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Provider: Royal United Hospitals Bath NHS Foundation Trust Good

On 26 September 2018 , we published a report on how well Royal United Hospitals Bath NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Listen to an audio version of the report for Royal United Hospitals Bath NHS Foundation Trust from our inspection on 05 June 2018, which was published on 26 September 2018. Listen to the report.
This provider has requested a review of one or more of the ratings.

Inspection Summary


Overall summary & rating

Good

Updated 26 September 2018

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

We rated the safe, effective and well led domains as good, with the caring domain rated as outstanding. We rated the responsive domain as requires improvement. The safe domain increased by one rating to good. All other domains remained unchanged.

Our inspection of the core services covered at the Royal United hospital were as follows.

  • Urgent and emergency care. Our overall rating of this service stayed as requires improvement. The core service ratings remained requires improvement in the safe and responsive domains. The well led domain dropped one rating to requires improvement. The effective and caring domains remained as good.
  • Medical care. Our overall rating of this service increased to good. All domains were rated as good, with both the effective and responsive domains increasing by one rating.
  • Critical Care. Our overall rating of this service increased to good. All domains were rated as good, with an increase of one rating in the safe, responsive and well led domains.
  • Children and Young People. Our overall rating of this service stayed as good. There were no changes to any of the domains, with the safe, effective, responsive and well led domains rated as good and the caring domain rated as outstanding.
  • Maternity services. Our overall rating of this service increased by one to outstanding. The effective domain remained as good, the safe domain increased one rating to good and the caring, responsive and well led domains increased one rating to outstanding.
  • On this inspection, we did not inspect surgical services, end of life care or outpatient services. The ratings awarded to these core services at the previous inspection in August 2016 form part of the overall rating awarded to the trust this time.
Inspection areas

Safe

Good

Updated 26 September 2018

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

  • Medical care remained as good for the safe domain. Staff understood and had received training on how to protect patients from abuse. Mandatory training was provided in key skills, and the majority of staff had undertaken this. Patients were protected from the risk of infections within the hospital because staff followed good practice with using personal protective equipment and hand hygiene. Equipment was suitable for its purpose and maintained on a regular basis. Patients had their risks assessed and were mostly treated appropriately for their needs. Care plans were written to guide staff caring for patients to follow. Medicines were administered safely. However whilst patient safety was constantly monitored on each ward and staff moved across the wards to meet the patient needs, planned staffing levels were not met in any area we visited. Some environments were in need of updating and repair and some areas used for patients who needed isolation did not have their own bathroom facilities
  • Children and young people services remained as good for the safe domain. Staff received training in safety systems, processes and practices and there were clearly defined and embedded systems, processes, and practices, which kept children safe and safeguarded them from abuse. Staff adhered to infection control practice when caring for and treatment children. The areas visited were visibly clean however the process for cleaning toys required improvement. The Dyson neonatal unit was conducive to providing high quality, safe, care and treatment to neonates, however, the children’s theatre recovery area was not appropriately separated from the adult recovery area. There was a positive and open incident reporting culture where lessons were learnt. Patient records were comprehensive, clear, legible, signed and dated. Patient risk was well managed. However there were times when the nursing team was understaffed, and the medical cover at night and weekends was not sufficient to meet the demand. Not all band six children’s nurses were trained in advanced paediatric life support. There were no risk assessments for the environment or young people’s independent use of the adolescent room or quiet room which posed a safety risk due to the number of ligatures and lack of staff supervision.
  • Critical care services improved to good. There were sufficient numbers of suitably trained staff to meet patient needs. There were good arrangements to protect people from abuse and neglect. Cleanliness and infection control processes were good. There was a positive incident reporting culture on the unit, with staff describing incidents as opportunities to learn.
  • Maternity services improved to good in the safe domain. There were systems and process in place to protect people from abuse, and the service worked well with other agencies to do so. There was sufficient obstetric, midwifery and other staff. Premises and equipment was suitable, sufficient, maintained and kept clean for use, however, improvements were required to evidence all equipment was available when required and had been serviced appropriately. Safety procedures were followed. Processes were followed to continually risk assess and review the health of each pregnant woman and baby. In the hospital, experienced and skilled staff were always available to respond to acute, severe and unpredictable obstetric emergencies. Medicines were prescribed, administered and stored safely although not all fridge temperatures were consistently checked.
  • Urgent and emergency care remained as requires improvement for safety. Compliance in mandatory training for medical staff fell below the trust target, though the results were better for nursing staff. Staff were not always completing assessments to ensure that children at risk were correctly identified. For children seen at the Urgent Treatment Centre there was no record-review system to ensure children at risk were not overlooked. The use of non-clinical areas to care for patients due to crowding was common and had not improved since the last inspection. Incidents involving patients were not always reported. Accurate data was not being collected to record the time to initial assessment of self-presenting or ambulance patients. This was despite telling the trust they must improve on this at the previous inspection. Patients were not always monitored for the duration of their stay in the department to ensure they were safe. At times, the department did not always achieve safe nurse to patient ratios when the department was crowded. Documentation was not always completed to a good standard and the use of prescription forms in the minors department was not suffiently audited. Fridge temperatures had been out of range for a number of days in the resuscitation area and no action had been taken to rectify it. However infection control practices in the department were generally good, with premises and equipment visible clean and in good condition. The prioritisation and streaming of patients worked well and helped ensure high priority patients were seen quickly and patients were directed to the appropriate care in a timely way. Patients brought in by ambulance did not wait for handover and ambulance handover times were better than the national average.
  • On this inspection, we did not inspect surgical services, end of life care or outpatient services. These services were rated as good for safe at the previous inspection. These ratings form part of the overall rating awarded to the trust this time. These services will be inspected again at a later date.

