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Southmead Hospital Requires improvement

We are carrying out checks at Southmead Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 6 April 2016

We carried out this focused inspection of the North Bristol NHS Trust to follow up on the areas that were rated as inadequate and requires improvement in our inspection in November 2014. Because we rated children’s services as good in November 2014 we did not inspect them. All services had been rated as good for caring in November 2014 so we did not reinspect this area, although we observed how people were cared for during the inspection.

The announced part of the inspection was carried out on 8, 9 and 10 December 2015 and the unannounced part of the inspection was carried out on 16 December 2015.

Overall we saw improvements had been made at this hospital, although the rating remained requires improvement.

Our key findings were as follows:

Safety:

  • Although we rated safety as requires improvement at Southmead Hospital, improvements had been made.
  • There were significant improvements within safety in urgent and emergency care services, with patients now receiving timely assessment on arrival.
  • Systems for investigating incidents were embedded in most areas. However, improvements were required in end of life care as not all incidents had been reported, for example, those from mortuary and bereavement services.
  • There had been a review of nursing and midwifery staffing in all areas of the hospital and numbers had increased in urgent and emergency care, medical services, critical care, surgical services and maternity services.
  • In places this increase in numbers had been through the recruitment of staff requiring development and in most places, notably urgent and emergency care and critical care, training and development support had been put in place. However, in the theatre department, improvements were required in ensuring that new staff were developed sufficiently to support the flow of patients through theatre lists.
  • Wards and departments were visibly clean, and equipment had ‘I am clean stickers’ on them. Staff were observed to observe the ‘bare below the elbows’ policy in the trust. Handwashing facilities were readily available at the entrance to each ward and alcohol hand sanitising gel was available. Staff were seen to be using the personal protective equipment (gloves and aprons) in all areas.
  • The hospital did, however, have higher than expected levels of Clostridium difficile infections and MRSA infections reported.
  • Following a Pseudomonas aeruginosa colonisation in the critical care department, the trust reviewed the cleaning regimen and replaced all of the tap faucets in the department. A full investigation was undertaken and actions identified to prevent further incidents occurring.
  • A new electronic records system had been implemented in the month prior to our inspection. Although training and support had been put in place for staff, some were hesitant and found the system difficult to navigate. The new system involved more steps for emergency department staff to complete when a patient attended the department and this was having an effect on the time taken with each patient.
  • In most areas of the hospital, paper records were stored securely. However, in the theatre department and outpatients areas, some were stored in rooms which were not secured.
  • Improvements had been made in medicines management. However, some controlled drugs cabinets were not of sufficient size to accommodate all medications and in surgical services it was not clear if the temperatures of medicines fridges had been checked or actioned if outside of range.

Effective:

  • We rated the overall effectiveness of services in the hospital as requires improvement. However, improvements had been made in urgent and emergency care services, which we rated as good.
  • Across the hospital there was involvement in audit and benchmarking both internally and externally. There were clear links to improvement in care within most areas. However, within end of life care the results of audit and monitoring had not yet enabled objective improvements in quality.
  • Improvements had been made in supporting staff within their roles, through the appointment of nurse education practitioners and education programmes in the emergency department and in critical care. Further support was required in the theatre department for newer staff.
  • Staff appraisals were undertaken across the hospital, but improvements were required within medical services.
  • In urgent and emergency care and surgical services assessments of patient need were clearly undertaken and recorded within patient records. However, within medical and end of life care services assessments were not always complete or recording the full range of patient needs. Within medical services this was due to omissions in the completion of the electronic patient record via the new electronic recording system.
  • Within medical services there were omissions in the assessment and documentation of patient capacity to consent to care and treatment. Within end of life care staff completing do not attempt resuscitation documentation were not always recording in line with the Mental Capacity Act 2005 Code of Practice.
  • Throughout the hospital we saw patients receiving timely pain relief.
  • Patients’ nutrition and hydration was well managed in all areas, including the emergency department where housekeeping staff provided regular hot drinks rounds.

