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Southmead Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 8 March 2018

Our rating of services stayed the same. We rated it them as requires improvement because:

  • We rated urgent and emergency services as good overall. This rating stayed the same. The overall rating took into account the previous good ratings in the effective, caring and well led domains. The safe domain was rated good because there were effective systems in place to assess and manage risks to patients. There were clear streaming and triage arrangements in place which identified and prioritised patients with serious or life-threatening conditions. A safety checklist provided a structured series of prompts for staff to ensure that all necessary steps were taken to ensure the safe care of patients, from arrival to discharge. There were clear pathways for addressing the particular risks associated with the care and treatment and referral of, for example, children, frail elderly or patients with sepsis, stroke or mental health conditions.

  • We rated medical care as requires improvement overall. This rating stayed the same. This was because the environments for patients were not always safe, especially during times of escalation when patients were accommodated in inappropriate areas on wards and in the interventional radiology department. Staffing levels and skill mix did not always meet patients’ needs. Staff understanding of Deprivation of Liberty Safeguards varied across the trust. We rated the responsive domain as inadequate. Flow within the hospital was poor due to insufficient medical beds. The hospital did not always ensure that appropriate patients were in escalation wards which meant some areas had unsuitable patients accommodated within them. Following our inspection the trust had updated the standard operating procedure to address concerns about the safety of placing patients in escalation areas.

  • We rated surgery as requires improvement overall. This rating stayed the same. This was because mandatory training rates did not meet trust targets. Infection control processes were not always followed. Care records were not always managed safely. Some people were not able to access the right care at the right time.

  • End of life care was rated requires improvement overall. This rating stayed the same. This was because incidents which related specifically to end of life care were not recorded consistently. Mental capacity of patients was not clearly recorded in their notes when it was assessed.

  • We rated outpatient services as good overall. This rating had improved since our last inspection. This was because there were processes to keep patients safe, which were supported by comprehensive staff training. There were sufficient staff to ensure outpatient clinics ran safely. Services provided by the outpatient clinics reflected the needs of the local population. 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.

Inspection areas

Safe

Requires improvement

Updated 8 March 2018

Effective

Requires improvement

Updated 8 March 2018

Caring

Good

Updated 8 March 2018

Responsive

Requires improvement

Updated 8 March 2018

Well-led

Good

Updated 8 March 2018

Checks on specific services

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.

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.

Urgent and emergency services

Good

Updated 8 March 2018

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

  • There were effective systems in place to assess and manage risks to patients. Ambulance handover operated efficiently; most of the time ambulance-borne patients were handed over promptly to emergency department staff. There were clear streaming and triage arrangements in place which identified and prioritised patients with serious or life- threatening conditions. A safety checklist provided a structured series of prompts for staff to ensure that all necessary steps were taken to ensure the safe care of patients, from arrival to discharge. This included prompts to undertake time-critical investigations and treatments. There were clear pathways for addressing the particular risks associated with the care and treatment and referral of, for example, children, frail elderly or patients with sepsis, stroke or mental health conditions. Regular audit of safety checklist completion provided assurance that staff provided appropriate care and treatment, which kept people safe from avoidable harm.

  • There were clear processes to maintain oversight of activity and acuity in the department and to escalate when there was a surge in demand and the emergency department became crowded.

  • The trust had taken steps to improve patient flow within the department and reduce crowding. This included streaming suitable (ambulatory or ‘fit to sit’) patients to the observation unit to await treatment.

  • The service had suitable premises, which were appropriately designed to provide easy access, circulation and observation of patients. Premises included separate and secure children’s waiting and treatment areas and a dedicated assessment room for patients with mental health problems, which complied with recognised safety standards.

  • Staff were trained in, and complied with safe systems in relation to infection prevention and control, management of medicines and safeguarding vulnerable adults and children. Staff checked emergency equipment regularly and maintained records of these checks.

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. We saw evidence of information sharing, focussed training and review of processes, following serious incidents. There was a culture of openness and transparency. When things went wrong, staff apologised and gave patients honest information and suitable support.

  • The service took account of patients’ individual needs, including patients in vulnerable circumstances or those with complex needs. The emergency department had undertaken some outstanding work to support frail elderly patients, including those living with dementia. In addition to completing mandatory dementia awareness training, 32 staff, including medical, nursing, porters and auxiliary staff, had completed training to become ‘dementia champions’. They supported their colleagues to use a range of dementia resources available in the emergency department to calm and distract agitated patients.

