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Provider: University Hospital Southampton NHS Foundation Trust Good

On 17 April 2019, we published a report on how well University Hospital Southampton 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

Inspection Summary


Overall summary & rating

Good

Updated 17 April 2019

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

In rating the trust, we considered the current ratings of four other services not inspected this time.

  • The staff survey results for 2017/2018 showed trust staff engagement had remained consistently high compared to the NHS average
  • The trust was ranked number seven in acute trusts, and the third best university teaching hospital. It was also ranked second in good communication between senior managers and staff.
  • Managers involved staff in changes to services.
  • Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses and to report them internally and externally.
  • The trust had established an integrated medical examiner group (IMEG) to review all deaths twice daily Monday to Fridays.
  • Staffing levels, skill mix and caseloads were planned and reviewed so that people received safe care and treatment.
  • Staff had access to necessary equipment and medicines; and had a range of policies and procedures based on national standards to support their practice.
  • Medicines were appropriately prescribed and administered to people in line with the relevant legislation and current national guidance and had improved since our last inspection.
  • People’s physical, mental health and social needs were holistically assessed and their care and treatment delivered in line with legislation, standards and evidence-based guidance.
  • Multidisciplinary working was strong across the services. Staff worked well together and with other organisations to deliver effective care and treatment.
  • The services had clear arrangements for supporting and managing staff to deliver effective care and treatment.
  • Staff had annual appraisals and managers encouraged staff and supported opportunities for development.
  • Staff were kind caring and treated patients with dignity and respect. Patients spoke of the positive care they received from staff.
  • Staff communicated with people so they understood their care, treatment and condition; and advice was given when required. Staff involved carers and families in the patient’s care, where appropriate.
  • Services delivered were accessible and responsive to people with complex needs or in vulnerable circumstances.
  • The trust was recognised as one of 16 exemplar Global Digital acute trusts in England. A benefit for staff and patients was through the medical patient records (My medical record) being accessible to patients and promoting supportive management of long term conditions.
  • The use of electronic white boards had been introduced for improving patient safety.
  • The volunteers for the trust, worked at the hospitals and were involved with a wide range of activities including hospital radio, patient support and chaplaincy and spiritual care.

However,

  • In the emergency department services, we found there were delays in triage of patients that could impact on the health and wellbeing of patients.
  • In medicine we found that not all paper records were stored securely to protect patients.
  • In maternity we found that systems for ensuring secure access to the unit were not well established.
  • In maternity and outpatients, we found infection control procedures were not fully applied.
  • There were challenges with the aging estates for fire, water, electricity, and ventilation maintenance. The patient environments were showing significant signs of wear and tear.
  • In outpatients there was not always the capacity to meet the needs of patients and their relatives attending.
  • In outpatients the risks were significant to patients due to delays for waiting for ophthalmology appointments.
  • In several services not all staff had recent updated mandatory training.
  • Not all staff were satisfied with the promotion of equality and diversity in the trust’s day to day work and for supporting opportunities for career progression. Board members recognised that they had work to do to improve diversity and equality across the trust and at board level.
  • The board assurance framework process did not ensure it covered all that the board needed and board meeting minutes did not reflect the degree of challenge and discussion that had been held.
  • Complaint response targets had not been met and there were delays responding to patients.
Inspection areas

Safe

Requires improvement

Updated 17 April 2019

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

In Maternity:

  • Emergency equipment was not maintained safely, as all the necessary checks were not completed in line with the trust policy and procedures.
  • The standard of cleanliness was variable particularly in areas such as the birthing pool on the labour ward.
  • Although safety information was collected, it was not on display to the service users. There was limited evidence the data from the safety thermometer was used to improve the service.
  • There were weaknesses in the security of the service at Princess Anne hospital which posed risks of unauthorised access to women and babies.
  • The shower facilities on antenatal and post- natal wards were in poor state of repair and did not meet the needs of women. Some parts of the environment were draughty and cold as windows needed replacing.
  • IT connectivity in the community was poor and staff could not easily access women’s records and blood results which could impact on care.

In Outpatient services:

  • The service provided mandatory training in safety systems, processes and practices but did not always ensure everyone had completed it.
  • The service did not effectively control all infection risks. Premises were not always clean which could increase the spread of infection. There was no consistent approach to infection control and prevention in the outpatient departments.
  • Not all outpatient services had suitable premises. Some departments had capacity issues and could not cope with the volume of patients attending clinics.
  • The service did not always maintain patient’s confidentially as patient details were left visible in some clinics.
  • Systems and procedures to monitor and manage risks to patients had failed which had led to patient harm.