Responsive:

  • Although there was a trust wide focus on patient flow within the hospital and improvements had been made this still required improvement. Bed occupancy within the hospital was consistently high at 96% and within critical care was above 80%. Research has shown that bed occupancy of both 85% (and above 70% within critical care services) could start to affect the quality of care provided to patients.
  • The four hour standard, within the emergency department, to admit or discharge patients to the hospital had been achieved for a three month period between June and August 2015. However this had deteriorated from September 2015 and in November 2015 only 82% of patients met this standard.
  • There was a high level of delayed transfers of care which was frequently above 100 patients per day and at the time of the inspection was 114. However, there had been significant work undertaken since the inspection in November 2014 to facilitate patient discharges. This included the implementation of an integrated discharge lounge in October 2015. There was a focus on embedding discharge pathways and gaining pace in discharge activity.
  • Within surgical services there was not timely access for patients to treatment and operations. There were long waiting times, delays and cancellations ongoing. Action to address this was not always timely or effective and had resulted in a high number of complaints. The trust performed worse than the England average for most national standards, this included the Admitted Adjusted Referral to Treatment time (where the time from referral to treatment should be less than 18 weeks). The trust was also not meeting standards for referral to treatment pathways within outpatient services.
  • The number of cancelled operations was worse (higher) than the England average and the percentage of patient not treated within 28 days of a cancelled operation was above (worse than) the England average.
  • This had an impact on the critical care unit which had a high number of delayed discharges from the unit and the length of stay for patients was higher than the NHS national average. This was not optimal for patient social and psychological wellbeing.
  • Within maternity services, ‘flow midwives’ had been introduced to provide an overarching approach to flow within the service. This enabled midwives to focus on providing direct patient care. Although bed occupancy remained high within maternity services (excluding the central delivery suite) this had improved flow within the service.
  • The needs of patients with complex needs were well understood within all areas of the hospital. Patients with dementia received care and treatment that was sympathetic and knowledgeable. The work undertaken by the dementia care team within medical services was seen as outstanding. There were 100 dementia champions within the trust (including the director of facilities) and a focus on environmental changes to support patients.
  • Useful information was provided to patients and visitors and communication aids including interpreters was readily available.
  • Complaints were dealt with in line with trust policy. It was easy for people to complain or raise a concern and they were taken seriously when they did so. Improvements were made to the quality of care as a result of complaints and concerns.

Well Led:

  • Improvements had been made in leadership across the hospital. In urgent and emergency care and medical services we rated the well led domain as good. However, we rated the well led domain in surgical and end of life services as requires improvement.
  • There was strong clinical leadership within urgent and emergency care services which had led to improvements in safety, effectiveness and some improvements in the responsiveness of the emergency department. The vision and values were clear and focused on safety and quality. Governance arrangements had been strengthened since our inspection in November 2014 and risks and quality were regularly monitored and escalated when necessary.
  • The medical directorate had gone through a period of consolidation by embedding governance and having a greater focus on learning change and improvement.
  • There was a culture of candour openness and honesty within the hospital. However, within the theatre department staff did not always raise concerns or report incidents because they were not always taken seriously or treated with respect when they did.
  • Governance arrangements in the theatre department required improvement and did not identify when important safety checks were not carried out.
  • Improvements in leadership for the specialist palliative care team had occurred since the last inspection. Governance and performance management arrangements within end of life care across the trust did not always operate effectively. Risk registers were not in place for end of life care and risks did not appear on the hospital or trust risk register. Quality issues and priorities were understood but the actions required to ensure change were not yet fully embedded.
  • In most areas of the hospital staff felt supported. However, within the end of life care formal substantive leaders were absent for chaplaincy and bereavement services, although temporary leadership arrangements were in place for staff in bereavement services. In the theatre department staff did not feel that leaders were visible or provided the guidance they needed.

We saw several areas of outstanding practice including:

  • As the major trauma centre for the Severn region the department was required to report all treatment results of major trauma patients to the national trauma audit and research network (TARN). Results for 2015 showed that the emergency department at Southmead hospital had the best survival rate of any trauma centre in England and Wales.

  • Frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

  • Managers were strong and committed to the patients and also to their staff and each other.

  • There was an outstanding example of responsiveness with the work of the dementia care team and the availability of 100 dementia champions in the trust including the Head of Facilities who was focussing on environmental changes.

