing mentally and physically them for discharge.

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

Importantly, the trust must:

  • Review nurse staffing levels and skill mix in the areas detailed below and take steps to ensure there are consistently sufficient numbers of suitably qualified and experienced nurses to deliver safe, effective and responsive care. This must include:

  • a review of the numbers of staff and competencies required to care for children in the emergency department,

  • a review of the arrangements to deploy temporary nursing staff in the emergency department,

  • a review of arrangements in the emergency department to ensure that nursing staff receive regular clinical supervision, education and professional development.

  • a review nursing staff levels at night on Amesbury ward, where the current establishment of one nurse for 16 patients, does not meet guidance and is not safe. Other surgery wards with a ratio of one nurse to 12 patients at night must be reviewed. Pressure on staff on the day-surgery unit, when opened to accommodate overnight patients, and still running full surgical lists, must be addressed.

  • ensuring there are appropriate numbers of, and suitably qualified staff for the number and dependency of the patients in the critical care unit.

  • ensuring there are adequate numbers of suitably qualified, competent and skilled nursing and medical staff deployed in areas where children are cared for in line with national guidance.

  • ensuring there are sufficient numbers of midwifery staff to provide care and treatment to patients in line with national guidance.

  • ensuring one to one care is provided in established labour in order to comply with national safety guidance (RCOG, 2007).

  • Ensure staff across the trust are up-to-date with mandatory training.

  • Ensure that all staff have an annual appraisal and that records are able to accurately evidence this.

  • Complete the review of triage arrangements in the emergency department without delay and take appropriate steps to ensure that all patients who attend the emergency department are promptly clinically assessed by a healthcare practitioner. This must include taking steps to improve the observation of patients waiting to be assessed so that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

  • Ensure staff effectively document care delivered in the patient’s healthcare record at the time of assessment or treatment in line with the hospital’s policy and best practice. This must include effective documentation with regard to intravenous cannulas and urethral catheters and the recording of patients’ weight.

  • Strengthen governance arrangements to ensure that all risks to service delivery are outlined in the emergency department’s risk register, that there are clear management plans to mitigate risks, regularly review them and escalate them where appropriate.

  • Ensure that all actions are implemented and reviewed to reduce patients being cared for in mixed sex accommodation.

  • Ensure that daily and weekly check of all resuscitation equipment are completed and documented appropriately.

  • Ensure there is a hospital policy governing the use and audit of the World Health Organisation surgical safety checklist. The audit of the checklist must be conducted as soon as an appropriate period of time has passed since its reintroduction. Results must be presented to and regularly reviewed at clinical governance.

  • Ensure there is a sustainable resolution to the issue of holes or damage in the drapes wrapping sterile surgical instrument sets, and all sets are processed and available for re-use to avoid delays or cancellations to patient operations.

  • Ensure patient charts are kept secure and confidential at all times.

  • Must ensure there is effective management of the conflict between meeting trust targets for performing surgery and the impact this has on patients. Patients must not be discharged home from main theatres unless this cannot be avoided. Surgery must not be undertaken if there is clearly no safe pathway for discharging the patient. Operations must take place in the location where staff are best able to care for their recovery.

  • Ensure staff consistently adhere to the trust infection control policy and procedures.
  • Ensure that patients are discharged from the critical care unit in a timely manner and at an appropriate time.
  • Ensure the process for booking patients an elective beds following surgery is improved and reduce the number of cancelled operations due to the lack of availability of a post-operative critical care bed.
  • Ensure that the governance arrangements for critical care operate effectively, specifically that identified issues of risk are logged and that risk are monitored, mitigated and escalated or removed as appropriate.
  • Ensure that care and treatmentat the spinal unitis provided in a safe way relating to the numbers of spinal patients waiting for video uro-dynamics and outpatient appointments and reducing the risk of harm to these patients.
  • Ensure that risks associated with the spinal service are managed appropriately with the pace of actions greatly improved. In particular, to the management of the numbers of patients waiting for video uro-dynamics and outpatient appointments.
  • Ensure care and treatment are delivered in a way to ensure that all patients have their needs met which reflects their preferences. This includes the training of agency staff, the availability of physiotherapy and occupational therapy sessions, and the availability of suitable activities for patients in spinal services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 7 April 2016

