Southampton General Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question outstanding. At this assessment the rating has changed to good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this. However there was inconsistency of documentation in end of life care plans and DNACPR forms.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The trust used an individualised End of Life Care Plan (EoLCP) document, supported by a clinical guideline, to assess and record patients' end-of-life care needs. Most care plans we reviewed demonstrated personalised assessments and planning. However, some documentation was not fully completed and there were occasional gaps in recording the rationale for decisions made. For example, of the six care plans reviewed, one had an incomplete section relating to religion and spirituality, and in another it was not clearly documented whether relatives had been involved in care planning discussions.

The trust had already identified opportunities to strengthen the consistency and completeness of end-of-life care documentation and had incorporated targeted actions within its end-of-life quality improvement programme. Improvements were underway to support more comprehensive recording of care discussions and decisions. This included the introduction of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process, which leaders anticipated would enhance the quality, consistency and accessibility of documentation relating to end-of-life care planning and treatment decisions. These actions demonstrated a proactive approach to continuous improvement and a commitment to strengthening person-centred end-of-life care.

The trust had an individualised EoLCP clinical guideline which stated nursing observations were to be completed at least every 4 hours. A review of care plans showed observations including mouthcare and fluids and nutrition taking place every 2 hours. This suggested that care was in some cases delivered above the minimum expected standard.

The trust had established processes to support timely assessment, treatment escalation planning and shared decision-making, including consultant oversight of escalation decisions and multidisciplinary input from specialist palliative care, critical care outreach and intensive care teams. Care plans and escalation decisions were reviewed and updated in response to patients’ changing needs. Following the inspection, the trust also reviewed 71 patient records and do not attempt resuscitation (DNACPR) forms, providing wider assurance regarding the quality of assessment, clinical decision-making and oversight of escalation planning across the service.

Pain assessments formed part of the individualised care plan and included regular routine observations to identify and manage pain. Staff used the Bolton Pain Assessment Tool (BPAT) which supported them in assessing pain for patients that were unable to self-report. The BPAT is a clinical tool designed for assessing pain in patients with dementia or communication difficulties, often used in hospitals to guide intervention.

The palliative team held handover meetings twice a day to review new referrals. We attended the morning handover and observed discussions around patients’ diagnosis, symptom management and advance care planning. Staff within the ward told us they could refer patients to the palliative care team as urgent and non-urgent and the team would respond accordingly.

Staff told us there was a flagging system on the electronic patient record (EPR) for learning disability. The trust had a learning disability team who had oversight of patients with learning disability and tracked patients in and out of the hospital with the community teams.

Patients were supported to eat and drink as long as they were able to. When patients were unable to eat and drink, they were offered regular mouthcare and liquid tasters on the mouthcare swab according to their wishes. Staff involved patients and their families in discussion around risks associated with maintaining oral intake either due to pre-existing conditions or the patient deteriorating to ensure they had a full understanding of what was happening.

The trust was working to improve the early identification and assessment of patients with supportive and palliative care needs through the use of the supportive and palliative care indicators tool (SPICT). This supported earlier recognition of deterioration, timely advance care planning and treatment escalation discussions, alongside responsive reassessment of patients approaching the end of life. The trust also undertook ongoing audit, guideline review and quality improvement activity to strengthen Fast Track processes and escalation planning arrangements.

Multidisciplinary (MDT) and multi-agency working was in place to assess and respond to the needs of patients with complex clinical, psychological and social care needs. Daily multidisciplinary reviews, coordinated discharge planning, escalation discussions and collaborative working with community, mental health, social care and hospice services supported the ongoing assessment and management of patients with rapidly changing or complex needs, helping to maintain continuity of care across care settings.

The evidence showed an exceptional standard. The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

The trust demonstrated an embedded approach to delivering evidence-based care through the use of clinical audit, service evaluation and quality improvement activity. Audits of areas including naloxone administration, fast track discharge processes and treatment escalation planning were used to assess practice and identify opportunities for improvement. Findings informed changes to clinical guidelines, prescribing processes, staff education and planned re-audit activity to evaluate the impact of interventions.

The trust also undertook evaluation of tools designed to support the early identification of patients with supportive and palliative care needs. This work reviewed patient outcomes, emergency department attendances, hospital admissions and treatment escalation planning to inform future service development and support earlier advance care discussions.

Structured assurance processes were in place through the clinical accreditation scheme, which incorporated unannounced ward reviews, multidisciplinary review processes, patient feedback and documentation audits. Findings were used to identify themes and drive targeted improvement initiatives across a range of clinical areas, including patient safety, communication, dementia care, nutrition and hydration, and patient-centred care.

