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Southmead Hospital

Overall: Good read more about inspection ratings

Trust HQ, Southmead Road, Westbury-on-Trym, Bristol, Avon, BS10 5NB

Provided and run by:
North Bristol NHS Trust

All Inspections

2 November 2023

During an inspection looking at part of the service

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Southmead Hospital.

We inspected the maternity service at Southmead Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Southmead Hospital provides maternity services to the population of Bristol, North Somerset and South Gloucester.

Maternity services include an early pregnancy unit, maternal and fetal medicine, antenatal clinic including sonography, day assessment unit and triage, antenatal ward (Quantock), central delivery suite including high dependency rooms, midwifery led birthing centre (Mendip Birth Centre), 3 maternity theatres, postnatal ward (Percy Phillips), transitional care ward (Mendip), an ultrasound department and community midwifery services. Between April 2022 and March 2023, 5,485 babies were born at Southmead Hospital.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

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

  • Our rating of good for maternity services did not change ratings for the hospital overall. We rated maternity services as good in safe and well-led.

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited all areas of maternity services including antenatal and sonography department, day assessment unit and triage, antenatal ward (Quantock), central delivery suite, midwifery led birthing centre (Mendip Birth Centre), maternity theatres, postnatal ward (Percy Phillips Ward), obstetric high dependency area and the transitional postnatal care ward (Mendip Ward).

We spoke with 29 midwives, 3 support workers, 6 doctors, senior leaders, the maternity and neonatal voices partnership and 10 women and birthing people. We received 533 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 9 patient care records, 6 observation and escalation charts and 4 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

10 December 2020

During an inspection looking at part of the service

North Bristol NHS Trust provides gynaecology services at Southmead Hospital and peripheral clinic locations.

We inspected but did not rate gynaecology services at Southmead Hospital and reviewed safe, effective, responsive and well-led key questions.

We inspected gynaecology services at Southmead Hospital to provide the public with information on the quality and safety of services. We were aware of improvements the trust had made and wanted to see if the trust’s actions had been effective in improving the safety of the service.

We did not rate this service at this inspection as we did not inspect all key lines of enquiry. Gynaecology services were last comprehensively inspected as part of the maternity and gynaecology inspection published in February 2015 and was rated requires improvement for safe and responsive, and good for effective, caring and well-led. In April 2016 during a focused inspection, maternity and gynaecology services were rated good for safe and responsive. In June 2017 CQC separated the maternity and gynaecology core services.

Our inspection was announced (staff knew we were coming) to ensure that everyone we needed to talk with was available. As this inspection took place during the Covid-19 pandemic we adapted our approach to minimise the risk of transmission to patients, staff and our inspection team. We limited the amount of time we spent at the service, followed the trust’s local infection control policies and spoke with staff by video call rather than in person.

We reviewed all the information the trust had provided us with before the inspection.

During the inspection we spoke with 21 staff including managers of the women and children’s health division and managers of the gynaecology service. We also spoke with the lead consultant for gynaecology, speciality lead for gynaecology, consultant lead for gynaecology oncology, gynaecology consultants, trainee doctors, the colposcopy coordinator, nurses and a healthcare assistant. We also spoke with the lead consultant for the gynaecology multidisciplinary team meeting based at the regional cancer centre.

We reviewed 15 records of women who had been referred to the gynaecology cancer service.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

25 June to 18 July 2019

During a routine inspection

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.


  • 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.

8 November 2017

During a routine inspection

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.

8, 9,10 and 16 December 2015

During an inspection looking at part of the service

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:


  • 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.


  • 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.


  • 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

12 and 13 October 2015

During an inspection looking at part of the service

We undertook this focused inspection to follow up the concerns identified in the warning notice served in December 2014, therefore rating of the service as a whole did not change. A further follow up inspection of North Bristol Trust is scheduled for December 2015 where the ratings for the service will be reviewed.