Effective

Good

Updated 7 April 2016

Caring

Good

Updated 7 April 2016

Responsive

Requires improvement

Updated 7 April 2016

Well-led

Requires improvement

Updated 7 April 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 7 April 2016

Care in both the gynaecology and maternity wards and delivery suite was consultant led. Patients had risk assessments completed and reviewed regularly. Incidents were reported and thoroughly interrogated for learning and safety improvements. Good safeguarding processes were in place, which included established links with the lead local authority. Staff demonstrated understanding of duty of candour regulations and compliance with this was also evidenced in records.

Safety improvements were required to the maternity services. The midwifery staffing levels did not comply with the Health and Social Care Act (2008) Code of Practice on staffing. The midwife to patient ratio exceeded (was worse than) recommended levels and one to one care for women in established labour was not evidenced to have been achieved 100% of the time.

The maternity services were responsive to the needs of local women. Positive feedback was consistently provided. This showed the majority of patients were highly satisfied with their treatment and care and would recommend services. We saw records documenting patient’s choices and preferences. The maternity services had achieved full accreditation with UNICEF UK breast feeding standards. The gynaecology service had links with other specialists and treatment centres. This supported the provision of effective care and treatment plans for patients. Annual audit plans were in place which enabled clinical standards of practice to be checked and improvements made. Policies and procedures were provided in line with national guidance and policy.

There were thorough risk management and quality and governance structures in place. These linked departmental with trust risk and governance meetings. This ensured an effective flow of information from ward to board and vice versa. Incidents, audits and other risk and quality measures were scrutinised for service improvements and appropriate actions taken. Systems were in place to effectively share information and learning. Staff were proud of the patient care they provided and a learning culture was evident. Leadership was described as good. Junior staff told us they were well supported and senior managers were visible and approachable. The trust board had approved a capital investment in the maternity services. This included the provision of a new midwifery led birth unit.

Medical care (including older people’s care)

Good

Updated 7 April 2016

We rated medical services as good overall. Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them. Learning from incidents was evident and care and treatment within the hospital protected patients from avoidable harm.. Medical cover, nursing levels and skill mix were appropriate to the needs of the patients on the eight medical wards we visited, which included the acute medical assessment unit, the endoscopy suite and the cardiac catheter laboratories.

We did however identify a breach in regulation in relation to record keeping, and specifically to the documentation of cannulas, catheters and patients’ weight.

Care was effective and was delivered in accordance with evidenced-based guidelines and current best practice. Staff managed patients’ pain well and feedback from patients reflected this. The trust ensured staff were adequately trained and competent to carry out their role.

Staff provided compassionate care and patients were treated with kindness, dignity and respect. Patients spoke positively about their experience of being cared for at Salisbury hospital. They felt included in their care and were kept informed about their care and treatment throughout their stay.

The provider planned services and coordinated care well for patients living with dementia. The layout and appearance of wards provided a suitable environment for these patients. Patients accessed care and treatment in a timely way.

Services were not always responsive to patients’ needs and required improvement. The provider could not always assure adequate patient flow within the hospital. This meant that mixed-sex accommodation breaches frequently occurred and patients were moved during their stay, sometimes late at night. The hospital could not always provide a bed for care and treatment of medical patients on a medical ward. These patients were called medical outliers and were admitted to surgical wards. However, staff and patients were always aware of which doctors were providing specialist medical care and treatment to them and nursing staff were competent to deliver their care.

