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Southampton General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 April 2019

Our rating of services went down. We rated it them as requires improvement because:

In rating the trust, we considered the current ratings of four other services not inspected this time.

  • In the emergency department services, we found there were delays in triage of patients that could impact on the health and well-being of patients.
  • In medicine we found that not all paper records were stored securely to protect patients.
  • In outpatients, we found infection control procedures were not fully applied.
  • There were challenges with the aging estates for fire, water, electricity, and ventilation maintenance. The patient environments were showing significant signs of wear and tear.
  • In outpatients there was not always the capacity to meet the needs of patients and their relatives attending.
  • In outpatients the risks were significant to patients due to delays for waiting for ophthalmology appointments.
  • In several services not all staff had recent updated mandatory training.
  • Complaint responses were very detailed and had contributed to delays responding to patients.

However,

  • Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally.
  • The trust had established an integrated medical examiner group (IMEG) to review all deaths twice daily Monday to Fridays.
  • Staffing levels, skill mix and caseloads were planned and reviewed so that people received safe care and treatment.
  • Staff had access to necessary equipment and medicines; and had a range of policies and procedures based on national standards to support their practice.
  • Medicines were appropriately prescribed and administered to people in line with the relevant legislation and current national guidance and had improved since our last inspection.
  • People’s physical, mental health and social needs were holistically assessed and their care and treatment delivered in line with legislation, standards and evidence-based guidance.
  • Multidisciplinary working was strong across the services. Staff worked well together and with other organisations to deliver effective care and treatment.
  • The services had clear arrangements for supporting and managing staff to deliver effective care and treatment.
  • Staff had annual appraisals and managers encouraged staff and supported opportunities for development.
  • Staff were kind, caring and treated patients with dignity and respect. Patients spoke of the positive care they received from staff.
  • Staff communicated with people so they understood their care, treatment and condition; and advice was given when required. Staff involved carers and families in the patient’s care, where appropriate.
  • Services delivered were accessible and responsive to people with complex needs or in vulnerable circumstances.
  • The trust was recognised as one of 16 exemplar Global Digital acute trusts in England. A benefit for staff and patients was through the medical patient records (My medical record) being accessible to patients and promoting supportive management of long term conditions.
  • The use of electronic white boards had been introduced for improving patient safety.
  • The volunteers for the trust, worked at the hospitals and were involved with a wide range of activities including hospital radio, patient support and chaplaincy and spiritual care.

We saw several areas of outstanding practice:

In Urgent and emergency care for example:

  • The trust was actively engaged in research across a wide spectrum of clinical conditions. Further, the service was also participating in research associated with the psychological impact of bereaved families whose relatives had been lost due to major trauma incidents.
  • Careful planning and consideration had been given to meeting the needs of the local population. Environmental changes including the development and building of the new enhanced care suite and the children’s emergency department were exemplar examples.
  • The arrangements for supporting vulnerable patients and other service users was exceptional. The knowledge and resources within the vulnerable adult support team ensured patients were supported in line with national best practice standards.
  • Staff were supported to access post-graduate training. This ensured the skill mix and competency of staff was of a level which promoted excellent multi-professional led care.
  • The department had recently introduced a comprehensive care bundle which was observed to be consistently used. The care bundle prompted staff to complete rapid assessments across a range of health measures including physical observations, falls risks and skin integrity, sepsis screening, peripheral cannula insertion records and visual infusion phlebitis management. Staff also consistently used hourly safety checklists which prompted staff to consider pain management, vital signs, level of consciousness, nutrition and hydration needs and speciality referrals for those who were identified as being vulnerable for example.
  • We observed rapid attendance of clinical specialities to the emergency department when pre-alert calls were received from the ambulance service. Health professionals were well prepared and were aware of their roles and responsibilities for managing specific conditions.
  • The trust had undertaken extensive work to ensure patients arriving by ambulance were handed over as quickly as possible in order ambulances could return to service to treat pre-hospital patients. Nurses were trained to undertake rapid assessments of patients, supported by a consultant.
  • There were several patient groups with a mixture of mental health, substance misuse and chronic medical problems that benefited from a consistent response from health professionals. To help frequent attenders to the emergency department (ED), monthly meetings called, “The high intensity service users’ group”, chaired by an ED consultant had been established. In the meeting, patients were discussed and a care plan was agreed which may alter behaviours and contribute more constructively to the patient’s needs.
  • The hospital had developed a frailty team who provided rapid assessments of patients in the ED who met certain referral criterial.
  • We observed episodes of care during which patients were truly respected and valued as individuals. Patients were empowered as partners in their care both practically and emotionally.
  • We considered the leadership team to be cohesive, with heightened visibility and presence across the department and well respected by peers and colleagues.

