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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

Reports


Inspection carried out on 30 April to 3 May 2019

During a routine inspection

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.


CQC inspections of services

Inspection carried out on 22 to 24 November, 1 December 2016

During an inspection to make sure that the improvements required had been made

We inspected University Hospitals Bristol Main Site as part of our comprehensive inspections programme of all NHS acute trusts.

The inspection was announced and took place between 22 and 24 November 2016. We also inspected the hospital on an unannounced basis on 1 December 2016.

We rated the trust as outstanding overall. The effective and well led key questions were rated as outstanding; safety and caring was rated as good; and the responsiveness of the hospital was rated as requires improvement. Surgery was rated as outstanding and all other services were rated as good.

Our key findings were as follows:

The trust had taken clear action to make improvements since our last inspection, not only in areas idenfied for improvement, but those identified as strengths. There was a strong safety culture across the trust in which staff were engaged. Patients reported that care was delivered to a consistently high level and that staff were caring and compassionate across the trust. Surgery services had consistently very positive feedback, with high response levels to the Friends and Family test and 98% of patients saying they would recommend the service. Services were well led at a service level through to trust board level.

Safe:

  • We rated safety in the hospital as good, and found safety was good in all the services we inspected.
  • Openness and transparency about safety was embedded in the services we inspected. Learning opportunities were identified and shared with staff within their own area and across the trust to support improved safety, and led to changes in practice.
  • There was clear oversight at board level of incidents and their investigations with learning shared across the organisation.
  • When things went wrong patients were provided with a timely apology and support. The majority of staff understood their responsibilities under the Duty of Candour requirement and could provide examples when they had been used.
  • Innovation was encouraged, such as SHINE in the emergency department, which provided staff with a simple checklist to ensure patient-safety based actions were completed. Since its introduction there had been no incidents of a deteriorating patient not being identified and then managed.
  • Wards and departments appeared visibly clean. A thorough cleaning programme was in place across the hospital and staff were observed using personal protective equipment to prevent infection. Staff were seen to use hand sanitising gel prior to providing care and treatment to patients. Clear signage was not always in place to advice patients, visitors and staff to wash their hands when entering ward areas.
  • Medicines managed safely and effectively in the services we inspected. Learning was evidenced from incidents relating to medicines, and medicines administration records were fully completed. However, on two medical wards a number of creams and treatments were stored in the ward sluice, and were not secure.
  • Nurse and medical staffing levels met national and local guidelines and planned to ensure safe care, and agency staff were only used when required to cover increased demand and vacancies. There were effective handovers and shift changes, to ensure staff can manage risks to patients who use services.
  • Consultant cover in the emergency department did not meet the 16-hours on-site standard and was reduced significantly at weekends. However, junior doctors felt well supported and both the local management team and trust executives were aware of this concern and had actions ongoing to improve the levels of cover.
  • Staff understood their safeguarding responsibilities. Staff were aware of local procedures and knew what to do if they had a concern. In surgery we found examples were staff had taken steps to prevent abuse from occurring and responding to signs of abuse by working with the safeguarding team and local authority to ensure patients were protected. There was lack of clarity around the correct processes to safeguard children between the ages of 16 and 18 years in the surgical trauma assessment unit. There were concerns in this unit around the levels of safeguarding training provided to staff working overnight.
  • Staff carried out comprehensive risk assessments for patients and developed management plans to ensure risks to patients’ safety were monitored and maintained. The World Health Organisation surgical safety checklist was utilised effectively to keep patients safe. However, the environment for patients on the oncology ward presented a potential risk to the safety of patients who may be confused or could not maintain their own safety.
  • Systems to ensure patients’ information was kept safe were not always implemented. Records were found to not be stored securely which could cause a potential breach of patients’ confidentiality in the emergency department, outpatients departments and on medical wards.
  • Mandatory training compliance for nursing and medical staff across the services we inspected were below the hospitals target, including fire, resuscitation and safeguarding training for medical staff. Receptionists in the emergency department had not received any training or guidance to help them identify potentially seriously unwell patients.
  • Chemicals were not always stored securely within the emergency department or on some wards.