  • In the pre-admission clinic they had a pharmacist working full time who reviewed elective patients. They made sure their VTE assessment was completed. They reviewed patients’ medications, wrote them up on the medication chart and gave advice to patients about their medication (what needed to be stopped prior to admission). The purpose for this was to reduce the amount of operations cancelled due to medication issues.

  • The bereavement midwife visited women in the CDS and also followed women up at home at any time, even beyond the normal time limit for postnatal midwifery care.Family support was also offered for subsequent pregnancies

  • The trust had developed some good training for staff in caring for patients living with dementia. Staff explained how they were able to offer extra time to this group of patients to ensure they were well cared for and made to feel relaxed and calm in an unfamiliar environment. Staff in the pre-operative assessment clinic were able to assess patient’s cognition and report back to GPs if it was below expected levels.

  • The specialist palliative care team was one of several in the country to join acute medicine unit board rounds to ensure patients’ needs were identified to access end of life care. We saw evidence that the specialist palliative care team had worked with the acute medical unit with complex end of life patients to improve patient outcomes.

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

Importantly, the trust must:

  • Improve patient flow within the hospital and ensure that there is a robust hospital-wide system of bed management so as to: significantly reduce delays in patient flow through the emergency department; reduce occupancy to recommended levels within medical services; and, ensure that there is capacity within the hospital so that patients can be admitted to and discharged from critical care at the optimal time for their health and well-being.

  • The medical directorate must improve access and flow in order to reduce occupancy to recommended levels.

  • Records must be fully completed and provide detailed information for staff regarding the care and treatment needs of patients.
  • Ensure there is capacity in the hospital so that patients can be admitted to and discharged from critical care at the optimal time for their health and wellbeing. This includes a robust hospital-wide system of bed management
  • Take action to improve the safe storage of medical notes
  • Ensure patient information remains confidential through appropriate storage of records in the outpatient clinics and theatre departments to prevent unauthorised people from having access to them.

In addition the trust should:

  • Check equipment in the emergency department resuscitation room to ensure that it is ready to use.
  • Review patient group directives in the emergency department to ensure they reflect current best practice.
  • Ensure that psychiatric patients attending the emergency department at night have timely access to appropriate treatment.
  • Ensure that the emergency department computer system is easy for staff to use and can provide information needed to manage current and future performance.
  • Integrate new emergency department triggers for escalation action into the hospital full capacity protocol.
  • Chemicals and substances that are hazardous to health (COSHH) should be secured and not accessible to patients and visitors to the medical wards.
  • Opening dates or in used expiry dates should be added to medicines where appropriate.
  • Controlled drugs cabinets should be of an adequate size for the required controlled drugs.
  • Medicines refrigerator temperatures within surgical services should be monitored, recorded and actions taken in accordance with trust procedures.
  • Equipment and medicines required in an emergency should be tamper evident.
  • Make sure any changes to practice should be shared with bank and agency staff who work a number of shifts so they are update to date.
  • Make sure auditing of safety checks of anaesthetic machines takes place to make sure they are being done.
  • Make sure cleaning of all theatre equipment takes place and provide evidence to support this.
  • Increase staff locker capacity in theatres to prevent storage of personal bags in the theatre room and to improve infection control practices in theatres.
  • Review the cleaning of laryngoscope handles to make sure they are in line with the current guidance.
  • Review the orange bags being used, as they were prone to leaking onto the cages used to transport clean linen in theatre.
  • Look at ways of making theatre management more visible to staff and improving staff morale.
  • The trust should improve the facilities for patients in interventional radiology if this is to be used as the escalation ward.
  • Continue to work on improving the WHO safe checklist score to meet their target.
  • Use the information from themes of complaints to make changes to practice to reduce the number of complaints received.
  • Ensure mandatory training is given suitable priority so that compliance rates across the hospital meet trust targets.
  • The system for checking resuscitation equipment should be consistent across the directorate.
  • Staff should ensure patient notes have clear records of assessments and best interest decisions for patients who lack the mental capacity to make their own decisions.
  • The security of confidential patient records should be reviewed to ensure they are safe from removal or the sight of unauthorised people.
  • Continue to support new staff in critical care to attain a post-registration award in critical care to ensure a minimum of 50% of nursing staff hold such a qualification.
  • Continue the recruitment programme in the critical care unit to ensure the recommended numbers of safe staffing, including supernumerary coordinators, are achieved at all times.
  • Ensure store rooms in critical care are kept locked at all times when unattended.
  • Ensure care records are available in a timely manner to allow useful mortality and morbidity reviews to take place.
  • Review the critical care response to deteriorating patients within the hospital, and follow-up of patients discharged from critical care.
  • Monitor the numbers of elective surgery that are cancelled as a result of no critical care beds being available.
  • Consider instructions for cleaning baths between uses are readily available for staff use.
  • Make available antibacterial hand disinfectant at the entrance from Quantock Ward to the Central Delivery Suite.
  • Consider how they are to progress towards meeting the Royal College of Obstetricians and Gynaecologists guidance for dedicated consultant hours on the delivery suite
  • Consider auditing the completion and submission of HSA4 forms in accordance with the legal requirements for termination of pregnancies.
  • Ensure sufficient staff within the recovery area in the maternity theatre department to meet the Association of Anaesthetists of Great Britain and Ireland guidance which states that no fewer than two staff (of whom at least one must be a registered practitioner) should be present when there is a patient in the post anaesthetic recovery area who does not fulfil the requirement for discharge to the ward.
  • Ensure that risk registers include risks associated with care for end of life.
  • Ensure that care plans for end of life care and associated supporting documentation including resuscitation information demonstrate complete and consistent recording to provide staff with full detail regarding the patients’ assessed care needs.
  • Ensure that patient records for patients at end of life care demonstrate complete and consistent recording including the relevant consent and decision making assessment requirements for specific decision making in relation to the Mental Capacity Act 2005 and resuscitation decisions.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 6 April 2016

