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Inspection Summary


Overall summary & rating

Good

Updated 25 September 2019

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

  • We saw improvements to ratings in emergency services with caring and well led ratings increasing to outstanding. In medical care, safe, effective, responsive and well led all improved to good. In surgery, safe, responsive and well led improved to good ratings, with a good rating overall. In end of life care, safe and effective improved to good, with caring and well led rated as outstanding, with an outstanding rating overall.
  • There were systems and processes to keep patients safe and safeguarded from abuse. There was a proactive approach to safeguarding and prevention of harm. Staff had mostly received up-to-date training. Staffing levels were planned and with staff with the right skills to keep patients safe. Medicines were used and provided safely. Services were well managed. Lessons were learned when things went wrong, and staff were confident about reporting incidents.
  • Care was delivered in line with national guidance and legislation and there was a strong emphasis on putting the patient first. There were good assessments of patients’ needs, including pain relief, hydration and nutrition. Staff were supported to develop their skills and their performance regularly reviewed.
  • Patients and relatives spoke highly of staff and the standards and quality of care. Feedback was positive, and patients we met said they had been treated with dignity and respect. Patients could make their own decisions, and the right people were involved if a patient was not able to do so. Patients’ emotional needs were recognised and supported.
  • Services were planned and arranged to meet the general and specific needs of local people. The needs and preferences of different people were accounted for to give patients the best outcomes. Patient views were actively sought and incorporated into plans.

  • The staff leadership had the skills, knowledge, experience to oversee services. High-quality and patient-centred care was promoted. There was a clear set of values for staff which were patient centred. Staff were well supported and there was good morale and a strong culture. Staff were willing to challenge poor practice and support each other.
  • There was a strong culture around innovation, research, development and improvement. Staff had good systems to assure themselves they were providing a good, safe and quality service.

However,

  • Some staff had yet to update their mandatory training in line with trust targets and not all relevant staff had completed level 3 safeguarding training. Not all areas were compliant with staff appraisals.
  • Not all resuscitation equipment was checked, or had been documented as checked and in some areas, equipment was not ready for use.
  • There were some areas where infection prevention and control practices were not in line with best practice and some areas where medicines were not being stored correctly.

  • Not all patient information was being stored safely in some areas, and there was more to do with recording do not resuscitate decisions and mental capacity act and deprivation of liberty assessments.
  • People could not always access services when they needed them and did not always receive the right care promptly. Waiting times were not in line with national standards and the trust was failing to meet a number of performance targets.
  • Environments in maternity, the mortuary and the emergency department were not always suitable for the services being delivered.
  • Services did not have consistent 24-hour access to mental health liaison and specialist mental health support if they were concerned about a patient’s mental health.
Inspection areas

Safe

Good

Updated 25 September 2019

Effective

Good

Updated 25 September 2019

Caring

Outstanding

Updated 25 September 2019

Responsive

Requires improvement

Updated 25 September 2019

Well-led

Outstanding

Updated 25 September 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 25 September 2019

Our rating of this service improved. We rated it as good because:

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. There was regular attention to staffing and innovative ways to focus on recruitment and retention. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients and therapy input was embedded within teams. Staff advised patients on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week. The understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards had improved since our last inspection.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service had made significant improvements since our last inspection to create clear processes to manage patient flow. The hospital was working within the wider system to support discharge. The service was inclusive and took account of patients’ individual needs and preferences, and treated concerns and complaints seriously to investigate and share learning.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care and there was an evident multi-professional and collaborative culture within the division. There were effective governance processes and management of performance and risk, with further governance improvements planned. Staff were committed to learning and improving services.

However:

  • There were a few areas where safety could be improved to be brought in line with best practice. Medicines were not always in date within medicine trolleys or opening dates were not always recorded on liquid medicines to ensure they were discarded when required.

  • The effectiveness of the service had some areas to be improved. There were inconsistencies with the recording of mental capacity assessments when making resuscitation decisions, appraisal rates were not meeting trust targets and patient fluid charts were not always completed in full.
  • Some improvements were needed in how staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Corridor areas did not help promote patient privacy and dignity.
  • Responsiveness was rated as requires improvement. The service was restricted by the challenges faced with capacity and flow, and the increase in demand outweighing capacity. Escalation areas were being used frequently, and some areas, for example interventional radiology, were still not a suitable environment for inpatients. Patients were being moved between wards or beds at night, and delayed transfers of care were not meeting commissioned targets.
  • The leadership team were stretched across all specialties within the medicine division, which compromised the time they had to support individual specialties. However, there were plans to revise the structure and improve support. Staff also told us they did not always feel confident to raise concerns with the division’s Freedom to Speak Up Guardian as they were in a more senior position.

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.

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.

