During an inspection looking at part of the service

We carried out a focused inspection of The Royal United Hospital Bath urgent and emergency care service on 4 January 2021 as part of our winter pressures programme. As this was a focused inspection, we only inspected parts of our key questions: safe, responsive and well led. We did not inspect effective or caring. Urgent and emergency care was the only service we inspected. We took into account nationally available performance data and concerns we had received about the safety and quality of the service. We also reviewed concerns identified at our last inspection in September 2018 in relation to safe staffing, crowding and paediatric care.

Our inspection had a short announcement (a few hours) to enable us to observe routine activity. Before the inspection we reviewed information we had about the trust based on the intelligence we had received. Due to the narrow focus of this inspection, we did not change the rating of the service at this inspection. Our rating of the service therefore stayed the same as requires improvement.

We found:

• The Royal United Hospital Bath emergency department did not always have enough staff with the right qualifications and updated training to keep patients safe from avoidable harm and to provide the right care and treatment at all times. There were concerns about the level of senior medical staff on duty at night due to the complex layout of the department and lack of visibility for some patients. The design of the environment meant social distancing in some areas was difficult and this could lead to overcrowding in the waiting area at busy times. Triaging and the ongoing care and treatment of children was not always undertaken by nurses with paediatric qualifications. Some patients’ medical records did not state the time the patient was reviewed by the doctor.
• Patients could access the service when they needed it but often had to wait longer than the national standard for a decision or treatment and a bed if they needed to be admitted. Demands on services throughout the hospital often resulted in patients in the emergency department or in ambulances waiting for beds. For a number of years, the emergency department's performance against national waiting time standards was worse than the NHS constitutional standards and the national average for England. However, no patient had waited for more than 12 hours during 2020 and fewer patients that the national average waited over four hours. As with most of the rest of the emergency departments in England, this performance was deteriorating in the last six months of 2020 and the winter months particularly. There was a need to resolve a difference in opinion around the responsibility for patients remaining in ambulances and oversight of their care and treatment.
• Service leaders had procedures and escalation plans to follow for managing periods of heavy demand. However, the action plan devised to improve service provision was in its early stages and had not had time to impact on improving performance.

However:

• The service controlled infection risk well and dedicated areas had been established to protect staff and patients from cross infection during the COVID-19 pandemic. Staff knew how to keep patients safe from abuse and how to report this.
• Although the service did not always have enough nursing staff, particularly at night and not enough trained children’s nurses to ensure safe care was always provided managers regularly reviewed staffing levels and the skill mix where possible to increase numbers of nursing staff.
• The service liaised with other health care providers to help reduce the demand on the emergency department. This involved signposting patients to other appropriate health care settings which were able to meet their needs.
• A new leadership team had been appointed both at service and executive level. They were working on an action plan to improve the service provision and outcomes for patients. They had the skills, knowledge and abilities to run the service and felt strongly supported by the trust leadership team. The trust and the emergency department leaders understood the priorities and issues the service faced both internally and externally and from the additional pressures of the COVID-19 pandemic. The team were visible and approachable for patients and staff. Staff felt respected, supported and valued.

During a routine inspection

Our rating of services improved. We rated it them as good because:

We rated the safe, effective and well led domains as good, with the caring domain rated as outstanding. We rated the responsive domain as requires improvement. The safe domain increased by one rating to good. All other domains remained unchanged.

Our inspection of the core services covered at the Royal United hospital were as follows.

• Urgent and emergency care. Our overall rating of this service stayed as requires improvement. The core service ratings remained requires improvement in the safe and responsive domains. The well led domain dropped one rating to requires improvement. The effective and caring domains remained as good.
• Medical care. Our overall rating of this service increased to good. All domains were rated as good, with both the effective and responsive domains increasing by one rating.
• Critical Care. Our overall rating of this service increased to good. All domains were rated as good, with an increase of one rating in the safe, effective, responsive and well led domains.
• Children and Young People. Our overall rating of this service stayed as good. There were no changes to any of the domains, with the safe, effective, responsive and well led domains rated as good and the caring domain rated as outstanding.
• Maternity services. Our overall rating of this service increased by one to outstanding. The effective domain remained as good, the safe domain increased one rating to good and the caring, responsive and well led domains increased one rating to outstanding.
• On this inspection, we did not inspect surgical services, end of life care or outpatient services. The ratings awarded to these core services at the previous inspection in August 2016 form part of the overall rating awarded to the trust this time.

During a routine inspection

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

During a routine inspection

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

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

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

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

The trust also had positive areas of practice:

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

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

From this inspection, the trust has demonstrated that it could lead significant change effectively. It had been open and transparent with partners about challenges and funding had been used to support innovative changes. It had engaged the national Emergency Care Intensive Support Team (ECIST) to change services in both the trust and across the local health and social care community to improve the management of patient admissions and discharge. The changes had significantly improved how the trust managed the demand for its services and ensured

that patients received good quality and safe care. Staff told us there had been a tangible shift in culture over the past few months from a corporate to a patient focus, and the trust was in a better position to manage winter pressures and unexpected demand for services.

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

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

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

During Reference: not found

During an inspection looking at part of the service

This inspection visit was to follow up compliance actions from the responsive inspection that was conducted in February 2013. At that time concerns were raised about the manner in which some patients had been discharged without adequate information and support. At this inspection we also reviewed governance systems and the mental capacity assessments that took place at the hospital.

We took a nurse with us who had expert knowledge in discharge arrangements, a psychiatrist with an expertise in the Mental Health Act 1983, who spoke with voluntary patients who were receiving treatment for their mental health, and a manager within CQC with expertise in Governance arrangements in acute trusts.

