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.