Effective:

  • We rated the effectiveness of services within the hospital as outstanding. Urgent and emergency services were rated as outstanding, and medical care and surgery were rated as good. We do not currently rate the effectiveness of outpatients and diagnostic imaging.
  • There was a truly holistic approach to planning people’s discharge or transfer to other services, and this was done at the earliest stage. The safe use of innovative approaches to care and how care was delivered was actively encouraged. Patients had comprehensive assessments of their needs, which include consideration of clinical needs, including both mental and physical health and wellbeing, nutrition and hydration needs.
  • We found there was a high level of multidisciplinary working and people received care from a range of different staff, teams or services, in a coordinated way. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
  • Patients’ care and treatment was planned in line with current evidence based guidance. Clinical care pathways were developed in accordance with national guidelines. Trust policies included reference to NICE guidance and other national strategies. However, the diagnostic imaging service did not always ensure it met best practice clinical guidance for report turnaround time for medical staff requesting diagnostic imaging to be carried out.
  • Patients received care from different teams who worked together to coordinate care. We observed board rounds taking place on wards, which demonstrated effective multi-disciplinary working. For some wards complex discharges were daily occurrences. A multidisciplinary audit programme was in place and actively used by staff to encourage and monitor improved outcomes. There were links with GPs and community providers to ensure safe patient discharge.
  • Staff were actively engaged in activities to monitor and improve quality and outcomes, including benchmarking and peer review. The hospital achieved good patient outcomes and delivered effective care in the emergency department and medical wards. Mortality rates were better than the England average in all audits we reviewed. A programme of local and national audits was used to monitor care and treatment. Some areas showed improvements, including the national stroke audit and national emergency laparotomy audit. In outpatient departments clinics were benchmarked against each other and actions put in place to improve outcomes. Outcomes for people who used the surgical services were mixed. The trust performed well in the bowel cancer audit and the oesophago-gastric cancer national audit. However, results were not always in line with the national scores. For example, in some aspects of the hip fracture audit, although the numbers of were relatively lower than other centres.
  • Innovative approaches were used to deliver care. This included simple solutions such as a touchscreen guideline system in the emergency department resuscitation area, and the close working relationships with external partners to deliver alternative care pathways and admission avoidance programmes. The SHINE patient safety assessment tool had driven significant improvements and clearly demonstrated improved outcomes.
  • Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
  • Not all staff had received an appraisal in the last year, with particular low compliance in the ancillary staff group. Without an appraisal, learning needs may not be identified and a plan put in place to support staff to develop their practice.

Caring:

  • Overall, caring within the hospital was rated as good. Surgery was rated as outstanding for caring and all other services we inspected were rated as good. We spoke with in excess of 200 patients and their relatives during our inspection and collected a large number of comment cards from 90 wards and clinics across the trust.
  • Patients and their families praised the staff for their kindness and compassion. Patients told us they had been treated with dignity and respect at all times by staff who were respectful and caring. Within surgery services, feedback from patients and those close to them were continually very positive about the way staff treated people with no negative comments. We were given multiple examples where staff had gone the extra mile and where care received exceeded patients' expectations.
  • Staff often went out of their way to meet the emotional and physical needs of patients. It was clear they had taken the time to get to know and understand their patients. Staff took the time to ensure patients were comfortable, responding compassionately to patients in pain or distress and giving reassurance and support.
  • We observed doctors and nurses introducing themselves when they met patients and their families for the first time. Patients in the emergency department were addressed by their preferred name.
  • Patients and those close to them were treated as partners in their care and supported to make informed decisions about their care and treatment. We saw examples where relatives and carers were included as part of the care provided for both physical and emotional wellbeing. In outpatient departments staff talked about patients compassionately with knowledge of their circumstances and those of their families. Relatives were encouraged to be involved in care as much as they wanted to be, while patients were encouraged to be as independent as possible.
  • We saw staff from all groups assisting patients and others who were confused or lost in the emergency department in a helpful and supportive manner. One doctor was seen helping a patient to the toilet.
  • Staff in the emergency department had received lots of positive feedback about the compassionate care provided in the form of cards and letters, and these were displayed in the staff room.
  • Patients’ privacy and dignity was respected and staff sought permission before carrying out care and treatment in all the services we inspected. In the emergency department staff used curtains around the bed spaces to provide privacy when assessing and treating patients, and ensured patients’ dignity was maintained when curtains were opened. Patients in the corridor, however, did not have the same provision to ensure their privacy. Staff did their best to ensure confidentiality and privacy in the corridor by keeping conversations as quiet as possible, but because of the close proximity of other patients and relatives conversations could still be overheard.