Our key findings were as follows:

  • The warning notice was fully met although there were some areas which required improvement. During our inspection the department was under significant pressure due to a higher number of ambulances arriving than usual and also because the hospital computer system had an intermittent fault and was not working properly. This had an impact on the ability of staff to swiftly assess and treat patients within the department. Despite this staff coped well with the challenges and provided care as promptly as possible.
  • Patients were seen to have a prompt assessment on arrival and were prioritised for treatment, although we did see a smaller number of patients who were not assessed and treated within the department within 15 minutes of arrival.
  • The majority of patients had their needs met in a timely manner. We saw one patient who did not receive antibiotics when they should have.
  • Patients in the seated assessment area, who were waiting for extended periods of time, had appropriate clinical risk assessments carried out.
  • Patients requiring mental health assessments, still remained in the department. However, they were situated in the most appropriate location. The department had increased the hours that the mental health liaison team provided support. Further improvements in this were required.
  • Privacy and dignity had been improved within the department. However, the inherent risk of privacy and dignity not being maintained when patients are waiting in the corridor remained.
  • Staffing levels were increased at times the department knew that it was likely to be busy. As a result of this additional staff called down from wards were not asked to do anything beyond their skill or experience. Nurse practice educators had been employed within the department to support new and existing staff.
  • Performance against the 4 hour target had greatly improved and was consistently just below the 95% target. The target was achieved during the months of June, July and August 2015.
  • The flow within the emergency department and emergency zone was much improved. Further improvements in patient flow throughout the hospital are needed to support the department in maintaining and improving performance.
  • Governance was effective. Risks were properly managed and evaluated and learning was shared. Information was effectively cascaded to the board and the managers felt well supported.
  • Relationships had improved greatly which reduced the pressures on the emergency zone.

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

The trust should:

  • Ensure that all care records are completed appropriately and filled in at the time of completion to contain an accurate record of care.
  • Ensure that there is adequate visibility of all patients in the waiting room to manage unpredictable risks.
  • Ensure that there is continued focus on improving flow throughout the hospital to support the emergency department in maintaining and improving performance.
  • Ensure that all patients receive an assessment in line with Royal College of Emergency Medicine guidance and that this is clearly documented.

Professor Sir Mike Richards

Chief Inspector of Hospitals

7, 8 and 18 May 2015

During an inspection looking at part of the service

We undertook this focused inspection to follow up on the concerns identified in a Warning Notice served in December 2014, following our comprehensive inspection of the trust in November 2014. The warning notice related to a failure to comply with Regulation 9 (1) (a)(b)(i)(ii)(iii) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010: Care and welfare of service users (now Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 : Safe Care and Treatment).

Compliance with the Warning Notice was required by 26 January 2015. The action plan supplied by the trust, detailing how compliance would be achieved, indicated full compliance would not occur until 1 April 2015.

The inspection was conducted on 7, 8 and 18 May 2015 and was unannounced.

Our inspection focused on the issues identified which occurred in the following areas:

  • Emergency Department (ED) which provides emergency care and treatment to adults with serious or life threatening emergencies. The department has facilities to treat children, although most paediatric care is provided at Bristol Children’s Hospital and this is where ambulance borne patients would attend.
  • The Minor Injuries Unit (MIU) which provides care and treatment for adults and children with illnesses or injuries that are not life threatening but still need prompt attention.
  • The Ambulatory Emergency Unit (AEU) which provides urgent assessment, diagnostic investigations, observation or treatment for adults who do not require a bed for assessment/treatment and who are not expected to require an overnight stay.