The trust had also strengthened organisational learning through trust-wide morbidity and mortality review processes, standardised review frameworks and multidisciplinary governance arrangements. Mortality reviews, patient safety investigations, deterioration reviews and LeDeR reviews were used to identify themes, learning and improvement actions, which were monitored through governance structures and shared across the organisation to support ongoing improvements in the quality and safety of care.

The trust took part in the National Audit of Care at the End of life (NACEL). The 2025 report which showed improvements from the 2024 report. For example, 94% of families reported an excellent or good rating for overall care from 64% in 2024.

Within the NACEL, the trust were performing above the NHS benchmark for seven of the ten key quality indicators. The trust reported performing well at recognising that the person would die during the final admission, providing a 7 day per week, 8 hours per day face-to-face specialist palliative care service, an individualised end of life care plan, prescription of anticipatory medications, and documenting communication with those important to the person about hydration, and documenting the persons ethnicity. Ethnicity is crucial in end-of-life care planning to ensure culturally sensitive, equitable, and patient-centred care, reducing inequalities in accessing palliative services.

Staff had access to end of life care policies and procedures which were based on national guidance such as the National Institute for Health and Care Excellence (NICE) NG31, which defines clinical best practice in care of dying adults in the last days of life. The individualised end of life assessment and planning document took account of the NICE guidance and prompted staff to consider all the domains.

Staff received training on the end of life care plan and told us they were familiar with this and aware how to use the documentation. The palliative care team had recently introduced a palliative end of life care educator role for the whole trust who visited wards and delivered learning sessions as well as formal education and training. Additionally, the palliative care team also ran education days for all staff and provided end of life care updates through the staff newsletter.

The evidence showed an exceptional standard. The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

The palliative care team worked well with ward staff and services to support people.

Leads within the palliative care team visited clinical areas to engage with ward leaders and promote good practices for dying patients and those important to them. Medical staff told us they had a good working relationship with the palliative care team. We spoke with a palliative care registrar who said they were very well supported by the consultants and could call them at any time.

There were a number of areas within the trust in which clinical end of life care leads were working with the palliative care team to improve end of life care. Within the emergency department for example the palliative team had worked with staff to co-design a simplified end of life care plan more suited for patients coming through the emergency department focusing on patient priorities, symptom management and good communication with patient and families.

We spoke with the bereavement team who told us they had a good working relationship with the palliative care team and described them as very responsive.

Volunteers spoke highly of palliative staff and how they worked fabulously as a team.

Patients’ care was well coordinated, and everyone involved in their care worked well together. The trust palliative care team members attended multi-disciplinary meetings for patients who may be in hospital or in the community, to support recognition of terminal phase and care planning. This aimed to support people being cared for in their preferred place.

Doctors and nurses within the palliative team also worked across the trust and a local hospice for young adults, to support transition from child to adult palliative care services, including young adults with highly complex needs and neurodisability.

The palliative care team met with the Hampshire and Isle of Wight integrated care board every 6 weeks where they presented a provider summary for end of life care sharing areas of success and achievement, opportunities and aspirations, challenges and mitigations and risks and escalations. In this way providers across the system could learn from each other and seek closer working and improved patient experiences.

Periodically the team also shared the hospice waiting list data with local hospices and worked closely with them to ensure fair access to hospice beds for patients from the acute hospital.

The palliative care team shared with us examples of success stories through MDT working which led to a positive outcome for the patient and their families. An example was provided of a patient who was admitted to the hospital on an end of life care pathway. Through enhanced care, individualised care planning and input from different teams, the patient was discharged with a care package and no longer required end of life care.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Patients and families had access to family information booklets, which contained a section on eating and drinking in the last days and weeks of life. This provided patients and families with information on how to support patients with eating and drinking and mouthcare.

One of the aims of the individualised end of life care plan was focused on supporting the patient with their individual hydration and nutrition needs. Staff told us this was regularly reviewed and we saw this in practice.

Mouthcare as well as nutrition and hydration was part of the trusts fundamentals of care project which was designed to develop and embed a more patient centred focus to care and included 8 core standards which included mouthcare, personal hygiene and nutrition and hydration. Mouth care is an essential aspect of palliative care in all settings and should be considered part of daily routine patient care. Assessment and intervention should be instigated early to optimise patient comfort and prevent more serious problems and treatment complications.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The trust ran a clinical outcome governance programme which was managed by the clinical effectiveness team. Each division produced a yearly report which was presented at the clinical assurance meeting for effectiveness and outcomes (CAMEO) covering clinical outcomes, internal and external audit, NICE standard compliance and approval of new procedures.

