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University Hospitals Bristol Main Site Outstanding

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Inspection Summary


Overall summary & rating

Outstanding

Updated 16 August 2019

Our rating of the trust stayed the same. We rated them as outstanding because:

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Apart from in the neonatal unit, services had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service managed patient safety incidents well with incidents reported, investigation and learning shared.

All services provided care and treatment based on national guidance and reviewed how effective this was. Staff worked together to provide cohesive and multidisciplinary care across the different divisions. The service understood the continuing development of the staff, skills, competence and knowledge was integral to ensuring high quality care. Staff were inducted, trained and given the opportunity to develop.

Staff cared for patients with compassion. Feedback from patients was positive. Throughout our inspection we observed patients being treated compassionately and with dignity and respect. In surgery we found care to be outstanding with people reporting that staff went the extra mile and their care and support exceeded their expectations.

The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. In most core services, people could access the service when they needed it. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

Managers and leaders in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Leadership teams were well-motivated and understood the challenges of the department and implemented a drive to improvement. The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. There was a systematic approach to continually improve the quality of the services it provided. In surgery we found well led to be outstanding.

However:

In surgery, maternity and urgent and emergency care, the service did not always follow best practice in all areas of prescribing, recording and storing medicines for adults and children. Mandatory training and safeguarding levels did not meet trust targets. Some facilities and equipment in the maternity and urgent and emergency care service were not sufficiently well managed and posed a risk to patients.

Not all staff had received an appraisal of their work and this was below the trust target.

In urgent and emergency services, people did not always receive care and treatment in a timely way. This was a continuing problem since our last inspection and patients experience delays to accessing treatment and onward care and waiting times to admit, treat and discharge patients were getting longer and did not all meet national standards.

In maternity, we found there had been a lack of action to address medicine storage and remedy issues with fixtures and fittings.

Inspection areas

Safe

Requires improvement

Updated 16 August 2019

Effective

Good

Updated 16 August 2019

Caring

Outstanding

Updated 16 August 2019

Responsive

Good

Updated 16 August 2019

Well-led

Outstanding

Updated 16 August 2019

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.

Services for children & young people

Outstanding

Updated 16 August 2019

Our rating of this service improved. We rated it as outstanding because:

  • Safe care was mostly being provided in children and young people’s service. Staff understood how to protect patients from abuse. Patient risk was well considered and there were clear processes for escalation and support should a patient deteriorate. Patient safety incidents and patient safety performance was monitored, managed and learning identified to make improvements to the service.

  • There was effective care within the children and young person’s service. Care and treatment was based on national guidance and evidence of its effectiveness. The effectiveness of care and treatment was monitored, and the trust was generally performing similar when compared to other trusts. Patients' nutrition, hydration and pain was well managed. Teams worked extremely well together to deliver care which benefitted the patient.

  • Excellent care was delivered to children and young people with dignity and respect. Staff were committed to giving the best care to patients and provided emotional support to those with physical or mental health needs. Patients were involved, informed and supported in the care and treatment provided, and relatives were included and involved too. Patients suffering pain were well managed within guidelines and protocols.

  • The trust delivered responsive care and planned and provided services tailored to meet the needs of children, young people and their families to ensure flexibility, choice and continuity of care. Children and young people, and their families were engaged in the design and running of the service. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice. The service treated concerns and complaints seriously, investigated them and learned lessons from the results.

  • The children and young person’s leadership team were clear about their roles and understood the challenges for the service. The leadership and culture of the service drove improvement and the delivery of high‑quality individual care. Innovation, high performance and the high quality of care were encouraged and acknowledged. There was excellent engagement with stakeholders and partners to improve and coordinate services. There were no barriers to innovation and development.

However:

  • In some areas safety could be improved and brought in line with good practice. Improvement in mandatory training for medical staff, particularly in resuscitation and safeguarding training, would assist the service to meet trust targets.

  • The service needed  to monitor staffing levels for neonatal intensive care unit (one to one) and supernumerary team lead role, in line with the British Association of Perinatal Medicine standards.