Our key findings of the inspection on 7, 8 and 18 May 2015 were as follows:

  • Patients arriving by ambulance requiring care and treatment in the corridor area known as ‘crossroads’ which led into the majors area did not always receive a timely assessment of needs in line with College of Emergency Medicine guidelines and trust policy.
  • Patients presenting at the emergency department with serious and potentially life threatening conditions did not always receive rapid assessment and treatment in line with College of Emergency Medicine guidelines and trust policy.
  • Shift coordinators of the emergency department did not have full oversight of the activity within the department. Patients were not being proactively managed by the shift coordinators. Consequently, patients were not receiving appropriate care and treatment in a timely manner.
  • The number and skills of staff on duty were not flexed in relation to known fluctuations in numbers of patients expected in the emergency department at different times and on different days.
  • The release of beds to the emergency department did not appear to take account of known or expected fluctuations in the numbers of patients being admitted to the emergency department and Ambulatory Emergency Unit.
  • Patients admitted to the emergency department and the Ambulatory Emergency Unit were not admitted to wards in the hospital in a timely manner.
  • Patients were not protected from the risk of harm caused by pressure damage within the Ambulatory Emergency Unit. Whilst risk assessments were available to staff within the hospital, risk assessments were not carried out in line with trust policy.
  • Patients waiting in the corridor (crossroads) area of the emergency department did not always receive timely or effective pain relief from emergency department staff.
  • Patients were not always afforded privacy and dignity whilst waiting in the corridor (crossroads) area of the emergency department.
  • The corridor (crossroads) area of the emergency department remained cold whilst patients were waiting to receive assessment, care and treatment.
  • Improvements had been seen in the management of patients within the reception area and minors’ area of the emergency department.

The Warning Notice dated 17 December 2014 has not been fully met. We are working with the Trust Development Authority, NHS England and Commissioners to improve services within the trust and are considering our regulatory response. A Risk Summit was held in June 2015

Professor Sir Mike Richards

Chief Inspector of Hospitals

4-7 and 17 November 2014

During a routine inspection

Southmead Hospital is one of five locations that are registered with the Care Quality Commission and form North Bristol NHS Trust. It is an acute hospital, which provides urgent and emergency services, medical care, surgical care, critical care, maternity and gynaecology, neonatal intensive care, end of life care and outpatients. It also provides specialist services such as neurosciences, renal and plastics/burns to people from across the South West and in some instances nationally or internationally. Inpatients services for children and young people are provided at a neighbouring trust.


In May 2014 the Brunel building on the Southmead Hospital site opened. This was a significant event with the majority of services moving from the ‘old’ Southmead Hospital and the Frenchay hospital site into this new building.

We carried out a comprehensive inspection because North Bristol NHS Trust had been flagged a medium risk on the Care Quality Commission (CQC) ‘Intelligent Monitoring’ system, which looks at a wide range of data, including patient and staff surveys, hospital performance information, and the views of the public and local partner organisations. The inspection took place on 4–7 and 17 November 2014. 

Overall, this hospital was rated as requiring improvement. We rated it good for being caring and as requiring improvement in safety, effectiveness, being responsive to patients’ needs and being well led. There were particular concerns relating to safety and responsiveness in the urgent and emergency services and we judged these aspects as inadequate.



Our key findings were as follows:



  • Safety was good in services for children and young people, but in all other areas it required improvement, and in urgent and emergency services it was judged as inadequate.
  • The emergency department regularly and frequently declared a status of red or black escalation. This meant that the department was considered to be “not able to function as normal” and “verging on unsafe for periods of time” or “dangerous for a sustained period of time (more than two hours)” when “normal care was not possible”. The department was often overcrowded and patients were not always cared for in the appropriate part of the department.
  • Staff were aware of how to report incidents and generally reporting was good, but some teams were not reporting all incidents.
  • Feedback following the reporting of incidents was mixed, with staff in most areas stating this was not consistent.
  • There were shortfalls in staffing levels across the hospital. Although staffing had been reviewed before the move to the new hospital, the workload in some areas was higher than predicted, including the emergency zone. In areas such as critical care, theatres and the neonatal intensive care unit, staff had been recruited, but there were issues with the skill mix and a high proportion of junior and inexperienced staff.
  • Medicines were not appropriately managed with weaknesses in storage and accurate recording of administration.
  • There were concerns with the availability of medical records and the use of temporary sets of notes.
  • Compliance with the WHO checklist was not consistently achieving the target of 100%. Review of records found issues with documentation.
  • The environment was clean and well maintained.
  • The hospital was performing better than the England average for MRSA and since the move to the new building the number of cases of Clostridium difficile had reduced.
  • Not all areas were meeting the targets for statutory and mandatory training.



