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Provider: University Hospitals Bristol NHS Foundation Trust Outstanding

On 16 August 2019, we published a report on how well University Hospitals Bristol NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Outstanding  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Outstanding

Updated 16 August 2019

Our rating of the trust stayed the same. We rated it as outstanding because:

Effective and responsive at core service level were rated good overall. Safe was rated requires improvement, and caring and well led as outstanding at core service level. The rating for trust management was outstanding. The combined to create an overall trust rating of outstanding.

We rated well-led at the trust as outstanding because:

  • The executive team, the trust’s non-executive directors and other senior leaders, demonstrated evidence of solid and positive working relationships within the team. All staff we met who were accountable to the executive team supported our view of a leadership team with commitment and integrity who upheld and demonstrated the values of the organisation. There was compassionate, inclusive and effective leadership at all levels of the organisation. Leaders at all levels were visible, approachable and supportive of their patients and staff. Nearly all groups of staff were positive about the strengths of the management team. Safe and high-quality patient care was reflected within all the priorities for the leadership and could be seen throughout trust documents and in the values of the staff.
  • There was a clear interconnected vision and strategy for the trust which recognised quality alongside sustainability. There was a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against the strategy. The strategy was aligned with local plans for delivery of care in the wider health and social care economy. The trust was active in developing relationships in the community with partners and stakeholders to drive the goal of providing better and more integrated care in Bristol and the surrounding areas.
  • The culture of the organisation was centred on people who used services. The values and vision for the trust placed people who used services at University Hospitals Bristol at the centre. The vision and values aimed to improve the quality and availability of services for the population served by the trust.
  • There were structures, processes and systems of accountability to operate a governance system designed to monitor the service and provide assurance. There was an effective and productive governance team at the trust with comprehensive roles and responsibilities. There were good arrangements to ensure the trust executive team discharged their specific powers and duties.
  • The trust recognised, acted upon and met its legal obligations to safeguard those people at risk from abuse, neglect or exploitation. The trust had appointed named nurses and doctors for both safeguarding adults and children, but the team worked in a combined way providing a joined-up service to the trust. We were assured that through the competent management of the safeguarding team, the trust worked well to protect those at risk from abuse, despite the particularly challenging demographic of the population it served.
  • The trust encouraged openness and honesty at all levels of the organisation in response to serious incidents. Staff at the trust were trained from induction onwards to understand and recognise the duty of candour. Staff we met said they recognised the need to be open and honest with patients and their families and told us this led to learning and better care.
  • The risks of the environment and estate were well understood and managed. There was a strong and cohesive team working within the estates and facilities team at the trust. The director of facilities and estates demonstrated a comprehensive understanding of the strengths and challenges of the organisation in relation to the estate and its infrastructure.
  • The trust engaged in a variety of ways with the public and local organisations to plan, manage and deliver services. The service was transparent, collaborative and open with all relevant stakeholders about performance, to build a shared understanding of challenges to the system and the needs of the population and to design improvements to meet them. During our core services inspection we found numerous examples of how feedback from patients and those close to them had shaped the way in which services were delivered. In the work surrounding learning from deaths the scope had been extended to include issues such as dignity for patients who were dying at the trust, in response to feedback from relatives.
  • There was a strong culture of reporting incidents to learn and improve. There was a fully embedded and systematic approach to learning from incidents to drive improvements. The trust and its staff understood the importance of learning from incidents and near misses. In all areas we visited during the core service inspection staff demonstrated a clear understanding of the requirement to, and reason for reporting incidents. We heard that feedback was given to those reporting incidents, so they could be assured the issues had been acted upon.
  • There were systems to improve the service and performance which aimed to provide continuous learning and quality improvement. The trust ran several strands of quality improvement (QI) projects including the junior doctors' QI projects. The QI lead at the trust was an emergency medicine consultant who was supported by the executive director of strategy and transformation as the executive lead. QI was seen as everyone’s business at the trust, and ideas encouraged.
  • There was a clear commitment from the trust to research and development and a recognition that to maintain pace in a changing environment it must be a key stakeholder in the development of research-based clinical improvements in the region, and nationally. Research was embedded within the divisional structure of the organisation, and we saw how it was available to all, and not reserved for specialist services.