The medical services were well led. Staff were aware of the hospital’s vision and values spoke of the family atmosphere of working in the hospital. The leadership, governance and culture promoted the delivery of high quality care. There was a clear set of values driven by quality and safety and staff were familiar with these. The trust engaged its patients and visitors regularly to obtain feedback in order to improve the patients’ experience in the hospital. Staff spoke highly of their managers and felt their views and concerns were listened to and acted upon. The staff survey showed staff recommended the hospital as a place to work.

Spinal Injuries Centre

Requires improvement

Updated 7 April 2016

Urgent and emergency services (A&E)

Requires improvement

Updated 7 April 2016

The emergency department (ED) was not consistently staffed by sufficient numbers of appropriately qualified, experienced and skilled nursing staff to ensure that people received safe care and treatment at all times. The nursing establishment did not ensure that an appropriate ratio of nursing staff to patients was consistently achieved. This was compounded by the fact the service had a significant numbers of nursing staff vacancies and relied heavily on temporary staff who did not always have the necessary skills and experience to provide safe and effective care.

Staffing levels at night were of particular concern and there were concerns about the lack of seniority of medical and nursing staff on duty at night. We had concerns that there were insufficient registered children’s nurses employed and there was a lack of assurance that this risk had been mitigated by ensuring that adult trained nurses had received specialist training to care for children. As a result of this lack of appropriately skilled staff, the separate children’s area was not being used and children instead received care and treatment in the adults’ department which was not an appropriate environment.

Staffing issues impacted on the department’s ability to ensure that patients were consistently promptly clinically assessed on arrival in the ED. We were particularly concerned about the delayed clinical assessment of self-presenting patients (adults and children) who were not adequately observed while they waited. We also had concerns that nursing documentation was not always completed to the required standard. Staff shortages may also have affected staff’s ability to complete mandatory training. Compliance with mandatory training was well below the trust’s target of 85%. We were not assured that nursing staff had sufficient opportunities for ongoing education and development or clinical supervision.

People’s 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. Compliance with protocols and standards was monitored through participation in national audits. Performance in national audits was generally about average compared with other English trusts, with the exception of the Royal College of Emergency Medicine mental health audit, where performance required improvement. There were action plans in place to make improvements where shortfalls were identified. We saw little evidence of local audit.

The trust’s un-planned re-attendance rate was consistently lower (better than) the England average. This was an indicator that care and communication with patients were effective.

Junior doctors felt well supported with regular education and supervision. The lack of senior medical presence in the ED was to some extent mitigated by senior review of all records of patients seen overnight.

The service worked well with other teams and services so that people received seamless care. Care was delivered in a coordinated way, with support from specialist teams and services. There were excellent working arrangements with the Acute Medical Unit, which worked closely with the ED as part of the ‘front door team’. There were clear policies agreed with specialty doctors which formalised their supportive role to ED and reciprocal support was offered by ED consultants to junior doctors in other specialties.

We observed that all staff treated people with compassion, kindness, dignity and respect. They responded in a caring and compassionate way when people experienced pain, discomfort or distress. Patients and their relatives were involved as partners in their care. Staff took the time to explain to patients and their relatives about their care and treatment. This was done sensitively and in a way that people could understand. The department had established an outstanding service to support bereaved relatives.

Feedback we received from patients and visitors was overwhelmingly positive. We spoke with many patients and visitors. Unusually, we were approached by some patients who were very keen to tell us how well they had been looked after. This feedback was consistent with results from patient satisfaction surveys. Friends and family scores were consistently high, with over 90% of respondents indicating that they would recommend the service.

Services were not organised and delivered so that all patients received the right treatment at the right time.

Premises and facilities were largely appropriate for the services delivered; however children were cared for in the adults’ department which was not an appropriate environment from them because they were exposed to sights and noise which may cause them stress. The children’s waiting room, whilst bright and welcoming, was overlooked by and could be accessed by adult patients and visitors. Patients’ privacy and dignity was sometimes compromised on the short stay emergency unit. The ward was cramped and the layout did not always allow for single sex accommodation to be provided.