However:

  • The trust was not meeting national standards and was consistently below the England average in relation to standards which measure:

  • The time that ambulance-borne patients wait for initial assessment or triage. This should be within 15 minutes.

  • The time that patients spend in the emergency department. The national standard requires that patients are admitted, transferred or discharged within four hours.

  • The time that patients wait for their treatment to begin. This should be no more than one hour.

  • The time that patients wait in the emergency department from the decision to admit to the time they are admitted.

  • At times when there was a surge in demand, patients brought to the emergency department by ambulance waited too long to be handed over to emergency department staff.

  • The emergency department was frequently crowded. When demand outstripped the availability of clinical spaces, patients queued in the corridor, which was not a dignified experience.

  • Senior staff in the emergency department had concerns about the lack of visibility of, and timely support from the trust’s site management team in response to escalation when the department was crowded.

  • Patients with serious mental health problems, including children and adolescents, who attended the emergency department at night, experienced long waits for specialist assessment and support.

  • The emergency department observation unit, which accommodated up to 20 patients, had only one toilet and no bathroom facilities. This was not sufficient to meet the hygiene needs of these patients. We had raised this as a concern at previous inspections but no improvements had been made.

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 8 March 2018

Our overall rating of this service stayed the same. We rated it it as requires improvement because:

  • There were significant patient flow issues. At the time of the inspection, there were 121 patients unable to leave hospital due to the inability to access community services. This meant patients were at risk of developing complications and deteriorating.

  • Because of patient flow issues, there were not enough beds within the medical division to manage medical patients. At the time of our inspection, there were more than 60 medical patients admitted to surgical wards. This meant that planned surgical procedures were delayed or cancelled for some surgical patients.

  • The high occupancy levels and use of escalation beds and areas had become ‘acceptable’ ’. Leaders could not tell us about the medical division’s plan to cope with winter pressures. Staff did not report staff shortages as an incident unless there was a specific need to so.

  • The use of escalation beds and areas, including interventional radiology, did not provide for safe care and maintain privacy and dignity for patients. This was highlighted as an area for service improvement in the last inspection but sufficient changes had not been made to improve the way escalation beds were managed.

  • There had been a number of patient falls, some of which had caused serious harm to patients. The average falls between April to December 2017 per 1,000 occupied bed days was 6.5 falls. This was worse than the national average of 6.0 falls per 1,000 occupied bed days.

  • There was variable understanding of when to complete applications for Deprivation of Liberty Safeguards (DoLS). We observed a high number of DoLS applications for authorisation were submitted without sufficient scrutiny and assessment of patients’ mental capacity.

  • Equipment was not always checked and some medical devices had passed their service date.

  • Medical records were not always kept secure, which could compromise patient confidentiality.

However:

  • We saw outstanding examples of multidisciplinary teamwork on all the wards we visited.

  • Staff were attentive and provided compassionate care. Feedback from patients we spoke with was overwhelmingly positive.

  • Staff spoke of good teamwork and enjoyed their work. Managers and senior leaders were proud of the workforce.

Surgery

Requires improvement

Updated 8 March 2018

Our overall rating of this service stayed the same. We rated it it as requires improvement because:

  • Not all areas or staff groups had completed their mandatory training. Staff had not received specific training on the potential needs of people living with mental health conditions, learning disabilities or autism.

  • Some staff did not always follow the trust infection prevention and control’s guidelines.

  • Resuscitation equipment and fridge temperatures were not always checked in line with professional guidance

  • People’s individual care records were not always managed in a way that kept them safe. Staff did not always respect people's confidentiality and patient records were often left unsecured.

  • The trust reported three serious incidents classified as never events in Surgery and a further never event was reported during the inspection period, in November 2017. It was not always clear on the ward areas if learning from recent never events had been shared across all departments.

  • There were four separate cases of serious delays in patients receiving cancer treatment, three of them in Urology. Two further serious incidents in urology included failure to act on test results.

  • We discovered an incident when the duty of candour had not been applied when a patient had sustained harm in theatres.

  • During times of escalation and bed pressures staff were not always able to maintain their patient’s dignity and privacy. The facilities and premises were not always appropriate for surgical patients who accessed outlying beds due to escalation bed pressures.

  • Cancelled Operations as a percentage of elective admissions were consistently higher than the England average.

  • Staff satisfaction was mixed. Some staff groups did not always feel actively empowered to raise concerns.