Effective

Good

Updated 26 September 2018

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

  • Medical care improved to good in the effective domain. National guidelines and standards ensure patients received effective care and treatment. Patient risks were reviewed by consultants in line with national guidance and were always available to offer advice to staff. Staff used technology to enhance patient care. Patients were supported to maintain their nutrition and hydration and additional nutrition was provided if it was needed. Staff monitored patients pain and treated them appropriately. The service took part in national audits for medical conditions such as diabetes, heart failure and strokes. Results were discussed and used to improve practice and patient outcomes. Many outcomes had improved since our previous inspection. Staff were competent to care for medical patients and specialist support was also available. There was a strong culture of multi disciplinary working. However, the Mental Capacity Act was not always followed with rigour. Assessments were undertaken by medical staff. Nursing staff did not take ownership completing best interests decisions and actions were not always documented. In addition, not all care plans contained all the information as advised on the risk assessment.
  • Critical care improved to a good rating. Patient outcomes were similar to outcomes for patients in other critical care units, as demonstrated by their participation in a wide range of local and national audits, including the Intensive Care National Audit and Research Centre (ICNARC). Multidisciplinary team working was well established, and comprehensive handovers for staff happened at the start and end of every shift. An organ donation nurse was based on the unit. They were present for all organ donation discussions with the families of potential donor patients, and there were no occasions where potential donors were not referred to the NHS Blood and Transplant’s organ donation service. However, not enough nurses had their post-registration qualification in critical care nursing.
  • Maternity services remained as good. Policies and practices were in line with national guidelines and best practice. All pregnant women known to the service had their physical, mental health and social needs holistically assessed and treatment and care was provided in line with evidence based guidance. Women identified with any risks had these managed in line with national guidance and specialist ante and post-natal clinics were provided by medical and midwifery staff. The regular use of audits enabled the service to benchmark the standard of maternity care provided at the trust against local and national standards. Processes were in place and staff had the competencies to support women and babies with their choices regarding nutrition and hydration. The maternity services had level three accreditation with the UNICEF (United Nations Children’s Fund) UK Baby Friendly Initiative. A range of medicines and other resources for the relief of pain and discomfort were available at all the birth centres. Midwifes had the skills and competencies required. Some consultants and midwives had developed specialisms and acted in lead roles for the whole maternity service. There was effective and positive multidisciplinary working, and the maternity services worked effectively with other departments and services. Health promotion was a routine part of all maternity care provided to women from their initial booking in appointment through to discharge. However, not all staff had been supported to have an annual appraisal.
  • Children and young people services remained as good. There was effective multidisciplinary working across the whole service. Staff had the skills, knowledge and experience to care, support and treat babies, children and young people. Children and young people’s nutritional and hydration needs were being met. The neonatal unit were working towards full accreditation of the neonatal Unicef baby friendly accreditation, in line with new neonatal standards. They were one of the few neonatal units working towards this accreditation. Guidelines were comprehensive, clearly laid out and were in line with guidance and best practice. Children and young people were empowered to manager their own health, care and wellbeing to maximise their independence. This was evident within the specialist paediatric services. Consent to care and treatment was sought in line with legislation and guidance. However, although pain was regularly assessed and managed, pain scores were not always clearly documented within patient records. There was no formalised clinical supervision programme for nursing staff.
  • Urgent and emergency care remained as good for effective. Treatment was based on best practice and national guidance. The department was staffed by a multi-professional team with the right skills and qualifications that ensured they could meet the individual needs of patients. Staff were well-supported though staff meetings, supervision and 1:1 meetings and most had regular appraisals. available 24 hours a day, seven days a week and the availability of mental health support had increased since the last inspection. Patients living with dementia were treated in a way that met their individual needs. However, there were delays in providing reviews by speciality doctors. Patient’s pain levels were recorded in a number of locations which made it difficult to monitor. Not all staff in the urgent care centre had completed specific training in paediatric assessment to support them in assessment of children.
  • We did not inspect surgical services, end of life care or outpatient services. These services were rated as good for effective at the previous inspection. These ratings form part of the overall rating awarded to the trust this time. These services will be inspected again at a later date.