  • The clarity of recording of sepsis monitoring, along with any interventions taken, could be improved along with further improvement of clear, up-to-date and coherent patient records. Further safety improvements could be made by following best practice when recording and storing medicines.

  • Consideration could also be made to improve the environment for the children and young people’s recovery area in the eye hospital, although it is acknowledged that there is limited space to do so.

  • To improve the effectiveness of the service further improvement in appraisal rates to meet compliance of trust targets needed to be focused on.

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.

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 and diagnostic imaging

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.

Surgery

Outstanding

Updated 16 August 2019

Our rating of this service stayed the same. We rated it as outstanding because:

  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so, and safeguarding incidents were reported and investigated. The service did have enough medical staff with the right qualifications, with vacancies in some specialties. There was safe provision of physiotherapy and occupational therapy for patients following surgery.
  • Staff from different professions or departments worked together as a team to benefit patients. All necessary staff, including those in different teams and services, were involved in assessing patients’ care and treatment. The patient records showed input from dieticians, physiotherapists and occupational therapists and therapy technicians. Records also showed input from pharmacists, medical teams, and diagnostic and screening services.
  • Feedback from people who used the service, those who were close to them and stakeholders was consistently positive about the way staff treated people. People thought that staff go the extra mile and their care and support exceeded their expectations. Staff delivered strong person-centred care, and were genuinely proud of the services they delivered.
  • There was a strong, visible person-centred culture. Staff were highly motivated and inspired to offer care that was kind and promotes people’s dignity. Relationships between people who used the service, those close to them and staff were strong, caring, respectful and supportive. These relationships were highly valued by staff and promoted by leaders.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders were visible and available to staff, and we saw and heard about good support for all members of the team. The matrons and ward sisters were an experienced and strong team with a commitment to the patients who used the service, and to their staff and each other.
  • Strategies and plans were fully aligned with plans in the wider health economy, and there was a demonstrated commitment to system-wide collaboration and leadership. It also included the national and local strategic context.
  • There was a demonstrated commitment to best practice performance and risk management systems and processes. The organisation reviewed how they function and ensured that staff at all levels had the skills and knowledge to use those systems and processes effectively. Problems were identified and addressed quickly and openly.

Urgent and emergency services

Requires improvement

Updated 16 August 2019

Our rating of this service went down. We rated it as requires improvement because:

  • We rated safe and responsive as requires improvement and effective, and well-led as good. We rated caring as outstanding.
  • We were not assured the service was always meeting the requirements to provide safe care in all areas. The service did not follow best practice in all areas of managing medicines including storing and record keeping. There were limited facilities and systems to care for patients with suspected communicable diseases in the adult emergency department, and the mental health assessment rooms for both adults and children did follow national guidance in all areas. There were delays in accessing the children’s mental health services. Some aspects of the environment were not suitably safe, for example, the access for children and the entrance stairs. The assessment and needs of mental health patients were not all met in a timely way. There was training for receptionists and no formal processes for receptionist to urgently access medical care for patients.
  • Effective care was rated as good. Audits did not all meet the required standards and the action plans made as a result showed not all had been completed. A further area of improvement needed was the completion of staff yearly appraisal.
  • The responsiveness of the service required improvement. People could not consistently access the service in a timely way. This was a continuing problem since our last inspection and while actions had been taken to improve the flow through the department, more was needed to ensure performance was able to meet patient need. There were delays to accessing treatment and onward care, and waiting times to admit, treat and discharge patients were getting longer.
  • Well led was rated as good.

However:

  • The departments were clean, and equipment well maintained. Patients in the emergency department were managed safely by using observation tools and risk assessments and were cared for by skilled staff. Records of patient care were well maintained, and any incidents reported, and action taken to address them.
  • The service provided care and treatment based on national guidance and reviewed how effective this was. Staff worked together to provide cohesive and multidisciplinary care. Staff provided pain relief, food and drink when needed, and understood their responsibilities to ensure consent and mental capacity were used to support patients’ choices.
  • There was excellent care provided to patients. Staff were committed to giving the best care to patients. The emotional needs of patients and relatives were recognised, and patients felt understood, involved and included.
  • The location and demographic of the service showed visibly high levels of patients with complex social and physical conditions including homelessness and drug and alcohol misuse. Staff approached the challenges in a proactive way, looking for ways to support these patients which were individual and considered the patients' circumstances. Staff showed both determination and creativity to overcome obstacles to delivering care and their approach did not show any fatigue.