  • Practices across the division were inconsistent as not all areas had good processes for providing staff at every level with the development they need, including high-quality appraisal and career development conversations.

However:

  • There was good overall knowledge and training around responding to and treating risk. There were effective handovers, safety briefings and shift changes to ensure that staff could manage risks to people who used the services.

  • Safeguarding adults, children and young people at risk was given sufficient priority.

  • People’s care and treatment was planned delivered and monitored in line with current evidence-based guidance, standards, best practice, legislation and technologies. People had comprehensive assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.

  • Expected outcomes were identified and care and treatment reviewed and updated. Appropriate referral pathways were in place to make sure patients’ needs were addressed. The service monitored the effectiveness of care and treatment and used the findings to improve. They compared local results with those of other services to learn from them.

  • Where people were subject to the Mental Health Act 1983 (MHA), their rights were protected and staff complied with the MHA Code of Practice. When people aged 16 and over lacked the mental capacity to make a decision, best interests decisions were made in accordance with legislation.

  • Staff were consistent and proactive in supporting people to live healthier lives. There was a focus on early identification and prevention and on supporting people to improve their health and wellbeing. People were enabled to manage their own health and care when they could, and to maintain independence.

  • People understood their condition and their care, treatment and advice. People and staff worked together to plan care and there was shared decision-making about care and treatment.

  • The number of patients whose operation was cancelled and were not treated within 28 days was consistently lower (better) than the England average.

  • The trust provided us with statistics, which demonstrated Dr Foster’s data on the trust’s length of stay. This compared the trust data to a peer group of hospitals and showed that that the trust was within the expected range for trauma and orthopaedics and performing better than the England average for other specialities.

  • People knew how to raise concerns or complaints about their experiences and could do so in a range of accessible ways. The service used the learning from complaints and concerns as an opportunity for improvement. Staff could give examples of how they incorporated learning into daily practice.

  • The leadership, governance and culture promoted the delivery of high-quality person-centred care. Leaders were visible and approachable. Staff were complimentary about their ward coordinators and ward managers.

  • Managers monitored performance and used the results to help improve care. All staff identified risks to good care and the service took action to eliminate or minimise risks.

  • There were effective selection, deployment and support processes in place along with succession planning.

  • The board and other levels of governance in the organisation functioned effectively and interacted with each other appropriately. Staff at all levels were clear about their roles and understood what they were accountable for. The leadership were knowledgeable about issues and priorities for the quality and sustainability of their services.

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 8 March 2018

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

  • Incidents which related specifically to end of life care were not being recorded consistently. The system used to report incidents did not have a category for end of life related incidents to be recorded. Staff were not confident in identifying the types of incidents which may relate to end of life. We were therefore not assured there was sufficient oversight of incidents that related specifically to end of life care

  • In the mortuary, refrigerators which were not connected to the main system had alarms that were isolated. There was a risk that when the mortuary was not staffed between 4.30pm and 7.30 am and at weekends, refrigerators could malfunction without staff knowledge.

  • Mental capacity of patients was not clearly recorded in their notes when it was assessed. We saw for patients with treatment escalation documents who did not have capacity, there was no evidence of the capacity assessment being completed in all bar one records looked at.

  • Palliative care provision was not available in line with guidelines of the Royal College of Physicians. At the time of our inspection, the team were only available between Monday and Friday.

  • Staff were not able to give examples of any changes to practice following complaints made about end of life care. The end of life strategy group meeting did not appear to capture the learning from complaints or disseminate this.

However:

  • Patients identified as being at end of life, were reviewed regularly by specialist teams. These teams worked with ward based staff to deliver timely care to patients.

  • Medicines for end of life patients, including anticipatory medicines were readily available on wards. This ensured patients did not have to wait for medicines which aimed to relieve their symptoms.

  • Patients’ pain was monitored, assessed and managed effectively. Pain relieving medications were prescribed in an anticipatory manner, meaning that patients had timely access to pain relief and were not left without medications.

  • End of life care delivered in the trust was based upon national best practice guidance and this was inherent in the documentation used by front line staff.

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

  • Staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity.

  • The palliative care team were responsive to referrals. There was a clear and embedded daily process for triaging new referrals and ensuring they were seen in a timely way.

  • At a local level, we saw high quality dynamic leadership from the bereavement and chaplaincy service, as well as within the mortuary and palliative care teams. Managers were truly visible to their teams, and took the time to support them in their roles.