Caring

Outstanding

Updated 26 September 2018

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

  • Maternity services improved to an outstanding rating for caring. Women and their families felt included with all aspects of care. There was strong evidence that compassionate care had consistently been provided to parents and that this had often-exceeded expectations. Care was led by parents needs and extended appointments were offered when required. There was an embedded culture and emphasis throughout the service and at all locations of providing understanding and compassionate care and support. Women with complex and/or difficult emotional needs were supported very effectively, with staff remaining respectful and non-judgmental at all times. Staff recognised the importance of developing trusting relationships based on understanding and compassion. This was particularly significant and nurtured by staff when supporting parents with loss and bereavement. Additional and specialist emotional support was provided when required. Feedback was consistently and overwhelmingly positive. There was a midwifery led service specifically for women who continued to require emotional support post birth. This was often accessed by women whose births had resulted in emergency procedures. Women whose babies were assessed as likely to require care and treatment from the neonatal intensive care unit (NICU) were well supported in advance and prior to the birth of their child.
  • The children and young people’s service remained outstanding for caring. Staff truly respected and valued the children and their families, empowering them to be partners in their care both on a practical and emotional level. Feedback from children and their families who used the service was continually and overwhelmingly positive describing care that exceeded expectations. Staff understood the impact a child or young person’s care, treatment or condition had, and were able to support the child and their families emotionally and signpost to other services for further support. Staff communicated with children and young people in a way they could understand, and prioritised communicating with them first before talking to parents.
  • Medical care remained as good for caring. Staff maintained patients’ dignity and privacy especially when personal procedures were being undertaken, providing care that was kind and compassionate. Staff were sensitive to patient needs and included relatives in care where this was a preference. However, religious beliefs were not always asked about. Staff would guide patients to the chaplaincy if they asked but were not proactive about assessing spiritual needs
  • The critical care service remained good for caring. Patients and family members spoke positively about the care they or their loved ones received on the unit, and staff interacted with patients in a respectful and considerate way, respecting privacy and dignity. Patients were treated as partners in their care, and were given time to ask questions or raise concerns. Patient diaries had been introduced to help patients know more about their time on critical care. Staff would go the extra mile to support patients on the unit. We saw that patients were taken outside for fresh air, or on trips away from the unit.
  • Urgent and emergency care services were rated as good for caring. Staff provided care that was kind and compassionate, spending time ensuring the patient understood what was happening, even when they were under pressure. Confidentiality was maintained, privacy was respected and chaperones were used when appropriate. Staff and volunteers would sometimes sit and talk to patients to provide company or provide emotional support whilst in the department.
  • We did not inspect surgical services, end of life care or outpatient services. Surgical services and outpatient services were rated as good for caring at the previous inspection, with end of life care rated as outstanding. These ratings form part of the overall rating awarded to the trust this time. These services will be inspected again at a later date.