Effective

Requires improvement

Updated 6 April 2016

Caring

Good

Updated 11 February 2015

Responsive

Requires improvement

Updated 6 April 2016

Well-led

Requires improvement

Updated 6 April 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 6 April 2016

This follow up inspection reviewed only the safety and responsiveness domains. Both were judged to be good because:

  • There was a positive culture around incident reporting and staff were encouraged to report concerns. Learning from incidents was shared with staff on a daily basis. Practice development midwives ensured learning points were embedded in the formal education programme and changes to practice were fed into the ongoing audit program.

  • The maternity unit appeared clean and hygienic, benefitting from a dedicated domestic team.

  • Systems were in place to identify vulnerable women or children. Staff were confident in using the referral system and felt supported by the specialist safeguarding midwives.

  • Staff reported access to mandatory training was good. Practice development midwives monitored attendance at and organised training sessions.

  • There were numerous systems in place to assess risk to both women and babies enabling staff to respond quickly and effectively when conditions changed.

  • Midwifery staffing levels had increased since our last visit meaning women and babies were being looked after in a safer environment. Recruitment was ongoing to ensure improved levels were maintained.

  • There was 74 hours of dedicated consultant cover on the central delivery suite each week. This was below the Royal College of Obstetricians and Gynaecologists’ Safer Childbirth recommendations but was kept under regular review as the issue was on the risk register.

  • Checks on adult and baby emergency resuscitation equipment were inconsistent. With some confusion amongst staff about what needed to be checked and when. This was pointed out to staff at the time and daily and monthly check sheets were immediately created.

  • Routine antenatal care was generally carried out in community settings near to where people lived. A range of specialist and multidisciplinary ante natal clinics were held at Southmead Hospital and in specific community settings to ensure women got the specialist care, advice and support needed.

  • During our last inspection we found that fathers had limited opportunity to stay with their partners overnight. At this inspection we were told funding had been secured for 14 reclining chairs. They had been ordered but were yet to arrive.

  • Elective caesarean section lists had been increased from three funded sessions per week to five funded sessions per week. This had improved the flow of women through the service.

  • The early pregnancy assessment centre took into account women’s preferences. When attending, women often experienced long waiting times. They were asked if they wanted an appointment system introduced. Feedback identified women preferred to wait and be seen on the same day even if it meant a long wait.