In Urgent and emergency care:

  • At the time of the inspection, clinical oversight of the adult waiting room was limited. With raised this with the trust who took swift action to mitigate against any possible risks.
  • Compliance against mandatory training (for doctors) was below the trust target of 85% in seven of the nine mandatory modules. It was reported there were mitigating circumstances to this and we saw evidence of an improved compliance rate at the time of the inspection

In Medical care services:

  • The service did not accurately record doctors’ completion of the relevant mandatory training.
  • Venous thromboembolism (VTE) risk assessments were not recorded as per the trust policy.
  • Incidents were not always fully investigated and learnt from including for medicine errors.
  • The results of the safety monitoring were not always known to staff or shared with patients and visitors.

However

  • Staff understood their safeguarding responsibilities and how to protect patients from avoidable harm. There was a good understanding amongst staff of what to report as an incident. Staff understood their responsibility to raise concerns and felt confident to report them.
  • Staff kept appropriate records of patients’ care and treatment. Records were clear, up-to-date and available to staff providing care.
  • The prescribing, giving, recording and storing of medicines was managed well.
  • The services managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

In the urgent and emergency care department:

  • The age of the urgent and emergency care department presented some challenges in terms of the available clinical space to treat patients. Staff managed the risks associated with this well.
  • Careful provision had been given to ensuring vulnerable patients and those who presented with acute mental health needs were treated in a safe environment.
  • Nursing staff monitored patients using the National Early Warning System (NEWS2) which produced an overall score to alert staff to signs of deterioration in condition. Patients were escalated in accordance with local policies.
  • The service controlled risks associated with infections well. Staff protected themselves and patients from the risk of infection by adopting good hand hygiene and utilising personal protective equipment in the majority of cases. However, some equipment and areas of the emergency department were found to be dusty or unclean.

In Medical Care services:

  • The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
  • Staff had a proactive approach to risk assessments. They recognised it was their responsibility to anticipate and manage risks to people who used the service. Staff kept clear records and asked for support when necessary.
  • The service had enough nursing and medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care.

Effective

Outstanding

Updated 17 April 2019

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

  • The services provided care and treatment based on national guidance in line with best practice and national guidance.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They followed the trust’s policy and procedures when gaining consent to care.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • Staff were proactive in supporting people to live healthier lives.
  • The urgent and emergency care department was a research active centre, participating in multiple research studies in conjunction with colleagues from across different specialities.
  • Where clinical audits demonstrated deviation from benchmarked peers, the urgent and emergency care department worked to identify contributing factors, instigate changes to practice and then revisit those changes to ensure positive clinical outcomes were achieved.
  • The urgent and emergency care department had been dynamic in developing alternative professional development pathways including encouraging staff to undertake the advanced care practitioner course.
  • The children’s emergency department was staffed by qualified children’s nurses 24 hours a day. The department employed four specialist paediatric emergency medicine consultants who supported the children’s ED whilst also liaising closely with the children’s hospital.
  • The vulnerable adult safeguarding team provided comprehensive support to vulnerable patients. The team comprised of highly competent and experienced practitioners whose role it was to support patients from across a group of vulnerable people. The team worked with both internal and external stakeholders to not only prevent patients being admitted to hospital but to also ensure patients were safeguarded, signposted to appropriate support services and ensure the holistic needs of patients was met.
  • All patients had their nutrition needs and hydration needs met and staff assessed and managed patients’ pain effectively.
  • The services made sure staff were competent for their roles. Most staff had been appraised to review staff’s work performance and held supervision meetings with them, when required, to provide support and monitor the effectiveness of the service.
  • The medical care service provided a seven-day service and staff supported patients to manage their own health, care and well-being and to maximise their independence following admission and as appropriate for individuals.

However:

  • Not all staff had received an annual appraisal or completed mandatory training requirements.

Caring

Good

Updated 17 April 2019

Our rating of caring went down

We rated Southampton General Hospital overall outstanding for Caring and the other locations as Good giving the trust overall Good for Caring

We rated it as good because:

  • All services involved patients and service users and those close to them in decisions about their care and treatment
  • Staff cared for patients and service users with compassion.
  • Staff provided emotional support to patients and service users to minimise their distress.
  • In Maternity services bereaved parents were supported by specialist teams and referred to counselling services as needed
  • Patients spoke positively about their care and treatment. They told us they were treated with dignity and compassion.
  • Throughout the inspection we observed staff speaking in appropriate ways with patients. Staff adapted their body language to enable them to communicate more effectively with patients.
  • 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.
  • We observed episodes of care in the urgent and emergency care department during which patients were truly respected and valued as individuals. Patients were empowered as partners in their care both practically and emotionally. This was especially the case for those patients who presented with mental health conditions or those patients who were recognised as vulnerable.
  • Staff de-escalated anxious patients through non-physical techniques. Members of the vulnerable adult support team had been trained to use motivational interview techniques; this technique enabled staff to help patients to change or alter their behaviour by helping people to overcome ambivalence about a particular course of action.
  • The trust’s urgent and emergency care Friends and Family Test performance (% recommended) was better than the England average from September 2017 to August 2018.