We reviewed the latest report for the palliative care team from September 2023 to August 2024 which included a summary of clinical outcomes and performance. These included the timeliness of initial patient assessment and discharge destinations for deaths and ongoing community palliative care team or supportive care clinical input.

Data for the period October 2023 until September 2024 showed that 84% of urgent referrals were seen within 24 hours which met the target of meeting more than 76% referrals seen within 24 hours.

The report also included an evaluation of the audits which were carried out during the time period and research and quality improvement projects the team was currently working on. This included three key areas which required further focus and an action plan to address these.

At the time of the assessment, the palliative care team were working on developing a system to collect data against the Integrated Palliative Care Outcome Scale (IPOS) for symptom tracking. This would help them to capture results that mattered to their patients regarding physical symptoms and psychological challenges for palliative patients.

The trust held mortality and morbidity (M&M) review meetings and had undertaken a number of trust wide mortality and morbidity workstreams which included the development of a platform to capture learning outcomes and identify themes to share cross the trust. M&M meetings are structured, often confidential, clinical forums where healthcare professionals review cases involving patient deaths or serious complications. The aims of these meetings is also to highlight good practice at the end of life, ensuring the standard of care prior to death was safe and of a suitable quality, and also to identify areas of learning for quality improvement.

Mortality and morbidity work involves using statistics (morbidity for illness, mortality for death) and conducting structured meetings (M&M meetings) to review adverse patient outcomes, aiming to improve healthcare quality, patient safety, and clinical education through system-wide learning, rather than blaming individuals.

The trust had also undertaken a learning from lives and death review (LeDeR) which is a national service improvement program to review the deaths of people with a Learning Disability to improve the quality of care. Learning from LeDeR was shared across various governance and education platforms to ensure learning.

The evidence showed some shortfalls. The service did not always tell people about their rights around consent.

We reviewed 6 DNACPR forms and found the majority of these to have clear discussions with patients’ relatives and the patients. The majority of documentation was complete, however, on one DNACPR form there was no evidence of any discussions which took place or whether the patient had been informed of the decision. This was fed back to the trust during the inspection, following which a briefing note was sent to medical staff to remind them of the importance of documenting DNACPR conversations in the patients’ medical notes and ensuring there was a summary of key points raised which reflected people’s understanding.

In response to wider national concerns, which had identified cases where blanket DNACPR decisions were inappropriately applied to people with learning disability or autism (LDA), the trust had undertaken structured case reviews of 71 case notes to ensure safe, lawful, and person-centred practice, key findings of which showed no evidence that DNACPR decisions were made on the basis of learning disability or autism. This provided broader assurance that decisions were made through appropriate consent processes, capacity assessments where required, and best-interest decision-making in line with the Mental Capacity Act.

The critical care outreach team (CCOT) supported clinical teams with treatment escalation plan (TEP) and end of life discussions on a regular basis during acute deterioration ensuring patients and relatives/carers were active participants within the discussions.

Staff had received training in relation to the Mental Capacity Act (MCA) 2005 and were able to explain the main principles. The hospital had a dedicated lead for MCA. Staff understood the importance of giving people choice in the support they received, and we observed staff seeking people's consent before providing support. People were supported to make their own decisions where appropriate, in accordance with the MCA.

The trust was implementing the ReSPECT process to strengthen shared decision-making and support patients to be involved in decisions about their care and treatment. This included providing staff with training on conducting and documenting treatment discussions, revising Treatment Escalation Plan guidance, developing a dedicated ReSPECT policy, and monitoring the uptake and completion of ReSPECT documentation. These actions were intended to promote person-centred decision-making and ensure consent and treatment decisions were recorded consistently and appropriately.

The trust had established oversight arrangements to support appropriate decision-making and documentation relating to DNACPR decisions. The resuscitation team completed quarterly audits of approximately 100 randomly selected DNACPR forms across all divisions, reviewing whether decisions had been made for appropriate clinical reasons, documented correctly, and authorised in line with trust requirements. Findings were generally positive, with forms completed to a high standard, although a small number demonstrated delays in consultant countersignature.

Audit findings and themes were reviewed through governance structures, enabling learning to be shared and concerns escalated where required. In addition, the trust monitored all cardiac arrest calls and participated in the national cardiac arrest audit to identify potential irregularities in practice. These processes provided assurance that decisions relating to resuscitation status and treatment were subject to oversight, review and ongoing governance.