  • Routine dating and growth ultrasound scans took place at Southmead Hospital. Scanning at Cossham Birthing centre and other community settings was being considered to relieve pressure of the main unit.

  • Bed occupancy for maternity services (excluding Central Delivery Suite) was 83.3% in the first quarter of 2015. This continued to be significantly higher than the England average for maternity services.

  • Staff completed incident reports if there were delays in transfer to or from the Central Delivery Suite (CDS) because there were no postnatal beds available once a woman had given birth. This also meant that at times, women remained on CDS longer than needed because of the lack of available postnatal beds.

  • ‘Flow midwives’ had been introduced, on a six month pilot. Their role was to have an overarching approach to patient flow issues and deal with the associated problems thus freeing up midwives on duty to continue with direct patient care. Staff told us they had found improvements in flow since their introduction.

  • There was access to translation and interpretation services. Information leaflets were available in the unit and on the trust website in a number of languages and could be produced in alternative formats if required.

  • Complaints were dealt with in line with trust policy. Women were often invited to the unit to discuss their concerns or outcomes of complaint investigations. Staff said changes in practice required as a result of complaint were communicated to staff via emails, newsletters and/or safety briefings.

Medical care (including older people’s care)

Requires improvement

Updated 6 April 2016

We have judged the medical care services overall as requiring improvement, although there were some areas of good practice and one of outstanding practice since the last inspection.

  • Patient safety required improvement overall but some areas were good.

  • There were inconsistencies in the systems for checking resuscitation trolleys to ensure equipment was fit-for-purpose.

  • The storage of medicines had improved.Medicines were stored in secure cupboards in all areas and were well managed.However, records of medicines administration were not always accurately maintained.

  • The completion of records did not consistently reflect the care needs of patients. Recording of assessments on some wards was not consistent and we were unable to see that assessments for some patients had been done in a timely manner.

  • The tracking system for patients requiring medical examination had improved and this meant that medical staff could assess and prioritise patients effectively.

  • Since our inspection in November 2014 there had been a review of staffing, skill mix and acuity of patients. There were safer nursing staff levels in the medicine directorate. Although some of the mandatory training compliance was below trust targets.

  • Effectiveness of medicine services required improvement to demonstrate patient care was delivered in accordance with best practice.

  • Participation in national audits had improved and the directorate had carried out a more comprehensive range of local audits to monitor performance.Continued pace was required and managers were keen to develop further action plans for national and local audit to demonstrate the effectiveness of care with actions taken and lessons learned to improve care.

  • Patients were well supported with nutrition, hydration and pain.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment through training.However, completion of appraisals was below trust target and required improvement.

  • The responsiveness of medical services required improvement, although some aspects were good and one was outstanding.

  • There had been improvements to patient flow; however, patient flow remained a challenge in the directorate with medically fit patients across the directorate awaiting social care packages to support their discharge from hospital.

  • The trust was participating in the ‘Enhanced Care Project’ to improve the way enhanced care was given to patients and had implemented certain aspects of the project in advance of the completion date as there had been overwhelming evidence of its efficacy.

  • There was an outstanding example of responsiveness with the work of the dementia care team and the availability of 100 dementia champions in the trust including the Head of Facilities who was focussing on environmental changes.

  • We have judged the leadership of the service as good with some areas requiring improvement.

  • The directorate was facing a period of consolidation following the move to the new building in 2014. Governance structures were embedding and managers were focussed on ensuring that audits, incidents, complaints and other key information were used to demonstrate learning, change and improvement.

  • Good local leadership was provided throughout the directorate and frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

  • Most staff were positive about working for the trust and showed commitment to their patients, their responsibilities and to one another.There was a strong camaraderie within teams with flexibility provided where possible.

  • Innovative practice across the directorate still required development.There had been an improvement since our previous inspection with a programme of local audit and an innovation programme had been introduced to improve the way enhanced care was given to patients.

Urgent and emergency services (A&E)

Good

Updated 6 April 2016

Overall we rated the emergency department as good because:

  • There had been significant improvements in safety and effectiveness since our last comprehensive inspection in November 2014. There had also been improvements in patient access and flow.