Responsive:

  • Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. We rated the responsiveness of services within the hospital as requires improvement. Urgent and emergency services was rated as requires improvement. However, surgery, medical care and outpatients and diagnostic imaging were rated as good.
  • Access and flow was an issue within the hospital. The hospital was consistently failing to meet the national standard which requires 95% of patients to be discharged, admitted or transferred within four hours of their arrival at the emergency department. The emergency department suffered from regular crowding, and this was cited as the department’s greatest risk. Patients spent longer in the emergency department compared to the England average.
  • However, there was significant engagement across the trust, and at all levels, with commissioners and partners to address system-wide flow issues and introduce innovative methods to improve patient flow.
  • Escalation procedures were well embedded and worked effectively with minimal impact on patient care.
  • Waiting times, delays and cancellations were minimal and managed.
  • Referral to treatment times for different specialties within the medicine division were not all within the England targets. Within surgery referral to treatment standards were being met 92% of the time. Where there had been a slip in performance there were clear actions to address these which had been proven to be effective. In the outpatients department referral to treatment standard were worse than the national average.
  • Processes to ensure patients who were medically fit to leave the hospital were not always effective. However, in the majority of cases, reasons for discharge delays were not attributable to the hospital.
  • We found that medical and surgical services were planned and delivered in a way that met the needs of local patients. The hospital offered choice and flexibility to patients and provided continuity of care. New clinics, services and virtual facilities were implemented, to ensure services met patients’ needs. However, sometimes incurred delays due to issues elsewhere.
  • The medical wards were creative to ensure patient flow through the hospital was maintained and was responsive to the ever-changing demand. There was a constant oversight by senior staff, of how different departments were managing flow, to ensure staff across all areas of the hospital prioritised patient safety, whilst maintaining the flow of patients through the hospital.
  • The flow of patients through the medical division was monitored and actions taken to minimise the numbers of patients being cared for on wards other than those related to their medical condition/specialty. These patients were known as medical outliers. The hospital ensured outlying patients received the care and input from nursing and medical staff, relevant to their medical condition/specialty.
  • The radiology department was slightly below the national standard of 90% of patients referred by the cancer referral process to be seen within two weeks. However; the diagnostic and imaging department was above the national average for the percentage of patients seen within six weeks.
  • Patients were not always able to locate the outpatients and diagnostic imaging departments because they were not clearly signposted. A wide selection of information leaflets were available to patients; however, they were not available in other languages.
  • The parking facilities did not always meet the demand leaving patients unable to find a space in a timely manner.
  • There was good support for patients living with dementia or learning difficulties, and translation services were available for patients whose first language was not English. Reasonable adjustments were made for people living with dementia or with learning difficulties including use of the ‘this is me’ document and access to activities for stimulation. There were access to dedicated teams for dementia, learning disabilities and psychology which were always available.
  • In response to the last inspection and feedback from patients, each outpatient department had introduced waiting time boards which displayed the waiting times for each clinic for that day.

Well led:

  • We rated the well led domain as outstanding. Urgent and emergency services and surgery were rated as outstanding and medical care and outpatients and diagnostic imaging were rated as good. Services were well led at an individual service level through the organisation to a trust board level.
  • The leadership, governance and culture promoted the delivery of high-quality person centred care. There was a clear statement of vision and values within the trust which was driven by quality and safety. We found clear statements of vision and values for medical care, surgery, and outpatients and diagnostic imaging, which were driven by safety and quality. The strategies and supporting objectives were stretching, challenging and innovative whilst remaining achievable. However, an emergency department strategy had not yet been drafted and agreed, although there were programmes of work underway which showed progress towards achieving the department’s vision.
  • Alongside the overarching trust strategy a clinical strategy had been developed, which was patient centred. This was ambitious and had clear standards for a high level of patient care.
  • Staff understood the vision and strategy and their role in in delivering it. They were proud to work for the hospital and patient focused. Staff demonstrated a kind culture, both to patients and relatives, and to each other.
  • Given the size of the organisation governance structures were complex. However, the board and other levels of governance within the hospital functioned effectively and interacted well. There was excellent oversight of risks and issues at board level and challenge was effective and supportive. Governance processes had been reviewed and there was a focus on continual improvement and development to ensure that processes were robust.
  • Staff told us their responsibilities were clear and quality, performance and risks were understood and managed. Risks were escalated when needed and the information communicated to the hospital board flowed well. Processes were in place to monitor, address and manage current and future risk. Performance issues and concerns were escalated to the relevant committees and board. There was a continued focus and drive to improve safety and quality through excellent governance and leadership.
  • Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired culture and to motivate staff to succeed. Leadership and culture were intrinsically linked within the trust. Leaders understood the challenges to good quality care within and outside the organisation, and there were collaborative relationships with stakeholders.
  • Staff felt leadership was good and divisional lead staff were accessible. Staff told us they felt supported and heard, and there was a collective culture of openness to drive quality and improvement. Leaders and staff demonstrated the participation and involvement of patients who used the service was important to them.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture. There were high levels of constructive engagement with staff. Where there had been a poor culture identified innovative and effective actions were put into place to resolve them.
  • Innovative approaches were encouraged and supported, and these had a clear focus on patient safety, quality and performance, from staff led forums to improve the efficiency of work streams to research in pioneering research techniques. Changes were monitored effectively to evidence the improvements to patient care the changes had.

  • Leaders demonstrated a drive for continuous learning and improvement through the ongoing evaluation and monitoring of the service and by delivering projects and innovative developments aligned to this.
  • The management and governance of current performance of staff mandatory training did not ensure all staff were fully training. For medical staff, this included fire, safeguarding and resuscitation training.
  • The medical division had recognised a risk in the acute oncology service at night, concerning both staffing levels and a lack of suitably skilled triage staff. However, sufficient action was required to minimise the risk to patients in both the service provision and staffing provision.

We saw several areas of outstanding practice including:

  • In times of crowding the emergency department was able to call upon pre-identified nursing staff from the wards to work in the department. This enabled nurses to be released to safely manage patients queueing in the corridor.
  • The audit programme in the emergency department was comprehensive, all-inclusive and had a clear patient safety and quality focus.
  • New starters in the emergency department received a comprehensive, structured induction and orientation programme, overseen by a clinical nurse educator and practice development nurse. This provided new staff with an exceptionally good understanding of their role in the department and ensured they were able to perform their role safely and effectively.
  • In the emergency department the commitment from all staff to cleaning equipment was commendable.
  • The comprehensive register of equipment in the emergency department and associated competencies were exceptional.
  • Staff in the teenagers and young adult cancer service continually developed the service, and sought funding and support from charities and organisations, in order to make demonstrable improvements to the quality of the service and to the lives of patients diagnosed with cancer. They had worked collaboratively on a number of initiatives. One such project spanned a five year period ending May 2015 for which some of the initiatives were ongoing. The project involved input from patients, their families and social networks, and healthcare professionals involved in their care. It focused on key areas which included: psychological support, physical wellbeing, work/employment, and the needs of those in a patients’ network.
  • The use of technology and engagement techniques to have a positive influence on the culture of an area within the hospital. There were clear defined improvements in the last 12 months in Hey Groves Theatres.
  • The governance processes across the trust to ensure risks and performance were managed.
  • The challenging objectives and patient focused strategy used to proactively develop the quality and the safety of the trust.
  • The use of real time feedback from staff via the ‘happy app’ to improve and take action swiftly in areas where staff morale is lower.
  • The focus on the leadership development at all levels in order to support the culture and development of the trust.
  • The use of innovation and research to improve patient outcomes and reduce length of stay. The use of a discrete flagging system to highlight those patients who had additional needs. In particular those patients who were diabetic or required transport to ensure they were offered food and drink.
  • The introduction of IMAS modelling in radiology to assess and meet future demand and capacity.
  • The use of in-house staff to maintain and repair radiology equipment to reduce equipment down time and expenses.
  • The introduction of a drop in chest pain clinic to improve patient attendance.