In Medical care services:

  • The trust introduced registered 18 pets as therapy dogs for both child and adult services. These pets visited the stroke and dementia wards regularly.
  • The trust had introduced ‘Eat, Drink, Move” initiative which had improved patient outcomes.
  • The trust achieved best practice tariff status in quarter 3 of 2017. A Best Practice Tariff (BPT) is a national price paid to providers that is designed to incentivise high quality and cost-effective care. The aim was to reduce unexplained variation in clinical quality and to encourage best practice. Only 42% of the NHS trust in England achieved this.
  • The trust met all the four key national standards to enable it to provide a seven-day medical service.
  • The proportion of patients reviewed by a consultant within 14 hours of admission at hospital improved from 76% in 2016 to 92% in 2018.
  • All cardiology patients received a 365-day echo cardiogram service and seven-day consultant. This meant that all new patients and those with complex conditions received a consultant review seven day a week including weekends.
  • Reduced admissions were achieved through the consultant-led ambulatory care unit (ACU) where patients were admitted via several different routes, including GPs helped identify patients in the community who required medical intervention without the need to be admitted to the hospital.
  • There was a specialist emergency assessment unit for older patients with a new frailty unit, where patients received rapid assessment by a team led by consultant geriatricians.
  • The care of the elderly consultants’ locality based model improved the continuity of inpatient care, and with communication with patients and families, and with other healthcare services in the community.

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

Importantly, the trust MUST:

In outpatient services:

  • Ensure the outpatient service environment is kept clean and fit for purpose. Infection control procedures are in place and adhered to.
  • Ensure systems and procedures are in place to monitor and manage patient’s care and outcomes. Thus, avoiding delays in patient appointments which has resulted in patient harm.
  • Ensure complete oversight of outpatient services across the trust sites for the management and leadership, governance, risk and consistency of services.
  • Ensure there is a finalised strategy for outpatient services.
  • Ensure staff personal property is stored appropriately and securely when on duty.
  • Ensure patients are kept safe from harm such as by having working emergency call bells and observation of patients left in waiting areas.
  • Ensure the physical capacity of the outpatient environments meet the needs of the number of patients waiting and being treated.

In Medical care services:

  • Ensure records are stored securely.
Inspection areas

Safe

Good

Updated 17 April 2019

Effective

Outstanding

Updated 17 April 2019

Caring

Outstanding

Updated 17 April 2019

Responsive

Requires improvement

Updated 17 April 2019

Well-led

Requires improvement

Updated 17 April 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 17 April 2019

  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
  • People who used the medical care services were kept safe from avoidable harm because there were suitable arrangements to enable staff to identify and respond to risks.
  • There were sufficient numbers of staff, and they had been provided with safety training. Staff were further supported through service related policies and procedures in addition to evidence based professional guidance.
  • Feedback from people using medical care services, and those close to them, was positive about the way staff treated them. Patients and their relatives gave us examples of how staff went an extra mile to provide care and support that exceeded their expectation. For example, the trust registered 18 pets as therapy dogs for both child and adult services.  These pets visited the stroke and dementia wards regularly.  
  • Patients told us staff demonstrated genuine affection, care and concern for them. Patients and family members gave us examples of how staff ensured patients’ emotional and social needs were as important as their physical needs.
  • Services provided by the medical care reflected the needs of the local population.
  • The service used technology innovatively to ensure people had timely access to treatment, support and care.

However:

  • Not all nursing and medical paper records for patients were stored securely.
  • Incidents and learning from medicine administration errors were not shared across the medical teams.

Services for children & young people

Good

Updated 23 April 2015

Children, young people and their families were positive about the care and support they received. They told us they were kept informed and involved in making decisions. The service provided outstanding support to children, their parents and families; peer support and social events were promoted and encouraged for children who attended the hospital often, because of the nature of their illness and particularly in the oncology and neonatal units.

There were systems in place to ensure that children at risk of harm, or considered to be of concern, were identified and protected if seen in the hospital. Following a high-profile incident in the past year, safeguarding procedures had been reviewed and new procedures put in place to protect and monitor children who may leave the ward environment. Staff were aware of how to report incidents and this information was monitored and reviewed, and the learning shared. Staffing levels were monitored and openly displayed. Areas were staffed with enough workers with the skills required to care for children and young people. On occasions when staffing levels were not as planned, action was taken to maintain a safe environment.

Children’s care was provided based on national guidelines and best practice. Staff were supported in their role, and development opportunities were available and accessible. There was good multidisciplinary team working. A 7-day service was established for medical staff and being developed for all areas including support services such as therapies and diagnostics.

The service was looking for ways to improve access and had extended services, for example, in orthopaedic care and for back pain. There were, however, problems with waiting times for some services (for example, spinal surgery) and children did not always have pre-admission assessment to prepare for surgery. The current environment and facilities needed to improve. There was a lack of bathrooms for children and young people needing extra support (for example, lifting aids), and there were cramped conditions in some ward areas such as Piam Brown. The environmental space had become too small for the services being delivered. This was recognised by the trust and there were plans to start work that would enable the relocation and expansion of two wards. Additional work was dependent on the proposed new children’s hospital that was now delayed because of funding problems. The new hospital was planned for 2020 .