During our inspection we looked at three areas of care at the hospital. These were all the older people�s wards, the emergency department and the day surgery unit (DSU). We also visited the theatre recovery area.

We met and talked with many patients during our visit. Staff were approachable and open in their discussions with us. Where patients were not able to talk with us for various reasons, we spent time observing how care and support was delivered. We saw and were given written evidence from the trust. This included patients' notes, hospital records and recordings of their clinical observations.

During an inspection in response to concerns

This inspection visit was prompted by information that had been shared with us. Concerns were raised about the manner in which some patients had been discharged without adequate information and support. Because of this we took a nurse with us who had expert knowledge in discharge arrangements.

During our inspection we looked at two discrete areas of care at the hospital. These were the older people�s wards and the day surgery unit (DSU). We also looked at pharmacy arrangements for providing medication for people to take home on discharge.

We met and talked with many patients during our visit. Where patients were not able to talk with us for various reasons, we spent time observing how care and support was delivered. We saw and were given written evidence from the trust. This included patients' notes, hospital records and recordings of their clinical observations.

We met with consultant medical staff, pharmacists, therapy staff, registered nurses and healthcare assistants. All the staff we met with showed a professional and caring attitude towards their patients. We also met with hospital directors and senior management staff, they explained to us that the hospital had recently been under unprecedented pressure. Inpatient admissions though the emergency department had increased by 13.9% in the current financial year against the previous four year average.

During a routine inspection

We carried out a visit to the Royal United Hospital NHS Trust in Bath between 20 September 2012 and 1 October 2012 and spent three days at the hospital. We met with senior/management staff on the 4 October to give them an opportunity to provide additional evidence.

Over the three days: we looked at the care arrangements for surgical procedures. The inspection team were assisted on day one of the inspection visits by a practising professional in the area of anaesthetics. We visited a number of wards and units in the hospital. These included three surgical wards, the emergency department which included accident and emergency (A&E), theatre, recovery unit, intensive care unit (ITU), pre-assessment unit, day surgery units.

We met and talked with inpatients and visitors, hospital directors, senior management staff, healthcare assistants, portering, security and domestic staff, theatre staff including anaesthetists, nurses from medical and surgical divisions, consultants doctors and staff from the human resources department.

We saw and were given written evidence from the trust. These included staff training records, staff appraisal and supervision records, patient notes, hospital records, audits, surveys, and board reports. This was in order to demonstrate how the hospital assessed itself against our Essential standards of quality and safety.

We talked with many patients during our visit. Where people were not able to talk with us for various reasons, we spent time observing how care and support was delivered to people. We also looked at patients' notes and recording of their vital signs and clinical observations.

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

During a routine inspection

We carried out a visit to the Royal United Hospital NHS Trust in Bath between 7 November 2011 and 11 November 2011 and spent five days at the hospital. Over the five days: we toured most of the hospital in the company of the director of nursing and chief operating officer; we visited a number of inpatient wards, the emergency department (which includes accident and emergency), the children's centre, a number of outpatient clinics, specialist units including X-ray and imaging; met with PALS (Patient Advice and Liaison Service); and talked with specialist staff teams and steering groups.

We met and talked with inpatients and outpatients, families and visitors, hospital directors, senior management staff, healthcare assistants, portering and domestic staff, radiographers, catering staff, nurses from medical and surgical divisions, administration staff, and consultants and doctors. We saw and were given written evidence from, for example, patient notes, hospital records, audits, surveys, and board reports. This was in order to demonstrate how the hospital assessed itself against the essential standards of quality and safety. We reviewed our visit on 11 November 2011 with the chief executive, James Scott, and members of his senior management team.

We talked with many patients during our visit. When we visited wards where people were not able to talk with us for various reasons, we spent time observing how care and support was delivered to people. We also looked at patients' notes and recording of their vital signs and clinical observations.

We looked at eight of the essential standards of quality and safety. We have found the hospital to be compliant with six of the essential standards and we have minor concerns and require improvements in two of the essential standards.

More detailed commentary on each of the essential standards is covered in other parts of our report under the relevant Outcomes.

During an inspection in response to concerns

On the day of our visit there were no patients known to the hospital staff we talked with who had learning disabilities. We were therefore not able to talk specifically with people with learning disabilities or their carers, or observe care. We were able to observe the care of people with dementia, but were only able to get limited information from these people. We met and talked to one carer who was visiting a person with dementia. This person told us that staff had been �marvellous� and that they made him feel welcome when he visited, which he did regularly. He said that staff were happy to allow him to help with the care of the patient, and that he wanted to help where he could.

We found staff to be engaged in their roles, dedicated, experienced and skilled. The hospital was largely full and staff on the wards that we visited told us that they had their full complement of staff on duty. The hospital was also dealing with an outbreak of Norovirus, which was being contained.

We found areas of training for dementia awareness that could be improved on the wards that were not dedicated to older people. We found that in terms of learning disabilities that the hospital already had put a programme in place to deliver improved care and support following a peer review of this area.

In all the wards we visited we had concerns around the assessment made to determine if a patient had the capacity to make their own decisions. The records to demonstrate how this had been assessed were not readily available. We also found inadequate records in relation to decisions taken over whether to attempt to resuscitate people. We had concerns over the lack of any detail in recording the decisions and how and with whom they had been made

Overall, we found that the hospital was taking steps for the most part to ensure that it respected and involved the people in their care. The hospital was taking steps to mostly ensure that people experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. We saw good evidence of this during our visit and from staff and patients that we met and talked with, and in the practice and care we observed.

We found some areas that require improvement for caring for people with an impaired ability to communicate and make their own decisions.