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

  • Ensure all medicines are stored correctly in medical wards, particularly those which were observed in dirty utility rooms.
  • Ensure records in the medical wards and in outpatient departments are stored securely to prevent unauthorised access and to protect patient confidentiality.
  • Ensure all staff are up to date with mandatory training.
  • Ensure non-ionising radiation premises in particular Magnetic Resonance Imaging (MRI) scanners restrict access.

In addition the trust should:

  • Ensure chemicals are stored securely at all times in the emergency department and on medical wards.
  • Ensure checks of the equipment in the emergency department’s resuscitation area are recorded consistently.
  • Ensure patients in the emergency department have access to call bells at all times.
  • Ensure reception staff are able to recognise patients who attend the emergency department with serious conditions need urgent referral to the triage nurse and provide a formalised process for summoning help.
  • Continue working towards providing 16-hours on-site consultant cover in the emergency department, and increase consultant cover at the weekend.
  • Ensure the emergency department is accessible to wheelchair users and the layout of the reception desk allows staff to interact with wheelchair users whilst sat at the desk.
  • Ensure the emergency department develops and formalises its vision and strategy.
  • Ensure staff in the emergency department are up-to-date with their mandatory training, including safeguarding adults and children.
  • Work with commissioners and the local mental health service provider to ensure mental health patients arriving at the emergency department receive the care they require in a timely manner.
  • Ensure all staff working in the emergency department and medical staff receive an annual appraisal.
  • Ensure clear signage and equipment is in place for staff, patients and visitors to wash their hands when entering a medical ward area.
  • Ensure the environment in the oncology department and ward keeps patients safe and comfortable, especially for patients who may be confused or cannot maintain their own safety.
  • Ensure access to the staff room on the medical assessment does not allow access to unauthorised people.
  • Take remedial maintenance action to ensure the heating system on ward D703 maintains a suitable and safe temperature for staff and patients.
  • Ensure staff have a greater understanding and awareness of the intercom system on the Hepatology ward, to ensure safe and prompt access to the ward and confidentiality of patient information.
  • Ensure medical doctors’ inductions are undertaken in scheduled blocks and planned so doctors do not start work on the wards without an induction.
  • Ensure clear signage and equipment is in place on medical wards to advice staff, patients and visitors to wash their hands when entering a ward area.
  • Ensure delays in take home medicines does not delay patients.
  • Ensure medical records are legibly and fully completed. This includes patient risk assessments.
  • Audit records in the cardiac catheter laboratory to ensure they are fully complaint with the World Health Organisation surgical safety checklist for all surgical procedures.
  • Address the risk in the acute oncology service where patients may be placed at risk by reduced staffing levels at night due to admissions of emergency oncology patients. There should be suitably skilled staff in place at night to ensure safe triage advice is given to patients accessing the emergency oncology service. Whilst the trust recognised these risks, sufficient action should be taken to minimise the risk to patients in both the service provision and staffing provision.
  • Ensure pain audits are established to monitor if pain was managed effectively for patients with an ability to express their pain.
  • Continue to monitor staff’s use of the Abbey Pain Scale to ensure patients with cognitive impairment in the specialised services division have an effective tool to assess their pain needs.
  • Continue to ensure all efforts be made to maintain flow through the hospital and patients be nursed on the correct wards to meet their needs.
  • Reduce the risk on the hepatology ward in relation to lone working practices, when accompanying patients off the ward at night to smoke.
  • Improve the level of safeguarding training for staff working overnight in the surgical trauma assessment unit.
  • Improve compliance for mandatory training in surgical areas.
  • Improve patient outcomes to bring them in line with the national average for the hip fracture audit and improve the National Emergency Laparotomy Audit.
  • Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
  • Monitor the World Health Organisation (WHO) Surgical Safety Checklist is always used in the appropriate area as a checklist when carrying out non-surgical interventional radiology.
  • Provide leaflets within outpatient departments are available in different languages
  • Check local and national diagnostic reference levels (DRLs) are on display as stated in Regulation 4(3)(c) of IR(ME)R 2000 and IR(ME) amendment regulations 2006 and 2011.
  • Make improvements on the follow up backlog waiting list to meet people’s needs and minimise risk and harm caused to patients through excessive waits on follow up of outpatient appointments andthe reporting of images.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2 December 2014

During a routine inspection

University Hospitals Bristol NHS Foundation Trust is an acute teaching trust located in Bristol and providing services to people in Bristol, the surrounding area and across the South West and beyond. It is one of the largest NHS trusts in the country and, although it has a number of locations, its main services are concentrated on one site in the centre of the city. This one site contains seven hospitals: the Bristol Royal Infirmary, Bristol Royal Hospital for Children, Bristol Heart Institute, Bristol Oncology and Haematology Centre, St Michael’s Hospital, Bristol Eye Hospital and The University of Bristol Dental Hospital. The trust also provides services from the South Bristol Community Hospital and the Central Health Clinic, both of which are located within the city of Bristol.