However,

  • However, due to the design of the urgent and emergency care department, patient privacy was not always maintained when they were being assessed at the triage stage. This was because the triage room contained two triage stations therefore allowing for two patients to be triaged by different nurses simultaneously. There were no dividers between the two triage bays and so patients and relatives could overhear other patient’s conversations when they were being triaged.

Responsive

Requires improvement

Updated 17 April 2019

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

  • The Royal College of Emergency Medicine recommends that the time patients should wait from time of arrival to receiving treatment should be no more than one hour. The trust did not meet the standard for any of the 12-month period from September 2017 to August 2018. The trust performance ranged from 68 to 92 minutes which was constantly worse than the standard and England average (which ranged from 56 to 64 minutes).
  • The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From October 2017 to September 2018 the trust failed to meet the standard and performed worse than the England average for seven months during the 12-month period.
  • From September 2017 to August 2018 the monthly percentage of patients that left the trust’s urgent and emergency care services before being seen for treatment was consistently worse than to the England average.
  • Services did not always investigate complaints in a timely way.
  • In outpatient services waiting times from referral to treatment were not in line with good practice for some specialties.
  • Follow up appointments were not managed effectively in some outpatient departments.
  • Some outpatient departments were cramped for the number of patients visiting the clinics.
  • Patients experienced delays in some outpatient clinics. Patient waiting times in the clinic were not monitored or communicated to the patients.

However

  • Services were planned and delivered to meet the needs of the local population.
  • Specialist midwives worked closely with mental health and needing extra support teams to support women with additional needs.
  • All the services treated concerns and complaints seriously, investigated them, learned lessons from the results and shared with staff.
  • In Midwifery services there was consideration for the diverse needs of women and a translation service was available to them. This included leaflets in many different languages.
  • In Outpatients staff were aware of how to provide additional support for patients with a learning disability or living with dementia.
  • The urgent and emergency care department had introduced various ways to support vulnerable patients. For example:
  • Twelve dementia champions who worked to raise awareness of those living with dementia and were available to offer advice and support to staff, patients and carers during their time in the department.
  • Patients with a learning disability or needs that required assistance were identified on presentation to the department. Staff explained how they encouraged relatives or carers to be part of the treatment process and encouraged people to remain with vulnerable patients during their stay in the emergency department.
  • Also, a comprehensive and extensive fact sheet was available to sign post current military and veteran personnel requiring support from a variety of organisations including those providing mental health services.

  • Staff had drafted standard operating procedures for the management of homelessness and a patient information leaflet about staying safe on the streets.
  • All patients were screened and risk assessed to determine whether they were regular users of recreational or illicit drugs. Relevant patients were provided with information, signposted to support services. Appropriate inter-professional referrals and safeguarding interventions were made.
  • From October 2017 to September 2018 the trust’s monthly percentage of patients waiting more than four hours from the decision to admit until being admitted was consistently better than the England average.
  • Departmental flow and the emergency access target was considered a “Trust-wide” target. We observed excellent working relationships with medical and surgical specialities who attended the department when required to review and assess patients.
  • There was a specialist emergency assessment unit for older patients with a new frailty unit, where patients received rapid assessment by a team led by consultant geriatricians

Well-led

Good

Updated 17 April 2019

Our rating of well-led went down. We rated it as requires improvement because:

In Maternity services:

  • Some staff felt there were limited career development opportunities available to them. The trust was working on feedback from the staff survey where some staff group were not treated as equals.

In Outpatients services:

  • Whilst there was management of outpatients in clinical speciality care groups, there was not a complete oversight of outpatient services for the trust for governance, risk and consistency of services.
  • A strategy for improving outpatients was still in the planning stages.
  • The quality of data collected and it effectiveness to keep patients safe was limited.

In Urgent and emergency care:

  • During the inspection we considered a lack of clinical oversight of the adult waiting room presented a risk to patients. Although senior staff were aware of the issue, no remedial action had been taken at the time of the initial inspection to address those risks. We raised this with the trust on conclusion of the inspection. The trust took swift action to address the identified risks, thus mitigating the risk to patient safety.

In Medical care services

  • The service had some nursing and medical paper records that were not stored securely.

However:

  • The trust had a vision to deliver excellence and value in patient care, teaching and research within a culture of compassion and integrity.
  • The trust’s strategy, vision and values underpinned a culture which was patient centred. Local managers across the service promoted a positive culture that supported and valued staff.
  • Managers in the trust had the right skills and abilities to run a service providing high-quality sustainable care.
  • The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care.
  • The services engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The services collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The services were committed to improving services promoting training, research and innovation.
  • The priorities of different health professions were considered and discussions at governance meetings. Nursing and medical priorities were aligned and professional standards were upheld and promoted by the leadership team. Clinical effectiveness, safety, patient experience, quality, performance and financial sustainability were all considered equally.
Assessment of the use of resources

Use of resources summary

Good

Updated 17 April 2019

Combined rating