  • Services were found to be effective in critical care, maternity and gynaecology, and children and young people. Improvement was required in urgent and emergency services, medicine, surgery and end of life care.
  • In the majority of areas we found care and treatment to be evidence based. There were examples of excellent practice relating to trauma management and the treatment of stroke patients in the emergency department.
  • Mortality rates were below (better than) the national average, as measured by the Hospital Standardised Mortality Ratio.
  • There was strong multidisciplinary working across the hospital. Working relationships between disciplines were good, with good access to specialist teams and services.
  • The hospital was working towards providing seven-day services. The general medical consultants provided seven-day cover, and pharmacy was open for four hours on Saturdays and Sundays. Some cover was provided at weekends by allied healthcare professionals. However special services such as the cancer nurse specialist, diabetes team and palliative care team were only available Monday to Friday.



  • Staff were providing kind and compassionate care and treatment in all services. The majority of patients and relatives we spoke with were complimentary about the care they received.
  • The design of the new building, with 75% of beds in single rooms, helped to provide privacy and dignity. However, there were some areas where this was compromised. For example, patients in rooms overlooking the atrium or on the ground floor could be seen by members of the public. While there were curtains that could be drawn to protect patients’ privacy, when these were drawn patients could feel very isolated in their room.
  • Some patients commented on the isolation they felt in the single rooms. While the trust provided free Wi-Fi, there was no access to televisions or radios.
  • Emotional support was available. There was a spiritual area known as ‘the Sanctuary’ in the atrium of the hospital, which was well utilised.
  • When the hospital first opened in May 2014, a number of volunteers known as ‘move makers’ assisted with the move and directed patients and staff around the building. This had been so successful that their role had continued and they were proactive in providing assistance to patients and relatives.


  • Services for children and young people were responsive to patients’ needs, but all other services required improvement, and the urgent and emergency services were rated as inadequate.
  • There were significant issues with the flow of patients into, through and out of the hospital. The four-hour target for patients attending the emergency department to be admitted, discharged or transferred was not being met. There were instances when patients remained on a trolley in the emergency department for over 12 hours. Medical patients could not always be accommodated in medical beds, resulting in medical patients being cared for in beds across all specialities. There were examples of medical patients in non-medical beds not receiving regular review from medical staff. Some patients were discharged home directly from the critical care unit because no ward beds were available for them to transfer to when they no longer required intensive care.  
  • People who attended the emergency department out of hours and required a Mental Health Act assessment waited too long in the department, often in an inappropriate area, including overnight.
  • Medically fit patients were delayed because of waiting for social care or community health packages; on one day of the inspection 96 patients had their discharge delayed.
  • There were concerns with equipment provided by the sterile services department, with equipment not available when required and kits not fit for use. This had led to cancellation of operations, delayed starts to theatre lists and, in one instance, a patient having a longer anaesthetic while issues with the kit were dealt with.
  • The national target time was not being met for the 18-week pathway for referral-to-treatment for outpatient services.
  • In outpatients services there was a backlog of unreported images (4,642 within the last year). Although actions were being taken to address this, the risk register lacked details of the actions, the timescales and who had overall responsibility.
  • There was a large backlog of appointment requests (49,000), although actions had been taken to address this and the number had decreased by 20,000 in the previous three months.


Well led

  • Services for children and young people, maternity and gynaecology, and critical care were well led; all other services required improvement.
  • Staff were highly motivated and passionate about providing high-quality care. Although the actual move to the new building had been a success, staff now faced a number of challenges, ranging from an excessive number of snagging issues to severe problems with flow and capacity, many expressed frustration with the quality of service they were able to provide.
  • The vision for the hospital had focused on the move; the development of a strategy for the future had been paused over the summer and some areas lacked clear direction.
  • There were examples of good local leadership by ward managers and department leads; in some areas, leadership beyond this level was less clear.
  • All services had governance systems in place. However, some risks that had been highlighted and that were in the process of being actioned had not been recorded on the risk register.