We carried out a comprehensive inspection as part of our in-depth inspection programme. The trust had been identified as a medium-risk trust according to our ‘intelligent monitoring’ system and had moved from the low- to the medium-risk category between March and July 2014. Concerns had also been raised about the trust. Our inspection was carried out in two parts: the announced visit, which took place on 10, 11 and 12 September 2014; and the unannounced visit, which took place on 21 September 2014.

Overall, University Hospitals Bristol NHS Foundation Trust has been judged as requiring improvement. The trust provided services that were effective and caring. Improvements were needed in the safety and responsiveness of services and also in some aspects of leadership. The team made judgements about 12 services over three sites. Nine of the services were judged as good and three judged to be requiring improvement; these were medical care, surgery and outpatients at the Bristol main site.

Our key findings were as follows:

  • Every service at each location was found to be caring. We observed caring staff providing kind and compassionate care and treatment. We saw many very positive interactions between patients and staff. There was evidence that staff regularly ‘go the extra mile’ in providing care.

  • Patients and relatives we spoke with were complimentary about the care that was received. Patients had a good understanding of their care. Both patients and relatives told us that they felt involved and were treated with dignity and respect.

  • People were receiving care, treatment and support that achieved good outcomes.

  • The board, executive team and senior leadership team demonstrated a shared sense of understanding of risks and challenges and also shared priorities for improvement.

  • Staff talked with real pride about their colleagues and about the services that they provided. Staff in all areas and at all levels talked about great teamwork. They described an open culture where they were encouraged to raise incidents and complaints.

  • The hospitals were clean, tidy and well maintained, even in areas where building work was being undertaken close by. There were some exceptions, for example in the fracture clinic, where late-running building work had led to a crowded and unsafe environment. This was reported during the inspection and action was taken.

  • There were issues with the flow of patients into and through the trust. This was having an impact on the ability of the accident and emergency (A&E) service to respond in a timely way to the needs of patients. Not all patients were being cared for in the most appropriate place and not all patients were supported to leave hospital when they were ready to do so. The occupancy rates in all the hospitals, with the exception of maternity services, were consistently high.

  • The pressures on the A&E department caused by an increase in demand were significant and were related to the issues described above.

  • The percentage of patients whose operation was cancelled and who were not treated within 28 days was consistently higher than the England average. Patients often went to theatre without an allocated bed having been identified. At times, patients, including critical care patients, had to remain in the recovery area overnight.

  • Mortality rates were within expected ranges and there were no indicators flagged as a risk or an elevated risk.

  • Outpatient services were struggling to meet the demand on their capacity and were not meeting the 18-week referral-to-treatment targets. There were long waiting times for people in clinics, with inconsistency in the information provided about those waits.

  • There were some shortfalls in staffing. Within theatres, staffing fell below recognised guidelines and wards were not always fully staffed to their establishment as bank and agency staff could not be recruited. There was frequent use of temporary staff within the urgent and emergency services and occasions when these services were forced to manage without a full complement of nursing staff. In a number of services within the Bristol main site, there were innovative solutions in place to ensure safe staffing levels.

  • Records were generally found to be kept well. However, in outpatient services there were issues with missing patient notes and records were not stored appropriately in order to maintain confidentiality.

  • There was generally good infection control although not all staff followed trust policies in this area consistently.

We saw several areas of outstanding practice. These included the following:

  • Teamwork in the A&E department was exceptional. Staff at all levels were committed, motivated and engaged. They worked very well with each other across all job roles and staff grades. They were cohesive and demonstrated excellent teamwork within their departments and with other departments.