  • Openness and transparency about safety was encouraged. Adverse impacts on patients following safety incidents had reduced significantly in the last year and patient safety remained a priority.

  • Risks to people who used the department were assessed, monitored and managed on a day-to-day basis.

  • Initial clinical assessment of patients took take place in a timely fashion. However, the lack of a rapid assessment and treatment system meant that there were often delays in seeing a doctor for patient arriving by ambulance.

  • Nurse staffing levels had been increased and all staff had high levels of skills and experience

  • Care and treatment followed national guidance and best practice evidence from professional bodies such as the Royal College of Emergency Medicine, the National Institute for Health and Care Excellence (NICE) and the Resuscitation Council UK. However, there was a lack of awareness of national standards for the treatment of broken hips.

  • Results of national audits showed that patient outcomes were similar to, or better than most hospitals England. Audit results from the national trauma and research network showed that survival rates following major trauma were the best in England and Wales.

  • Changes had been made to working practices in order to reduce delays but the department was not consistently meeting the 95% standard to admit or discharge patients within four hours. There had been a noticeable decline since September 2015 and by November 2015 the standard was only being met for 82% of patients.

  • Delays for patients who needed admission to a ward were a particular concern. During October and November 2015 19% of patients waited between four and twelve hours to be admitted.

  • The total time patients spent in the department compared badly to other hospitals. In September and October the average (median time) that all patients spent in the department was three hours. The England average was two hours.

  • The needs of people with complex needs were well understood and addressed appropriately. People with dementia received care and treatment that was sympathetic and knowledgeable.

  • There was strong leadership in the emergency department which had resulted in improvements in quality and had led to improving staff morale. Governance and performance were proactively reviewed and reflected best practice. Lessons learned and changes in practice were communicated to staff via monthly governance meetings and newsletters.

Surgery

Requires improvement

Updated 6 April 2016

We rated surgery as requires improvement because:

  • Patient records were not being stored securely on the wards and in theatres, so there was a risk of access by unauthorized people.
  • Not all staff in theatres was reporting incidents; for example, staffing shortages, because they felt there was no improvement or response from their managers.
  • National guidelines were not followed in theatres for infection control procedures and the cleanliness of some equipment.
  • Evidence did not demonstrate that essential daily safety checks on equipment in the theatre department had consistently taken place.
  • There was a high turnover of staff in the theatre department and the sickness rate was higher than the trust’s target. The theatre department had recruited a large number of predominantly Band 5 (junior) staff but they required training to obtain the skills and knowledge to meet the clinical standards and needs of this department. Some surgical wards were also experiencing higher levels of sickness and staff vacancies. The trust was working to address this shortfall.
  • The hospital had a mixed performance in a number of national audits, including the Patient Reported Outcome Measures (PROMs) for April 2014 to March 2015, which is based on patients reporting to the hospital on their outcome following surgery for groin hernias, hip replacements, knee replacements, and varicose veins. The trust also had mixed performance in a national hip fracture audit.
  • Patients relative risk of readmission rates after surgery (due to corrective measures being needed or infections) were variable between elective (planned) and emergency surgery. From June 2014 to May 2015 (in relation to how many procedures were performed) this was worse than the England average. The average length of stay for surgical patients within the hospital was also worse than the England average. It is recognised as sub-optimal for patients to remain in hospital for longer than necessary and a barrier to other patients being admitted.
  • Access to surgical services for patients required improvement. The trust-wide Admitted Adjusted Referral to Treatment (NHS England consultant-led referral to treatment time standards of within 18 weeks) performance was worse than England average between September 2014 and August 2015. The number of operations cancelled as a percentage of elective operations was higher (worse than) the England average between April 2013 and April 2015.
  • Due to pressure for their beds and the demand for their services, the trust had to use the interventional radiology day unit to house patients overnight. There were limited facilities for patients, including toilets, and there was only one shower that was away from the unit, and this was a staff shower. This meant staff had to escort patients to the shower and were away from the unit. This put pressure on the unit when fitting in their planned patients for procedures.
  • From September 2014 to October 2015, the surgery directorate had the most complaints in the trust. Which they felt was due to cancelled operations.
  • Theatre staff felt the leadership in theatres was not good, they felt unsupported by them and they were not visible.
  • However:
  • At the last inspection, issues were identified with the Sterile Services Department (SSD). At this inspection, we heard from theatre staff and surgeons about the significant improvements made resulting in less anxiety and complaints from staff and fewer operations being cancelled due to issues in the sterile equipment trays.
  • The pre-admission clinic had a pharmacist in attendance to review patients’ medications, write up their medication for admissions and liaise with their GP if required. This was to reduce the number of cancelled operations due to medication issues with patients. This was outstanding practice.
  • All staff were’ bare below the elbow’ and this was also an improvement since the last inspection.