End of life care

Outstanding

Updated 25 September 2019

Our rating of this service improved. We rated it as outstanding because:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, and supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. In all areas of end of life care we visited, we saw that staff were truly person centred. As much emphasis was placed in the caring for and about those close to patients as patients themselves.
  • People’s individual needs and preferences were central to the delivery of tailored services providing end of life care. The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it. There was a clear drive to increase the presence of the palliative care team at the trust, and clear actions were planned to achieve this.
  • Leaders had a deep understanding of issues, challenges and priorities in their service, and beyond. They ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. All staff we met were clearly inspired and motivated by the clinical lead for end of life care, and this translated into the delivery of high-quality end of life care. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The environment in the mortuary – specifically around storage fridges - did not meet the needs of the service and presented risk to the identification of some types of the deceased.
  • The documentation of capacity as part of the “Do not attempt cardio-pulmonary resuscitation” was not clearly recorded.

Outpatients and diagnostic imaging

Good

Updated 8 March 2018

We rated this service as good because:

  • There were processes to keep patients safe, which were backed up by comprehensive training. This included comprehensive infection control processes and checks, safeguarding processes, and the management of patient risks.

  • There were sufficient staff to ensure outpatients ran safely.

  • During this inspection we found 9% of patients were seen in outpatients without their full records being available. However, this was an improvement from the last inspection. There was a digital plan to reduce the reliance on paper records which was ongoing during the inspection.

  • Patients were receiving care in line with evidence based practice and guidance.

  • Feedback from people who used outpatients, and those who were close to them, was continually positive about the way staff treated people.

  • Services provided by the outpatient clinics reflected the needs of the local population. Staff were finding different and innovative ways to manage patient care to improve the efficiency of clinics.

  • The service was able to identify and meet the information and communication needs of people living with a disability or people with mental ill health. This included the management of dementia, learning disabilities and patients with self-harming or suicidal thoughts.

  • People could access the service when they needed it. Most patients were able to access the service in a timely way, with most specialties in line or close to the national averages for waiting times.

  • Leaders within outpatients had the skills, knowledge, experience, integrity and enthusiasm to lead effectively. Governance processes were innovative, and focused on improving safety, quality, and patient experience specifically for outpatients. The transformation plans for outpatients had a clear vision for the service.

However:

  • Not all staff were trained in meeting the needs of patients living with dementia.

Surgery

Good

Updated 25 September 2019

Our rating of this service improved. We rated it as good because:

We rated safe as requires improvement. We rated effective, caring responsive and well-led as good. Overall, we rated the service as good.

  • Most staff received updated mandatory training. They were clear about the processes they should follow to risk assess patients and respond to those who may deteriorate. Managers regularly reviewed and adjusted staffing levels and skill mix to ensure patients received safe care. Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, and available to staff providing care. The service used systems and processes to safely prescribe and administer medicines. The service managed patient safety incidents well and staff were clear on how to report incidents.
  • There was effective care within surgical services. Staff used monitoring results well to improve safety. The service provided care and treatment based on national guidance and evidence-based practice. Staff monitored the effectiveness of care and treatment, using the findings to make improvements and achieve good outcome for patients. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients.
  • Care provided to patients was compassionate. Staff supported patients to make informed decisions about their care and treatment.
  • The service met the needs of individuals. Care was planned to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. Most patients could access the service when they needed it.
  • Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Staff felt respected, supported and valued. Leaders operated effective governance processes and managed risk, issues and performance well. Leaders and staff actively engaged with patients, staff, the public and local organisations to manage services. All staff were committed to continually learning and improving services.

However:

  • Some areas within safety needed to be improved. There was an unacceptable standard of infection control in theatres. Not all staff in medirooms had immediate life support training as part of their mandatory training. Some mandatory training modules were not meeting trust targets. Medicines were not always recorded and stored safely.
  • Although effective, caring, responsive and well led were rated as good, there were aspects of the service where improvements could be made. The trust’s appraisal target was not met by all staffing groups. Although the service had made improvements in its handling of complaints, complaints were frequently not responded to in good time. Awareness of the freedom to speak-up guardians was limited across the service. Although there had been improvements, interventional radiology remained unsuitable for surgical patients to stay overnight. 

Urgent and emergency services

Good

Updated 25 September 2019

Our rating of this service stayed the same. We rated it as good because:

  • We rated the safe and effective key questions as good and the caring and well-led key questions as outstanding. We rated the responsive key question as requires improvement.

  • Staff assessed patients promptly on their arrival in the emergency department to ensure those with serious or life-threatening illness or injury were prioritised. Staff identified and quickly acted upon patients at risk of deterioration and staff were alert to those conditions where time-critical investigations were necessary. There were robust systems to ensure oversight of patient safety when the emergency department was crowded.

  • The emergency department was well laid out, well maintained, well equipped and clean. Patients’ records were clear, up-to-date, stored securely and easily accessible to staff. Staff followed best practice when prescribing, giving, recording and storing medicines and complied with good hand hygiene practice. Staff had training on how to recognise and report abuse, and they knew how to apply it.

  • The emergency department had enough staff with the right qualifications, skills, training and experience to care for patients and keep them safe. Staff were expected, encouraged and supported to develop new skills.

  • The service had a good track record on safety, monitored safety performance and managed incidents well. There were well-embedded risk management processes to ensure that incidents, including deaths and unexpected outcomes, were reviewed and learning shared.