Responsive

Requires improvement

Updated 26 September 2018

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

  • Urgent and emergency care services remained as requires improvement. The urgent treatment centre did not always have a GP on duty; shifts were often filled by Health Practitioners. This led to a reduced service for the local population with urgent heath care needs. The ability of staff to respond to the clinical needs of emergency patients was significantly impeded by high numbers of medical patients waiting in the department for beds. The trust had consistently failed to meet the four-hour performance target, to treat, admit or discharge a patient within 4 hours of their arrival. Patients in the observation area were not in single-sex bays in line with best practice guidance. Patients were frequently waiting too long in the department to see a doctor with the authority to admit them in an in-patient ward for treatment. Waiting patients suffered loss of privacy and dignity, were waiting for long periods on trolleys, rather than beds. They were in a busy and noisy environment, not conducive to rest or recovery. On average, the total time patients spent in the department was 3.5 times higher than the England average. However, the co-location of the urgent treatment centre meant streaming helped decrease waiting times for patients and supported access the right care sooner. There were a number of pathways used to direct patients to appropriate teams and services without having to be referred through the emergency department. There were a range of clinical areas to meet the specific needs of patients. Having step-down (high dependency) beds ensured that the resuscitation bays were available for patients requiring critical interventions without delay. The paediatric department ensured that children stayed safe and comfortable whilst waiting and receiving care. The department responded well to ambulance arrivals. The pre-alert systems worked well, staff responded appropriately to resuscitation and trauma calls and ambulances could transfer their patients without delay. Handovers between staff and ambulance crews were effective. Services available in the department were well co-ordinated, with multi-professional in reach teams offering a range of services aimed at delivering high quality care and avoiding unnecessary admission. The frailty flying squad helped to ensure that patients who could suffer most from unnecessary admission were assessed by a specialty team and supported to stay at home. The discharge assessment team helped ensure that discharge decisions were safe and the patients had the necessary support at home. Most patients had their treatment initiated within 60 minutes of their arrival into the department. Staff responded well to the needs of vulnerable patients, in particular those with mental health problems and dementia.
  • The children’s and young peoples service remained good for the responsive domain, consistently reflecting the needs of children, young people and families who were engaged and involved when improving the design and running of the services. The facilities and premises met the needs of people using the service. The Dyson neonatal unit was a purpose-built centre which was conducive to high quality care and treatment. The design and running of the service always considered how to make it family integrated. There was use of technology to ensure families were involved in their baby’s care. There was a proactive approach to understanding the needs and preferences of children and young people. This ensured individual needs were met, promoted equality and enabled accessibility. Innovative methods were used to support children and their families, engage children and young people, and signpost and link children with similar needs and experiences together in the community. Specialist nursing services also provided support to schools to help meet the children’s needs. Children and young people could access the service and appointments in a timely way and at a time that suits them. Waiting times and delays were minimal. The paediatric demand management project had helped to improve patient flow, manage paediatric referrals, and support primary care.
  • The critical care service had improved to a rating of good for responsiveness. Patient flow in critical care had improved since the last inspection. There was nurse presence at the daily bed meetings which increased the profile of the unit and its managers with other parts of the hospital. There were arrangements to collaboratively manage patients using a ventilator who had weaning difficulties (the process of coming off the ventilator) and failure (if it was not working), including the transfer of some patients with complex weaning problems to another hospital. The critical care outreach team visited patients on wards within 48 hours of discharge from the critical unit to support staff looking after them in their recovery. The service identified and met the information and communication needs of people with a disability or sensory loss. However, the unit did not offer a follow up clinic for patients admitted to critical care.