The needs of patients in vulnerable circumstances were not always met. Patients with mental health needs, particularly children and adolescents, who required assessment by a mental health practitioner, did not always receive a responsive service. This meant that these patients experienced long waits which could be detrimental to their mental health and they were sometimes admitted to hospital unnecessarily.

The department had not taken adequate steps to support patients in vulnerable circumstances, such as those living with dementia.

The ED was consistently meeting national standards in respect of the time people spent in the department, and the time they waited for treatment, although this was becoming more challenging with increasing demand on the service. There were relatively few ambulance handover delays but at busy times, some patients queued on ambulance trolleys in the department and this impacted on their comfort, privacy and dignity.

The ED worked well with the patient flow team and the rest of the hospital to minimise blockages and overcrowding in ED. The trust had invited an external review of patient flow by the emergency intensive support team (ECIST) and had developed an improvement plan based on their recommendations and had taken some immediate actions, although some changes required time to embed. Further improvements were planned but required time and resource.

The service had not developed a clear vision or a cohesive strategy. Although the service had responded appropriately to recommendations made by an external reviewing body and there were ongoing staffing reviews, these were largely reactive plans and did not form part of an overarching strategy. Staff had not been involved or engaged in developing a vision or strategy and there was limited evidence of patient involvement.

Risks to service delivery were understood by the management team but risk management processes were not fully effective. The risk register did not capture the multi-factorial risks to patient safety and quality and we could not be assured that risks were appropriately escalated or mitigated.

Staff enjoyed working in this service and the culture was one of mutual respect and teamwork. Staff felt supported and valued by senior managers who were both visible and accessible. However, morale was overshadowed by issues relating to staffing. Staff had little confidence that these issues would be resolved in the short term and there was a risk that these issues may in the future, impact on recruitment and retention of staff.

Surgery

Requires improvement

Updated 7 April 2016

As the hospital recognised, nursing and operating-department practitioner staffing levels were not always satisfactory. In some wards the established levels of nursing care provided at night were not following recommended guidance and unsafe. The workloads from high levels of agency staff at times were causing some staff stress and anxiety. Patients praised the care but a number felt reluctant to call for support due to a perception of nurses and nursing assistants being too busy.

Safety in operating theatres was good but some improvements were needed in assurance and culture. Problems with surgical instrument sets needed resolution. Reviews of deaths in the hospital needed to be improved to show learning and improvement happened. Security of patient charts needed to be improved as some were not being kept confidential. Staff mandatory training updates was not meeting trust targets.

The hospital was clean and infection prevention and control protocols followed. Incidents and near misses were being well reported and investigated. There was a safe level of cover from the medical staff and deteriorating patients were recognised and responded to.

Length of stay in the hospital was mostly better than the England average. Patients’ pain, nutrition and hydration were well managed with specialist input when needed. Staff were skilled and experienced, although not all had received an annual performance review. There was strong multidisciplinary input to patient care. Important services were provided seven days a week and there was good access to information. The majority of audits showed patients were getting good outcomes, but some audit results needed more attention where they were not being used to demonstrate change, learning or improvement.

Feedback from patients and their families had been almost entirely positive overall and several patients described their care to us as outstanding. The Friends and Family Test produced excellent results. Patients we met in the wards and other units spoke highly of the kindness and caring of all staff, although not without mentioning how busy they were. Staff ensured patients experienced compassionate care, and worked hard to promote their dignity and human rights.

The hospital had not resolved the conflict between meeting targets for patients to have treatment and putting undue pressure on services to perform. There were many aspects of good responsiveness, but pressure for beds was leading to too many patients being inappropriately discharged from the main theatres or day-surgery unit. As with most NHS hospitals, this hospital was regularly faced with a high number of patients who were fit for discharge, but without transfer of care packages.

Patients were complimentary about the food. There was a wide-range of leaflets and information for patients and people with additional needs were being looked after. Cancelled operations were low, and the pre-admission, admission and discharge services provided good support.