  • The service provided care and treatment based on national guidance and best practice. Regular audit provided assurance that staff followed guidance. Patient outcomes were generally in line with other similar services and results were used to drive improvement.
  • Staff regularly checked patients’ comfort and ensured they were given adequate pain relief, food and drink. They supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.
  • Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care. Most key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers. Feedback from patients and those close to them was consistently positive. We saw and heard about numerous examples of care where staff had ‘gone the extra mile’. This included many examples where staff had undertaken fund-raising events in their own time to provide things that would make a difference to patients’ experience.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. The service provided excellent support to patients with complex needs and those in vulnerable circumstances. Staff champions had developed resources to support patients with dementia and those with learning difficulties. Premises in the emergency department had been adapted to meet the needs of people living with dementia.

  • Managers had the right skills and abilities to run a service providing high quality and sustainable care. They were highly respected by the workforce as inspiring leaders and role models. They promoted a positive culture. Staff felt supported and valued; they had a positive and optimistic attitude and spoke about their department and their colleagues with pride and passion. There was a strong emphasis on staff wellbeing and there were numerous examples of initiatives designed to support staff.

  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services. There was a vision statement, supported by a series of objectives and workstreams to achieve these objectives and staff were engaged in numerous projects to realise the vision and objectives.

  • The service used a systematic approach to continually improve the quality of its services and safeguard high standards of care. There were well-embedded and effective governance and risk management systems, supported by effective data collection systems and information streams. Quality and improvement were everybody’s business and staff in the emergency department were proud of their achievements and of a proactive culture, which encouraged and supported learning and innovative practice. There were many examples of recent and current research and quality improvement projects, some of which had been locally and nationally recognised.

However:

  • People could not always access the service when they needed it and did not always receive the right care promptly. Waiting times were not in line with national standards. The trust was consistently failing to meet national standards in relation to the time patients spent in the emergency department, the time they waited for their treatment to begin and the time they waited for transfer to an inpatient bed.

  • Facilities and premises in the emergency department were not wholly appropriate for the services being delivered. Demand for services frequently outstripped the availability of appropriate clinical spaces to assess and treat patients. This meant the emergency department frequently became crowded and patients had to be accommodated in the corridor. There were inadequate bathroom facilities in the emergency department observation unit.
  • The service did not have consistent 24-hour access to mental health liaison and specialist mental health support if they were concerned about a patient’s mental health.
  • Daily checks of specialist equipment in the emergency department did not take place consistently.
  • Medical staff reported good working relationships with some specialties, but others were not considered to be responsive when patients in the emergency department required specialist review. There were internal professional standards to ensure swift review of specialty patients in the emergency department, but compliance was not routinely monitored.
  • Training data provided in respect of intermediate and advanced life support training was incomplete and some staff were overdue for refresher training.
  • The service did not comply with recent guidance regarding advanced training to safeguard adults.
  • There was limited understanding and application of the policy which requires services to meet the communication and information needs of patients with a disability or sensory loss or patients whose first language was not English.

Maternity

Good

Updated 25 September 2019

We rated it as good because:

We rated safe as requires improvement. We rated effective, caring, responsive and well-led as good. Overall, we rated the service as good.

The service managed patient safety incidents well and monitored safety performance. The service had enough medical, nursing and midwifery staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect women from abuse and the service worked well with other agencies to do so. Staff were trained to use facilities, premises and equipment. Staff kept records of women’s care and treatment. Staff completed and updated risk assessments for each woman and quickly acted upon women at risk of deterioration.

Staff provided care and treatment based on national guidance and evidence-based practice. Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. Staff monitored the effectiveness of care and treatment. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.

Staff treated patients with compassion and kindness and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their condition.

The service planned and provided care in a way that met the needs of local people and worked with others in the wider system to plan care. People could access the service when they needed it. Staff took account of patients’ individual needs and preferences and coordinated care with other services and providers.

Leaders understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service. They supported staff to take on more senior roles. There was a business plan to turn the strategy into action, developed with relevant stakeholders. Leaders collaborated with partner organisations to help improve services for patients. Staff felt respected, supported and valued and were focused on the needs of patients receiving care.

Senior leaders operated effective governance processes throughout the service. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

However;

We rated safe as requires improvement because we were not assured that the care provided was always as safe as it could be. The service did not follow procedures to ensure cleanliness as a measure of infection prevention and control. The entrance to the maternity unit did not provide adequate security and not all patient information was safely secured. The systems and processes to safely prescribe, administer, record and store and dispose of medicines were not always followed.

Although effective, responsive, caring and well led were rated as good, there were aspects of the service where improvement should be made. Managers were not completing staff appraisals in a timely way. Not all key services were available seven days a week to support timely patient care. Staff did not always do everything possible to respect women’s’ privacy and dignity. It was not easy for women to raise concerns about care received because complaints procedures were not displayed. There were gaps in assurance processes at ward level. Not all risks were identified, and prompt actions were not always taken to reduce known risks.