  • Staff took account of patients’ needs and planned a service to meet them. Pathways had improved to support patients and staff to manage challenging situations in a positive way. Complaints were handled well.

  • The service was well led with a skilled leadership team, effective governance process and a culture of high-quality care. The trust used a systematic approach to continually improve the quality of its services and manage risks.
  • The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and was committed to improving services by learning from when things went well and promoting training, research and innovation.

Maternity

Good

Updated 16 August 2019

We previously inspected maternity jointly with gynaecology, so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The midwifery staffing levels in the central delivery suite, wards and clinics were maintained through daily assessment of acuity and safe staffing on a shift by shift basis.
  • The service had enough consultant obstetricians with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. There were two locum consultants as part of the team.
  • There was a consultant on call out of hours, every night of the week.
  • There had been a reduced number of senior registrars, from seven to five due to maternity leave, but steps had been taken to remedy the problem.
  • Women in labour received one-to-one care.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • Patients received good care and support from the perinatal mental health team of psychiatrists and psychologists and from the mental health liaison team.
  • Doctors, midwives and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.
  • The service worked well with multidisciplinary teams within the trust and with other trusts in the south west region.
  • The midwives worked closely with the neonatal team from the neonatal intensive care unit.
  • The Friends and Family Test showed that women were very satisfied with the care and treatment provided.
  • Women in labour and in the postnatal stage received effective pain relief.
  • Staff kept detailed records of patients’ care and treatment.
  • Staff completed and updated risk assessments for each patient and removed or minimised risks.
  • The service managed patient safety incidents well. Serious incidents had been dealt with in accordance with the trust’s policy and procedure.
  • The service provided care and treatment based on national guidance and evidence based practices. The service followed national guidance, and actively participated in NHS England initiatives. The continuity of carer initiative was launched recently.
  • The service used monitoring results well to improve safety. The performance of the service was monitored by bringing together a number of critical indicators on a monthly basis in the maternity dashboard spreadsheet and highlighting any surprising figures.

However:

  • In the maternity service, medicines had not been managed appropriately.
  • In the central delivery suite, some medicines were not stored securely. These medicines were kept on open shelves within the clinical room, where non-clinical staff could access them.
  • In the midwife-led unit, medicines had been exposed to high room temperatures for long periods of time. Therefore, patients could be given suboptimal medicines.
  • Staff used denaturing kits intended to render CD drugs unusable, so that they were less hazardous for disposal, but were doing this incorrectly, so the CD drugs were still active.
  • In the fetal medicine unit, the keys for the medicine fridge were found in an unlocked drawer in the treatment room which non-clinical staff could access. 
  • The service provided mandatory training in key skills to all staff. However, the trust had not ensured everyone completed it. In maternity the 90% target was met for 15 of the 28 mandatory training modules for which qualified nursing and midwifery staff were eligible. The 90% target was met for seven of the 18 mandatory training modules for which medical staff were eligible.

  • The service provided mandatory training in five safeguarding training modules. However, the trust information showed not all the staff, including medical staff, had completed the mandatory safeguarding training modules for the period April to December 2018. The 90% target had not been met for four out of five topics, for nursing, midwifery and medical staff.
  • The fixtures and fittings had not been well maintained. We found bathroom, toilet and handwashing facilities were in a state of disrepair. There was a risk of cross-contamination in the wards due to cracks in the panels of some baths and showers which had not been repaired.
  • There were a number of showers, handbasins and toilet facilities in the antenatal and postnatal ward that had been out of order for some time. Despite repeated reminders, senior managers had not taken appropriate action to address the problem.
  • The trust was taking too long to investigate complaints in maternity, 59.9 working days on average, whilst the trust policy specified 30 days maximum. Although some complaints make have taken longer to respond to as the trust needed to seek further clarification from the complainant. 
  • The service had no specialist bereavement midwife to support women going through bereavement.