Staff worked effectively in teams and were positive about the leadership of the service. The strategy for the service was encompassed in the new hospital. There was no current clinical strategy and plans were being developed to manage service issues as they materialised. There was an established governance system to monitor risk and quality . Young people’s opinions and input were actively sought through surveys and consultation, and their feedback was used to improve the service.

Critical care

Outstanding

Updated 13 June 2017

End of life care

Good

Updated 13 June 2017

Surgery

Good

Updated 13 June 2017

Urgent and emergency services

Good

Updated 17 April 2019

  • Treatment was delivered in accordance with National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (RCEM) guidelines.
  • The department was a research active centre, participating in multiple research studies in conjunction with colleagues from across different specialities.
  • Where clinical audits demonstrated deviation from benchmarked peers, the department worked to identify contributing factors, instigate changes to practice and then revisit those changes to ensure positive clinical outcomes were achieved.
  • The department recognised an unplanned re-attendance rate which was marginally higher than the national average; it was considered this was likely attributable to data quality issues and the way the trust reported their data.
  • The department had been dynamic in developing alternative professional development pathways including encouraging staff to undertake the advanced care practitioner course. Nursing staff and advanced care professionals were trained to undertake advanced procedures including the management of patients who presented with acute coronary syndromes. We observed nursing staff managing specific clinical cases with good support provided by consultants.
  • The children’s emergency department was staffed by qualified children’s nurses 24 hours a day. The department employed four specialist paediatric emergency medicine consultants who supported the children’s ED whilst also liaising closely with the children’s hospital.
  • Twelve health care assistants had received training in dementia and were recognised as dementia champions. Staff working across the emergency department had good knowledge of the procedures and policies to support people in crisis.
  • Doctors and nurses of all grades were given protected work time to participate in training.
  • The vulnerable adult safeguarding team provided comprehensive support to vulnerable patients. The team comprised of highly competent and experienced practitioners whose role it was to support patients from across a group of vulnerable people. The team worked with both internal and external stakeholders to not only prevent patients being admitted to hospital but to also ensure patients were safeguarded, signposted to appropriate support services and ensure the holistic needs of patients was met.
  • The department was an exemplar at demonstrating multi-disciplinary working with both internal colleagues and also across the wider Southampton health system.

There were multiple clinical pathways in place which enhanced the patient experience in the department. Clinical pathways aim to promote organised and efficient patient care based on evidence-based medicine and aim to optimise outcomes.

  • Staff had the right skills and knowledge to provide safe care and treatment for patients.
  • Clinical education was used to support staff and patients.
  • All patients had their nutrition needs and hydration needs met and staff assessed and managed patients’ pain effectively.
  • Staff had access to best practice reference guides and trust policies in relation to assessing capacity.
  • Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • The service supported patients by promoting healthier lifestyles.
  • We saw staff being compassionate to patients and their relatives. Patients and relatives spoke highly of the kindness and compassion shown to them by staff.
  • We saw staff communicated with and included people so that they understood their care and treatment.
  • Staff were non-judgemental and ensured patients were placed at the centre of care planning.
  • The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was better than the England average from September 2017 to August 2018.
  • The service had managers at all levels with the right skills and abilities to run the service, providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and we saw evidence of actions to achieve it.
  • Managers promoted a positive culture that supported and valued staff, free from bullying, harassment or discrimination, creating a sense of common purpose based on shared values.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • Learning from complaints were shared across the emergency department through daily regular team meetings. Complaints were reviewed through the emergency department governance meetings. There was evidence of changes to practice and the way the service was provided in response to complaints.
  • Leadership at departmental level was considered by staff to be supportive and effective.
  • Departmental staff were aware of the departments values and the values of the trust.
  • There were assurance systems implemented to ensure the identification and management of risks was undertaken and appropriate action taken.

However:

  • Not all staff had completed their statutory and mandatory training.

Outpatients

Requires improvement

Updated 17 April 2019

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated it as requires improvement because:

  • The service did not effectively control all infection risks.
  • The service had capacity issues in certain departments and could not cope with the volume of patients attending clinics.
  • Systems and procedures to monitor and manage risks to patients had failed which had led to patient harm.
  • It was unclear if there was a robust system for providing feedback and lessons learnt from complaints or incidents to staff working in outpatient services.
  • It was unclear if the outpatient services had robust, well-established and effective leadership and governance processes.

However:

  • Staff were supported through service related policies and procedures in addition to evidence based professional guidance.
  • Feedback from people using outpatient services, and those close to them, was continually positive about the way staff treated them.
  • Services provided by the outpatient departments mostly reflected the needs of the local population.
  • Most patients were able to access the service in a timely way, with many specialties in line with or close to the national averages in waiting times.