Intensive/critical care

Good

Updated 6 April 2016

We have judged the critical care unit to be good for safety, and as requiring improvement for responsiveness. Because this inspection was focused on the areas that required improvement following our inspection in November 2014, we did not inspect against the caring, effective and well-led domains. The overall rating for the service is good because:

  • The most pressing issue for the safety of the unit in November 2014 was the low numbers of nursing staffing, and the lack of skill and experience of the nursing staff group. During this inspection we found the unit had increased staffing numbers, improved its skill mix and supported staff development in achieving a post-registration qualification in critical care. Although there were still some gaps in staffing, for example supernumerary cover, detailed recruitment plans had been agreed and a full establishment of staff was expected to be in place by the end of March 2016.
  • The critical care unit was designed to accommodate patients in single rooms, called ‘cubicles’. Our November 2014 inspection reported challenges with this design because patients were not visible at all times. A new standard operating procedure had been introduced to help staff adapt their practice. This had helped to improve observations of patients most of the time, but a challenge remained at times; for example, when staff were taking rest breaks.
  • Incident reporting, learning and improvements to practice following incidents had improved, with daily safety conversations being introduced.
  • There was an improving picture in relation to the incidence of patient harm. In November 2014 we found an unusually high incidence of falls, pressure ulcers and patients removing their own medical devices. The unit had responded to this with increased staffing and education, and a reduction of 50% was expected to be achieved by the end of the year. However, the majority of the mandatory training topics, including falls training, were below the trust’s target for 85% of staff to have completed their training.
  • Our previous inspection in November 2014 found the responsiveness of the unit required improvement. This was because the poor flow of patients through the hospital affecting the ability of critical care to respond effectively. During this inspection we found there were still a very high number of delayed discharges, despite the unit working hard to identify patients who could be discharged in the early morning. Bed occupancy also remained high, affecting access for patients requiring intensive care.
  • The length of stay for patients remained much higher than the NHS national average and was not optimal for patient social and psychological wellbeing.
  • There was no critical care outreach team (a recommendation of the Core Standards for Intensive Care Units (2013)) to provide a response to deteriorating patients elsewhere in the hospital, or to follow-up patients who had been discharged from the critical care unit.

Services for children & young people

Good

Updated 11 February 2015

Neonatal services at Southmead Hospital were rated as good across all five areas. Staff were caring and compassionate and worked in partnership with parents to provide family-centred care. Care was evidence-based and in line with national good practice. Systems were in place for incident reporting and investigation. Incidents were reported and investigated. Where lessons had been learnt, these were fed back to staff. The unit was clean, there had been no recent issues of cross infection and the staff had achieved 100% in the hand hygiene audits. Medicines were stored appropriately. A double-checking system had been introduced to reduce the number of medication errors. Medication errors had reduced as a result. The NICU had robust safeguarding processes in place and a clear process of referral for staff when concerns were identified. Nurse staffing was funded to establishment, but did not meet the standards set by the British Association of Perinatal Medicine. The parents were extremely complimentary about the staff and the care their babies received. No complaints had been received since before September 2013, but a complaint management system was in place. The NICU had good governance arrangements in place. Staff were aware of these arrangements and how these linked to wider trust committees. The unit was well led by its ward sisters and head of nursing.