We saw several areas of outstanding practice including:

  • The emergency department’s performance in relation to stroke treatment was excellent.
  • Clinical staff in the emergency department were compassionate and caring; they showed passion, resilience and determination to provide high standards of care in the face of significant challenges.
  • Staff in the emergency department worked well as a team. The senior team were strong, highly respected leaders, who motivated and supported their staff.
  • There was a high level of dedication among the senior management team in critical care to ensuring the welfare of their staff, patients and one another.
  • The emergency department had designed a quiet room, for relatives and friends of the deceased patient. The room was sensitively decorated and had the capacity for up to 12 people. Hot and cold refreshments and a telephone were available for relatives to use. Access to toilet facilities and the viewing room was designed so that the bereaved did not have to enter the emergency department.
  • The specialist palliative care team were passionate and committed to providing a high-quality service to patients at Southmead Hospital. The team was highly regarded throughout the trust and were praised for their knowledge, skills and support by everyone we spoke with.
  • The participation in research and improvement in clinical outcomes as a result of obstetric skills training.
  • In maternity services, there was clear evidence of learning from incidents and improvements which took place as a result.

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


Importantly, the trust must:

  • Improve its performance in relation to the time patients wait to be assessed and the time they remain in the emergency department.


  • Improve patient flow through the hospital to ensure that patients arriving at the emergency department by ambulance do not have to queue outside the department because there is no capacity to accommodate them in clinical areas of the emergency zone.


  • Work with healthcare partners to ensure people with mental health needs who attend the emergency department out of hours receive prompt and effective support from appropriately trained staff to meet their needs.


  • Ensure that the seated assessment area is used appropriately for the short-term assessment, diagnosis and treatment of patients who are not expected to be admitted. If patients require a lengthy or overnight stay, they must be accommodated in an appropriately equipped ward that provides same-sex accommodation to ensure their dignity is protected.


  • Ensure that nurse staffing levels in the emergency department are urgently reviewed and aligned to match current patient demand, flow and acuity.


  • Ensure that temporary staff employed in the emergency department receive appropriate induction to ensure their familiarisation with the department and their competence in the role.


  • Enable and facilitate emergency department staff to undertake mandatory and essential clinical training and professional training and development.


  • Take action to support emergency department staff, including senior staff, to ensure their psychological wellbeing.


  • Ensure there are enough staff with the rights skills and experience to provide safe and quality care to patients at all times.


  • 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.


  • Ensure it acts in full accordance with the law as it relates to the Deprivation of Liberty Safeguards and the Mental Capacity Act 2005.


  • Ensure staff meet the targets for statutory and mandatory training.


  • Ensure that more than 50% of the nursing staff in critical care have attained their post-registration qualification in critical care nursing.


  • Ensure that equipment required for surgical procedures is available in sufficient quantities so all patients operations can go ahead as planned.


  • Ensure all surgical equipment and materials are ready for use.


  • Ensure that all medicines are stored safely and appropriately and records relating to administration are accurate.


  • Ensure that all incidents are reported and investigated, and that feedback is provided to staff. The specialist palliative care team did not consistently report medication errors.


  • Take action to address the problem of the backlog of unreported images.


  • Continue to take action on, and monitor, the patient appointment request backlog.




In addition the trust should:

  • Continue to participate in local and national audits to benchmark practice and ensure continuous improvement in patient experience and outcomes in the emergency department. In particular, staff should take steps to improve pain management.


  • Ensure that appropriate records are maintained for the disposal of controlled drugs in the emergency department, in accordance with the trust’s medicines policy. This will reduce the risk of misuse of these medicines.