The surgery service had an effective governance process, although some areas needed to be improved to show a consistent approach. There was good leadership and local-level support for staff. All the staff we met showed commitment to their patients, their responsibilities and one another. There was a strong camaraderie within teams. We were impressed with the loyalty and attitude of the staff we met. Staff were recognised by the trust for their commitment, professionalism and going the extra mile for the patient.

Intensive/critical care

Requires improvement

Updated 7 April 2016

Critical care services required improvement to be safe and well led. We found the service good for caring, effective and responsive.

Policies and procedures to prevent patients from the risk of healthcare associated infections were not consistently adhered to. The use of personal protective equipment was inconsistent by bedside nursing staff during the inspection. A commode was found to be dirty and a standard cleaning procedure for cleaning the commodes was not available on the unit.

There were occasions when nurse staffing numbers did not meet recommended staffing ratios. Medical staffing was found to be in line with core standards for intensive care services.

There was sufficient equipment to provide critical care and respond to emergencies. However, the resuscitation trolley log was not consistently signed to indicate that it had been checked and was ready for use. The bed spaces did not comply with best practice guidelines for critical care facilities regarding accessibility and space.

Incidents were reported and appropriate actions were taken to attempt to prevent recurrence. However, mortality and morbidity meetings had commenced recently and therefore could not provide assurance of any improvements or actions taken.

Overall, staff were aware of their responsibilities to report abuse and how to raise concerns about safety. Some online mandatory training rates for trained nurses were lower than the trust target of 85% and mandatory training compliance data for unit based staff was not supplied, which meant there was a risk that staff were not up-to-date with current practice.

Records and medicines were found to be stored and managed securely. However, documentation in the healthcare records and charts was not always complete or timely.

Patients’ needs were comprehensively assessed and care and treatment regularly reviewed on the unit. Information about care and treatment and patients outcomes was routinely collected and monitored. Local and national audits were taking place and results were being used to improve care, treatment and patients’ outcomes. Staff could access the information they needed in order to deliver effective care. Patients care and treatment was planned and delivered in line with current evidence based guidance, particular focus was given to rehabilitation. However, we found that there were some guidance and policies on the unit that were out of date. In addition, documentation of patients’ pain scores could be improved.

There was input into patients care from relevant members of the multidisciplinary team in order to provide effective treatment plans. However, the pharmacist did not attend consultant led ward rounds as recommended in the guidelines for the provision of intensive care services (GPICS 2015).

Staff were qualified and had the skills to carry out roles effectively in critical care. This included competencies in blood transfusion and intravenous therapy administration. However, half of the nursing staff had not received an appraisal in the last twelve months, order to identify learning needs. In addition, training in the use of equipment on the unit required further improvement for both medical and nursing staff.

Discharge from the unit was planned and included follow up services after going home from hospital, to support patients post critical illness.

Patients we spoke with were positive about the care they had received. Many kind and caring interactions were seen during the inspection. Staff were seen to maintain a high regard for patient’s dignity and privacy.

Relatives expressed that they had been kept up to date with their loved ones progress and supported by the staff at the bedside. Not all relatives had received timely communication; one family had not been updated by medical staff. However, this was not a consistent finding amongst all relatives and visitors, and the majority were very happy with the level of emotional care and treatment they and their loved ones had received.

The support continued following discharge home from hospital via the follow up team that supported patients after critical illness. The follow up clinic that the team provided had recently held a reunion event which had been well attended.

Aspects of the refurbishment and design or the unit had been made in collaboration with staff and local people. The facilities for relatives had been improved with a thoughtful inclusion of secure storage of valuables in the waiting area. However, not all bed spaces were capable of giving reasonable auditory privacy. There were no toilet or shower facilities for patients within the unit. However, patients were able to access these facilities in a neighbouring ward without entering a general public area.