  • Medicine improved to a rating of good. Services were planned to reflect the needs of the population. Wards had been reconfigured to provide suitable care and promote shorter lengths of stay for patients. Discharge planning was monitored on admission and at each ward round. A discharge team was available to support discharges for patients who needed more complex support. Patient’s individual needs were met by staff. Wards for patients with dementia were designed to provide for their needs and signs provided picture cues for patients. Staff provided appropriate care for patients with learning disabilities and tried to provide consistency of care wherever possible. Staff liaised with other departments to increase the flow of patients through the hospital. Staff in the medical assessment unit and in ambulatory care assessed which patients they could treat from the emergency department to reduce pressure. However, having medical beds available for patients who needed them was a constant challenge. Initiatives were acted on to increase patient discharges. A ‘frailty flying squad’ saw older patients in the emergency department with the aim of preventing unnecessary admissions. Medical patients cared for on other wards were reviewed each morning by a team of doctors dedicated to see outlying patients. However, Patients were not always cared for on their specialty ward. Patients were often waiting in the emergency department for a medical bed which increased the crowding in the emergency department, as there was often no medical beds available.
  • Maternity services rating improved to outstanding. A responsive patient led culture was evident throughout the maternity services. The service was flexible and offered choice and provided continuity of care. A formal service review was underway to ensure local needs would continue to be met in the long term. Information about the maternity services was available in a variety of sources and locations. Clinic appointments were offered in the hospital and community locations and during evenings and weekends, providing options on where women wished to attend and at times that suited them. Staff worked in partnership with women to provide maternity care that met individual needs. Staff had actively identified different population groups whose needs were not being met. This included those assessed as vulnerable or with complex needs and then acted on feedback to improve the service delivery. This had included travelling communities and refugees. Women identified with mental health issues during and after pregnancy were supported by maternity staff with mental health expertise. There was evidence of effective relationships with other external services to support with mental health issues and other vulnerabilities. The service had a new purpose-built bereavement area that was sensitively equipped, furnished and decorated using feedback from families and with help from volunteer fund-raisers. The facilities had a separate entrance to promote privacy and had received overwhelmingly positive feedback from women and their partners. All areas were equipped with facilities to help parents who wanted support with breast feeding. Flexible access was offered to women and partners who wished to attend for additional feeding support. Facilities had been provided to support partners staying for extended periods of time. This included a dedicated partner bathroom and the provision of recliner chairs, mattresses and bedding. Kitchenette areas were also available, stocked with supplies to make hot and cold drinks and snacks. Patient resources had been produced to support enhanced recovery processes for women having planned caesarean section. Other measures related to food and fluid had also been put into place to safely meet the needs of women and improve their experience of a caesarean section. Women with complex health needs or with a multiple birth had their individual needs and risks explained and managed through consultant led antenatal clinics. This included plans regarding the timing and type of birth. An antenatal triage service was provided 24 hours a day, seven days per week from the birth unit at the hospital which supported access and flow. Established and effective communication between the acute and community based midwives ensured that the transition of care from the hospital to community services was seamless. Staff took concerns and complaints seriously and were motivated to learn from these. The proactive approach to concerns had also had a positive and significant impact on the rate of formal complaints received.
  • We did not inspect surgical services, end of life care or outpatient services. Surgical services and outpatient services were rated as requires improvement for responsiveness at the previous inspection, with end of life care rated as outstanding. These ratings form part of the overall rating awarded to the trust this time. These services will be inspected again at a later date.