  • Ensure that appropriate records are maintained in the emergency department in respect of emergency medicines and that the medicines trolley is sealed to show that it has not been used. This will ensure that appropriate emergency medicines are always available when needed.


  • Ensure that resuscitation equipment in the emergency department is appropriately sited and regularly checked.


  • Review and amend the standing operating procedure for the emergency zone and the standing operating procedure for triage in the emergency zone to accurately reflect current practice.


  • Ensure that patients, including children, are adequately monitored in the emergency department waiting room to ensure that seriously unwell, anxious or deteriorating patients are identified and seen promptly.


  • Take steps to improve the experience for patients and visitors in the emergency department waiting room. This should include customer service training for receptionists, the provision of TVs, appropriate reading material and information about waiting times.


  • Ensure that concerns about nurse staffing levels are appropriately documented on the emergency department risk register and escalated for consideration at the directorate and/or trust level, as appropriate.


  • Keep under review the emergency department staff skill mix and training to ensure staff are competent to care for children.


  • Improve the provision and take up of training for emergency department staff in dementia care, supported by departmental champions and the development of a pathway for dementia care. This is so that the needs of patients with dementia are identified and appropriately met.


  • Ensure that the reception staff in the emergency department are receptive to patients arriving and observe those that are waiting to be seen.


  • Improve access to cleaning materials on Percy Phillips ward for the cleaning of patient baths.


  • Improve access and flow through the maternity service to ensure capacity meets demand.


  • Ensure that medical records are available for patient appointments, mortality and morbidity reviews and data recording, and that they are stored securely so that patient confidentially is maintained.


  • Ensure that patients are kept informed of the waiting times in clinics.


  • Display safety metrics and quality performance information in the clinic waiting areas.


  • Ensure that chaperoning is available and that patients are aware of this service.


  • Ensure that information about reporting complaints is clearly displayed and available to patients and visitors to the hospital.


  • Continue to develop and improve the centralised booking system with increased staffing and training. This should include reducing the backlog of appointment requests referrals.


  • Ensure that information for the benefit of patients, such as translator and interpreter services and chaperoning, is available and visible.


  • Review the incidents they are reporting to ensure they represent a full and accurate reflection of the events within the service.


  • Improve feedback to staff about incidents they have reported and demonstrate learning and improvements from remedial actions.


  • Improve the quality of safety thermometer and patient outcome data and how it collects this data in the critical care unit to ensure the service is able to innovate and improve.


  • Ensure staff meet the targets for annual appraisals and performance reviews.


  • Ensure that monitor alarms in the critical care unit can be heard or seen at all times.


  • Ensure that the critical service develops a set of standard operating procedures to ensure consistency of clinical approach to patients.


  • Ensure that the critical care service investigates ways to develop the emotional support offered to patients, their relatives and friends.


  • Ensure that the critical care service produces a booklet for patients, their relatives and friends about staying on and visiting the unit.


  • Make sure that all wards have the correct consent form in place for staff to use when caring for patients who lack capacity to consent to treatment and surgery.


  • Consider improving early identification of patients who could be in the last year or months of their life.


  • Ensure all staff are trained to enable optimal end of life care to be delivered.



Professor Sir Mike Richards

 Chief Inspector of Hospitals

31 July 2013

During an inspection looking at part of the service

This was a follow up visit to look at patient records held at the bedside. This was because when we visited in January 2013, the records we saw were not fit for purpose. Although we spoke with some of the patients we met on wards 1 and 4, we did not ask them about their care records.

We looked at bedside and electronic records. We found that accurate records in respect of each patient were in place and that the Trust had implemented robust audit arrangements to ensure that the improvements were maintained.

15, 16, 17, 22 January 2013

During a routine inspection

We spoke with 40 patients during our inspection. Some patients were on ward 1, ward 4 and U ward and others were people waiting to be seen by the nurses and doctors in the four outpatient departments.