There were delayed patient discharges due to a bed elsewhere in the hospital not being available. Similar to most critical care units in England, in the last five years between 60% and 70% of all discharges were delayed by more than four hours from the patient being deemed ready to leave the unit.

Urgent surgical operations had been cancelled due to the lack of an available bed in critical care. This was above (worse than) the national average. Figures from NHS England reported 53 cancelled operations at the hospital between July and December 2015. We found that there was no limit per day for how many beds could be booked on the unit for those patients that require critical care after elective operations.

Despite the pressures on bed availability, patients were admitted to the unit in a timely fashion and the unit had not transferred patients to other units for non-clinical reasons for over twelve months. Data from the Intensive Care National Audit and Research Centre (ICNARC) showed that the unit transferred less patients to the wards out of hours that the England average (performed better).

Arrangements for governance of critical care services did not always operate effectively. For example, the risk register did not include risks that staff highlighted during the inspection and the risks had not been reviewed and updated. The governance structure and processes seemed immature and not embedded. In addition, it was not always clear how the local governance linked with formal trust wide processes. This meant that there was a risk that issues that required escalation were not being raised formally.

Following the refurbishment and recent changes in leadership of both nursing and consultant leads, the team appeared to be in a period of adjustment.

The team culture was strong within the unit. However, opportunities for staff engagement could be improved, for example unit meetings had been abandoned due to poor attendance.

Services for children & young people

Requires improvement

Updated 7 April 2016

Overall we found the services for children and young people to require improvement.

Staff were clear they wanted to provide the best care they could for children and young people but there was no clear vision for how the service wanted to be performing in the coming years.

Staffing levels for both medical and nursing staff did not meet the nationally recommended guidelines for the acuity of children cared for in the hospital. Risks to patient safety regarding nurse staffing levels had been raised as a concern but no permanent arrangement had been put into place to maintain safe staffing levels. High dependency patients were nursed on the ward but there was no funding available for the extra nursing staff needed to care for these patients.

Safeguarding training did not meet national guidelines at the time of our visit but we were shown a plan was in place to provide this training and a timeline for meeting the guidelines.

There were times when children and young people were cared for in areas used for adults such as some outpatient appointments, main theatre and day surgery unit. Some provision had been made to protect children from adults in these shared areas. We found the screens to protect a child were not always used.

Learning from examples of past practice was encouraged and medical staff felt well supported by their senior colleagues. Staff were able to access training that would add to their skills and the majority of nurses in the neonatal unit were trained in their specialty. Children and young people’s needs were cared for and responded to by competent staff. Policies and protocols were based on national guidelines ensuring that best practise was observed. Audit programmes were contributed to both internally and nationally to demonstrate how well the department performed against other trusts.

All staff worked flexibly to support the needs of children, young people and their families. Staff worked together and shared information appropriately with community staff to ensure the safety and wellbeing of children who were being discharged home.

Staff were compassionate in their treatment of patients and their families and privacy and dignity was respected at all times. Children and young people’s views were listened to and their consent was always sought in a way they could understand. Facilities were provided and used flexibly for parents to spend time with their children and at times included the accommodation for the patient’s whole family.

Staff had developed methods of gaining feedback from children of all ages and had made changes to facilities in response. Patient and parent feedback we saw was positive with comments including “unconditional support and care”, “cheerful, even at the end of a long shift” and “patience and honesty”.

Staff from the children’s unit were supporting those areas where adults were also nursed with projects designed to improve a child or young person’s experience when they visited that area.

End of life care

Good

Updated 7 April 2016

We have judged the overall end of life service as being good.

The trust could organise rapid discharges effectively but there were delays due to funding of care packages in the community. The trust had not recently completed an audit of patients achieving their preferred place of dying.