However:

  • Poor representation from the black and minority ethnic (BME) group in the higher levels of management was seen to represent limitations to development opportunities for this group of staff. Whilst the group spoke highly of the behaviours and attitudes of senior leaders with regards to staff of a BME background, it was also felt that a lack of movement to better represent the diversity of the workforce at a more senior level was a cultural issue borne out of a lack of action in this regard for many years.
  • The trust had yet to audit its service against compliance with the requirements of the Accessible Information Standards (AIS) and had not published its policy on the website.
  • Urgent and Emergency services also known as accident and emergency services or A&E; were rated overall as requires improvement. Caring improved with a rating of outstanding. Responsive remained the same with a rating of  requires improvement. Safe dropped from good to requires improvement and effective and well led dropped from outstanding to good. We were not assured the service was always meeting the requirements to provide safe care in all areas. There were limited facilities and systems to care for patients with suspected communicable diseases in the adult emergency department, and the mental health assessment rooms for both adults and children did not meet the required standards for safety. People could not consistently access the service in a timely way and this was a continuing problem since our last inspection. However, the service provided care and treatment based on national guidance and reviewed how effective this was. There was good care provided to patients and the service was well led with a skilled leadership team, effective governance process and a culture of high-quality care.

  • Surgery maintained an overall rating of outstanding. Caring and well led were rated as outstanding which was the same as our last inspection. Safe and effective were rated as good which was the same as our previous inspection. Responsive improved with a rating of outstanding. The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. There was also a strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences. A person-centred culture was at the forefront and staff were highly motivated and inspired to offer care that was kind and promotes people’s dignity. The service provided care and treatment based on national guidance and evidence of its effectiveness.

  • Maternity was rated as good overall with good ratings in effective, caring, responsive and well led. Safe was rated as requires improvement. We had not previously inspected maternity as a stand-alone core service therefore we do not have previous ratings to compare to. Doctors, midwives and other healthcare professionals worked together as a team to benefit patients. The service provided care and treatment based on national guidance and evidence-based practice, and actively participated in NHS England initiatives. Staff cared for patients with compassion and the service planned and provided care in a way that met the needs of local people and the communities served. However, there were issues with the safety of the management of medicines including safe storage, handling and disposal. Also, the environment and equipment within the maternity department were not always maintained.

  • Children and Young People was rated as outstanding with safe, caring and responsive rated as good which was the same as our last inspection. Effective maintained the rating of outstanding, with well led improved to a rating of outstanding. Patient risk was well considered and there were clear processes for escalation and support should a patient deteriorate. Patient safety incidents and patient safety performance was monitored, managed and learning identified to make improvements to the service. There was effective care within the children and young person’s service and these were monitored. Staff were committed to giving the best care to patients and provided emotional support to those with physical or mental health needs. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice. The children and young person’s leadership team were clear about their roles and understood the challenges for the service. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.

  • On this inspection we did not inspect medicine, critical care, outpatients, diagnostic imaging or end of life care. The ratings we gave to these services on previous inspections in 2014 and 2016 are part of the overall rating awarded to the trust this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
  • Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RA7/reports.

Inspection areas

Safe

Requires improvement

Updated 16 August 2019

Our rating of safe went down. We rated it as requires improvement because:

In surgery, maternity and urgent and emergency care, the service did not always follow best practice in all areas of prescribing, recording and storing medicines for adults and children. Mandatory training and safeguarding levels did not meet trust targets. Some facilities and equipment in the maternity and urgent and emergency care service were not sufficiently well managed and posed a risk to patients.

However:

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Apart from in the neonatal unit, services had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service managed patient safety incidents well with incidents reported, investigation and learning shared.

Effective

Good

Updated 16 August 2019

Our rating of effective went down. We rated it as good because:

All services provided care and treatment based on national guidance and reviewed how effective this was. Staff worked together to provide cohesive and multidisciplinary care across the different divisions. The service understood the continuing development of the staff, skills, competence and knowledge was integral to ensuring high quality care. Staff were inducted, trained and given the opportunity to develop.

However:

Not all staff had received an appraisal of their work and this was significantly below the trust target. This had not improved since our previous inspection.

Caring

Outstanding

Updated 16 August 2019

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

Staff cared for patients with compassion. Feedback from patients was positive. Throughout our inspection we observed patients being treated compassionately and with dignity and respect. In surgery we found care to be outstanding with people reporting that staff went the extra mile and their care and support exceeded their expectations.

Responsive

Good

Updated 16 August 2019

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

The trust planned and provided services in a way that met the needs of local people and took account of patients’ individual needs. In most core services, people could access the service when they needed it. The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff.

However:

In urgent and emergency services, people did not always receive care and treatment in a timely way. This was a continuing problem since our last inspection and patients experience delays to accessing treatment and onward care and waiting times to admit, treat and discharge patients were getting longer and did not all meet national standards.

Well-led

Outstanding

Updated 16 August 2019

Our rating of well led stayed the same. We rated it as outstanding because:

Managers and leaders in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Leadership teams were well-motivated and understood the challenges of the department and implemented a drive to improvement. The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. There was a systematic approach to continually improve the quality of the services it provided. In surgery we found well led to be outstanding.

However:

In maternity, we found there had been a lack of action to address medicine storage and remedy issues with fixtures and fittings.

Assessment of the use of resources

Use of resources summary

Good

Updated 16 August 2019

Combined rating