We spoke with the nursing, clinical and administrative staff on the wards and those who were working in the outpatients department. We also spent time with allied healthcare professionals (physiotherapy, occupational therapy, speech and language therapy and dietetics) who provided both outpatient and inpatient services.

Patients told us they were treated well, received all the information they needed and were involved in making decisions about their care, treatment and support. The management of medicines was in line with good practice.

There was an overall positive view about the quality and quantity of food and drink provided by the hospital and patient's diverse dietary needs were well catered for.

Patients told us they felt safe in the hospital and there were good reporting protocols in place where concerns were raised about patient's treatment and safety. Staffing levels in the wards we visited were adequate although nursing staff reported that at times there had been reduced staffing levels.

We have asked the Trust to look at their patient care records because there is inconsistent practice. The records do not provide a clear and accurate account of the care and treatment given. There is the potential that people may not receive the appropriate care.

21 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

15 September 2011

During a routine inspection

Five inspectors visited eight wards during our three day visit to Southmead Hospital. These included maternity services, a stroke ward, general medicine ward, a surgical ward, a cardiac ward, a dementia care unit and a day assessment unit.

We spoke with at sixteen people who were users of the service, four relatives, eighteen members of staff, eight ward managers, three matrons and two doctors.

People told us that staff treated them with respect and that they were involved in decisions about their care.

People we spoke with told us that they understood the care and treatment they were receiving. Medical staff and nurses took their time to explain to people about their care before surgery, what would happen during surgery and what care they would receive following surgery to aid recovery.

Comments from people using the maternity services of North Bristol Trust were generally positive. These included 'the medical staff team are excellent', 'The midwifery staff are excellent very courteous',' The ward is very clean',' Everything was perfect'.

People told us that staff were responsive to their needs and responded in time when they used the call bell.

The wards that we saw were visibly clean and had suitable facilities available for hand washing. There was alcohol gel available at the entrance of each ward and signs alerting visitors to use it. People who use the service told us that they felt that the wards were cleaned regularly. We observed cleaning of areas being carried out during the visit.

Staff supported and encouraged family members to be involved with care as confirmed in conversations with relatives and staff working on the wards.

People who use the service told us that they felt or were aware that the wards were short staffed and that care staff were working very hard to ensure that everyone's care is delivered. One person said "I am aware the ward was short staffed but this has not impacted on the care I have received", another person said "they were short staffed yesterday and the ward manager assisted with the care", another person said "I was told that they [staff] were busy and I would have to wait for half an hour before could be assisted I was not happy".

Generally people told us the nurses were good and responded to their needs and were knowledgeable about what they were doing. One person said "the younger nurses are very patient", another person said "the surgeons appeared rushed".

North Bristol Trust seeks the views of people, using in-patient surveys. The Trust uses the information gathered to monitor and improve the quality and safety of services. This was confirmed in quality audits we saw completed on wards. We were told by the senior management team that where common trends had been identified matrons would then liaise with the wards to devise an action plan to address the issues.

9 May 2011

During a themed inspection looking at Dignity and Nutrition

Most patients and their relatives told us that they were very satisfied with the care and treatment they received at Southmead Hospital. They said they had been treated with courtesy and respect and that their privacy and dignity had been well-protected.

We observed personal care being provided behind closed curtains including examinations and discussions with medical staff. Although some of the discussions could be heard throughout the bay area as observed on the day of our visit.

We observed staff that were polite, friendly and sensitive. They were involving people whilst undertaking a range of care tasks. The atmosphere on one of the wards we visited was calm and welcoming in contrast to the other that appeared busy although welcoming.

Men and women did not have to share accommodation or bathroom facilities. There were signs in place to promote awareness. There is a dignity policy which includes reporting breaches on where people have had to share accommodation with the opposite sex.

Some people told us they had been asked what they wanted to be called on their admission to hospital and that this was respected throughout their stay. However, one person said 'I was not asked what I wanted to be called as I would prefer to be called by my title (Mrs) and surname'. We found that some people did not have their full names written up over their beds or what they preferred to be called by.