There was an improvement plan in place for end of life care that was being overseen by a strategy steering group. There had been a number of changes put into place in the previous twelve months. These were initiated following the results of the National Care of the Dying Audit that was completed in 2014 and also to respond and implement national directives such as the NICE Quality Standard on End of Life Care. These included a new personalised care framework, to replace the discontinued Liverpool Care Pathway, improved rapid discharge processes and the appointment of two end of life care facilitators to roll out the new documentation and provide training. Whilst some of the changes were not fully imbedded the staff were committed and motivated to provide an improving service and embraced the initiatives that were being developed by the end of life steering group.

There was evidence of leadership in both the palliative care team and at board level however despite the work undertaken to deliver the improvement plan there was no trust wide strategy or policy on end of life care. This was combined with limited representation at the strategy steering group from board members.

Staff understood their responsibilities to raise and report concerns, incidents and near misses. They were clear about how to report incidents and we saw evidence that learning was shared across the teams.

Equipment was readily available and properly maintained for the use of patients. Anticipatory medicines were always available and patients being discharged home had their medicines provided promptly.

There were processes in place to assess and respond to patient risk. Staff were able to contact members of the palliative care team for advice about deteriorating patients and this team was responsive and supportive to urgent requests for input. The palliative care team were staffed sufficiently to provide the advice and support that was requested.

The trust was providing a seven day service from members of the palliative care team but this was only currently being funded until the end of March 2016.

There was a range of training that was provided for members of the palliative care team and also training that was available to other staff if they could be released from their duties but there was currently no mandatory end of life training for staff trust wide.

Patients received compassionate care and were treated with respect and dignity by staff. Patients were communicated with sensitively and kept informed about their diagnosis and prognosis.

Staff worked in a positive and open culture and felt supported by their colleagues and line managers. Staff felt valued by the trust and were engaged with the trust objectives.

The end of life service rated poorly in the 2014 National Care of the Dying survey. New paperwork and processes were being introduced and every member of staff on every ward was receiving a two-week training package in end of life care. There were no audits to evidence how the service was achieving rapid discharge or if patients were supported with their preferred place of care. The leadership needed to develop a trust wide strategy and policy for end of life care.

Outpatients

Good

Updated 7 April 2016

Salisbury NHS Foundation Trust outpatient and diagnostic services were overall rated as good.

There were good systems in place for incident reporting and learning from when things did not go as planned. Systems were in place for the safe administration of medicines and for the prevention of infection. The outpatient and medical records department achieved a high standard in making sure medical notes were available for 99.91% of appointments. Staff were knowledgeable about safeguarding and their responsibilities to vulnerable adults and children. During our inspection we observed an emergency situation in the outpatients department. The way in which this was handled showed staff were aware of the health of their patients and responded quickly and appropriately to any deterioration in a patient’s health.

Staff were very competent in the roles they were being asked to perform. There were some outstanding areas of practice including the nurse led pathways within the rheumatology outpatients clinics and one stop clinics within urology outpatients. There was good multidisciplinary working both within the trust and with other external organisation such as other health care providers and the Ministry of Defence.

Staff communicated in a professional but friendly manner with patients and their families. Comments from patients and relatives were very positive about the staff and how they provided their care and treatment. Patients were involved in their care and treatment and always put them first.

The departments provided a good service to make sure people were not waiting long periods of time for either outpatients or diagnostic services. The trust was working with other local hospitals and looking at capacity demand in order to make sure waiting lists did not increase. We saw that the trust was achieving 92.94% for its cancer two week waiting time against a standard of 93%. Outpatients departments operated a ‘patient initiated follow-up’ appointment which meant for a three month period patients could arrange a follow-up appointment if they felt they needed it. We saw evidence that complaints were discussed at departmental meetings and changes were made where necessary to help prevent further complaints.

Staff were supported at all levels from their immediate manager through to the trust executive team including the chief executive. Good governance systems were in place across outpatients and diagnostics. Whilst some staff described the culture as a ‘them and us’ we did not see this view shared by the majority of staff. The majority of staff we spoke with felt the culture was open and that staff strived to make sure the experience for patients was outstanding in line with the trust vision.