End of life care

Requires improvement

Updated 6 April 2016

We rated end of life care as requires improvement because:

  • Some incidents were not reported at the time they occurred and there were issues in end of life care that were not being formally monitored. For example, incidents relating to the adherence to the policy on the management of a deceased adult patient or last offices policy by ward staff. Mortuary staff who dealt with the incident did not always report incidents. The number of incidents that occurred when bereaved relatives tried to pick up death certificates were not being monitored.
  • The risks associated with anticipated events and emergency situations were not fully recognised, assessed or managed for end of life care. All relevant parties were not fully aware of their role in a major incident and the response plans had not been tested and reviewed regularly with all relevant staff. For example mortuary and specialist palliative care team staff had not been involved in major incident exercises.
  • Patients identified as being at the end of their life or receiving end of life care were sometimes at risk of not receiving all relevant care or treatment. This was because care assessments did not always record the full range of patient’s needs.
  • Patients end of life care and treatment was planned and most was delivered in line with current evidence-based guidance, standards, best practice and legislation. However, staff completing the do not attempt resuscitation documentation were not recording in line with the Mental Capacity Act 2005 code of Practice. The spiritual and emotional aspects of care were sometimes overlooked in assessments.
  • Seven day services were not available for face to face end of life care from the specialist palliative care team. We saw evidence that patients received care from a range of different staff, teams or services, which was coordinated.
  • The arrangements for governance and performance management of all end of life care in the trust did not always operate effectively. There was not a risk register in place for end of life care. There were risks identified during our inspection, which were known about. We did not see these recorded on a local or trust wide corporate risk register.

However:

  • Patients receiving end of life care and those close to them were treated with dignity and respect and were involved in their care. Feedback from patients and those close to them was positive about the way staff supported and cared for them. We saw patients were treated with dignity, respect and kindness during interactions with staff.
  • Patients had assessments which included consideration of clinical needs, health, physical health nutrition and hydration needs.
  • Pain was managed well as was nutrition and hydration.
  • End of life care took account of the local population when planning services.
  • Reasonable adjustments were made and action was taken to remove barriers when patients found it hard to use or access services. There was openness and transparency in how complaints were dealt with. Complaints and concerns were taken seriously, responded to in a timely way and listened to.
  • Access to care was managed to take account of patient’s needs, including those with urgent needs. Discharge from hospital and to patients preferred place of care was achieved in many cases. The specialist palliative care team had worked to ensure they and others in the trust had access to information needed to support patients who received end of life care.
  • The trust supported the director of nursing and the specialist palliative care team to promote high quality person-centred end of life care. The specialist palliative care team had a clear statement of vision and values and end of life care was driven by the desire for quality and safety this included plans for a seven day service. The strategy was credible and strategic objectives had been identified recently as part of commissioning for quality and innovation and were supported by quantifiable and measurable outcomes. Despite the recent work of the specialist palliative care team and the director of nursing the strategy and vision for good end of life care had not yet been fully implemented throughout the trust.
  • Staff in the specialist palliative care team we spoke with felt they were respected, valued and supported. Staff we spoke with valued the specialist palliative care team.

Outpatients

Requires improvement

Updated 6 April 2016

We judged the safety and responsiveness of the outpatients and diagnostic imaging service as requires improvement because:

  • There were areas in outpatients where patients’ medical notes were left unattended and records were stored insecurely.
  • There were a high number (between 10 and 20%) of patient notes ‘missing’ in outpatient clinics. This posed a risk to patient safety. No data was collected on the number of patient appointments which were cancelled as a result.
  • Patients did not always receive timely access to treatment. The trust were found to be breaching the standards for referral to treatment pathways

However,

  • . We found there were systems in place for all reported incidents to be investigated, staff were clear on the process for reporting and felt able to report appropriately.
  • The cleaning of the outpatient and diagnostic areas was of a high standard, staff reported a responsive cleaning team to the needs of the services they provided.
  • There were processes in place to assess and respond to patients risk and staff were trained to recognise and act upon abuse or suspicions of abuse in vulnerable people.
  • We found the outpatient services and opening times were flexible to meet the needs of the general population.
  • The staff were very knowledgeable in responding to the needs of patients living with dementia in the outpatient setting, enabling them time to adjust to a different environment and ensuring the patients received a tailored service.