  • The maternity service (St Michael’s Hospital) was an impressive and highly functional unit. Staff worked hard together to provide excellent services to the local population and, as a regional referral unit, to the wider population of the South West and South Wales. Teams and individuals were highly flexible and the team was creative in finding ways to manage and mitigate the risks of working with a lower than optimal midwife-to-birth ratio. Multidisciplinary working within St Michael’s Hospital, the local community and regional partners was well established, with the welfare of the mothers, babies and their families at the heart of the services provided.

  • The children’s hospital had outstanding safeguarding procedures in place. The safeguarding team had links in every department where children were seen. The trust considered child safeguarding issues in relation to adult patients in the Bristol Royal Infirmary: for example, A&E consultants checked all overnight admissions for safeguarding concerns. Weekly multidisciplinary meetings were held and there were clear links to the safeguarding board.

  • The arrangements for young people to transition from children’s to adult services, for example within oncology, were very good. The trust had a transition group that involved young people. This group highlighted and promoted good practice in order to replicate it in all areas.

  • The trust had a paediatric faculty of education. This had been put in place to support the development and retention of staff. Specialist courses, accredited by the University of Plymouth, were on offer up to and including at master’s degree level. Courses included paediatric critical care. All the staff spoken with by the inspection team were highly complimentary about this. The trust planned to allow access to the courses to children’s nurses from other organisations.

  • In addition to the statutory child death review processes a process to review any death of a child had recently been implemented. A full review and debriefing of the case occurred within 24 hours of a child’s death (whether expected or not). Parents were involved in the reviews and kept informed of progress.

  • The specialist palliative care team was passionate about the service it provided and demonstrated excellent team working. The team facilitated weekly end of life multidisciplinary meetings with other professionals to discuss patients’ care. In addition, the consultants regularly attended seven different condition-specific multidisciplinary meetings that were held every week.

  • The specialist palliative care team was innovative and adapted to local needs and national policy by continually developing and evaluating tools and training to promote good end of life care for patients. The team shared its knowledge and learning within the trust and published its research. The team’s responsiveness, support and skill were highly regarded by colleagues throughout the trust. The team was established in wider palliative care networks, including the local hospice and clinical commissioning group.

  • The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, including details of their current medicines. There was evidence that this was improving the quality of care.

  • The computerised patient record system in adult critical care was an excellent innovation. This had been developed by the critical care unit and alerted the consultant and nurses if a patient’s safety and wellbeing were compromised.

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

Importantly, the trust must:

  • Take action, with others as needed, to improve the flow of patients into and through the trust. This includes improving access to services, including A&E services, and ensuring that patients are cared for in the most appropriate place and that they are supported to leave hospital when they are ready to do so.

  • Take action to ensure that staffing levels meet the needs of patients at all times in both wards and theatres.

  • Ensure that staff are able to attend mandatory training, particularly annual resuscitation training, in order to care for and treat patients effectively.

  • Work with partner organisations to ensure that people with mental health needs receive prompt and effective support from appropriately trained staff to meet their needs.

  • Continue to improve patient flow through the Bristol Royal Infirmary to ensure that patients arriving at A&E by ambulance do not have to queue outside the department because there is no capacity to accommodate them.

  • Ensure that the discharge process starts at an appropriate stage of a patient’s care, so that discharges are not delayed due to the unavailability of care packages.

  • Improve the flow of patients to reduce, as far as possible, the need for night-time moves and to reduce the number of patients nursed in areas other than specialist wards.

  • Ensure that patients whose surgery is cancelled have their nutritional needs met.

  • Ensure that the A&E department’s observation ward provides same-sex accommodation so that patients’ dignity is protected.

  • Ensure that the privacy and dignity of patients who remain in the recovery areas overnight are maintained.

  • Ensure that all resuscitation and safety equipment is checked regularly and that this is recorded and audited.

  • Ensure that all medicines, including controlled drugs and fluids, are stored safely and appropriately.

  • Ensure that records accurately reflect the time at which medicines are administered and taken.

  • Ensure that fire exits are clear and accessible.

  • Ensure that patient records are stored securely, maintaining confidentiality, and are available to clinicians when required.

  • Ensure that appropriate risk assessments are in place when building work is undertaken in areas used by staff and patients.

Please refer to the location reports for details of areas where the trust SHOULD make improvements.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

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Organisation Review of Compliance