Well-led

Good

Updated 26 September 2018

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

  • Medicine rating for well led remained good. Leaders were experienced and had the skills and knowledge to lead the service. The leadership team were visible and approachable. Patient safety was a top priority for all staff in the division. Risks were reported, mitigated against and monitored and staff were aware of the risks in the division. Staff felt engaged and consulted by their managers. Staff were recognised for good practice and provided with opportunities to develop new initiatives. They worked in collaboration with a local university and volunteer organisations to improve patient care and sustainability for services.
  • Maternity rating for well led improved one rating to outstanding. Senior staff demonstrated they had the knowledge, skills and experience needed for their roles. Junior staff reported leaders were supportive, visible and approachable, and aspiring midwife managers were provided with a programme of leadership training. Staff who had completed this spoke positively regarding how this had assisted them to develop management skills and experience. Throughout the services, staff demonstrated a broad understanding of the trust’s core values. Staff were positive regarding the working culture. Medical staff spoke highly of the midwives and vice versa. Effective governance and risk management processes were evidenced as in place and followed. This included audit trails to track progress on any required actions and evidence of widely sharing learning for the benefit of patient safety and care. The opinions of women, their partners and maternity staff was sought and had been used to develop service improvements. The women and children’s division staff engagement score from the 2017 staff survey was 3.83 which was above (better than) the trust and the national average.
  • Children’s and young people rating for well led remained good. Leaders had the skills, knowledge and experience, and understood the challenges to quality and sustainability, and were able to identify actions needed to address them. Leaders were visible, accessible, approachable and supportive. There was a clear vision for the children and young people service, which was supported by a strategy. There was a strong sense of advocacy for children wherever they were in the trust. Staff felt positive and proud to work in the children and young people service. There were clear responsibilities, roles and systems of accountability to support effective governance and management with clear and effective processes for managing risks, issues and performance. People’s views and experiences were gathered and acted on to shape and improve the service and culture. However, the leadership on the neonatal unit was in a process of change. Staff were not always clear of how this was working at the time of our inspection.
  • Critical care improved to a rating of good for well led. Leaders had the skills, knowledge, experience and integrity they needed. There was a strong commitment to delivering a safe service. Leaders understood the challenges to quality and sustainability, and could they identify the actions needed to address them. Actions required to bring the unit up to modern building standards were well understood. There were arrangements for identifying, recording and managing risks, issues and mitigating actions. All risks were discussed monthly and new or updated risks were escalated to the surgical division clinical governance board. There were systems to support improvement and innovation work, including objectives and rewards for staff, data systems, and processes for evaluating and sharing the results of improvement work.
  • Urgent and emergency care rating dropped to requires improvement. Since the previous inspection the trust had failed to make any meaningful improvement on key performance areas that impact on safe care in the emergency department. The department was still over-crowded, patients were still waiting too long on trolleys and the risks were still concentrated on the emergency department, rather than being shared through the system. The senior leadership team and departmental managers did not have shared priorities and did not work in harmony to address risks within the department. Locally, department leads voiced major concerns about nurse and medical staffing and considered this a key risk to patient safety. The ‘Full Capacity Protocol’ had been introduced but department leads had not contributed to its development. Direct admission to the medical admissions unit was a key priority for departmental managers, but there was little evidence of this being an active work stream within the trust’s improvement plans. We were not assured that the risks and harm experienced by patients was properly understood. Occasions where time-critical treatment was not provided in a timely way due to capacity or staffing pressures were sometimes not individually recorded and the level of harm sustained was not established, however the rate of serious incidents was used as a measure of risk and quality in the department. Since the last inspection, the trust was still not collecting information about the time patients were waiting for initial assessment. Although improvement had been made, the trust’s new computer system (and staff familiarisation with the system) meant that data had been unavailable since November 2017. The department did not have a multi-professional approach to clinical governance where all groups of staff were involved. The department did not monitor or collect data reflecting the amount of time spent at 100% occupancy to ensure there was accurate information about crowding. It also did not report medical and nurse staffing levels within its 4 hour performance metrics, despite this being a departmental risk. However, local leadership was good and relationships between staff and managers were respectful and positive. Department leads provided a high level of support to their teams, were visible and considered approachable by staff. The working culture in the department was excellent. Staff were committed and enthusiastic whilst working under challenging conditions. They supported each other and worked as an effective team. Engagement with staff and patients was good.
  • We did not inspect surgical services, end of life care or outpatient services. Surgical services, end of life and outpatient services were all rated as good for well led at the previous inspection. These ratings form part of the overall rating awarded to the trust this time. These services will be inspected again at a later date.
Assessment of the use of resources

Use of resources summary

Good

Updated 26 September 2018

Combined rating