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Provider: Salisbury NHS Foundation Trust Good

On 01 March 2019, we published a report on how well Salisbury 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

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Good

Updated 1 March 2019

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

  • We rated effective, caring, responsive and well-led overall as good, and safe as requires improvement. We found that safety for patients had improved in urgent and emergency care, surgery and critical care. However; spinal services remained requires improvement. In rating the trust, we took into account the current ratings of the five core services not inspected this time. This meant due to our aggregation of ratings principles, the overall rating for safe remained requires improvement.
  • At this inspection, the overall rating for spinal services remained rated as requires improvement. Urgent and emergency services and surgery had improved their rating from requires improvement to good. Critical care improved their rating from requires improvement to outstanding.
  • We rated caring, responsive and well led in critical care as outstanding. We found significant actions had been undertaken to treat people in a safe manner. We found staff cared for patients with compassion. There was compassionate, inclusive and effective leadership at all levels. Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care.

On this inspection we did not inspect medical care, maternity, outpatients, end of life care, or services for children and young people. The ratings we gave to these services on the previous inspections in November 2015 are part of the overall rating awarded to the trust this time.

  • We rated well-led at the trust as good. There was effective, experienced and skilled leadership, a strong vision for the organisation and embedded values. The leadership had the capacity and capability to deliver high-quality sustainable care. Leaders understood the challenges to quality and sustainability and they were visible and approachable. There was a clear vision for the trust and strong values. Whilst we found the that Non-Executive directors were well engaged we felt they would benefit from development and support to improve the constructive challenge they provide to the executive team.
  • The strategic plans fitted with local integration plans for and the strategy was aligned to the wider health and social care economy. Overwhelmingly staff felt valued and supported, positive and proud to work for the organisation. There were cooperative and supportive relationships throughout the trust. There were however some pockets where staff did not feel as well engaged and supported and the trust leadership was keen to understand this and to make improvements. There was good governance and structures to assess the care provided and give assurance around quality. There were processes for managing risk, issues and performance. Information and data was of good quality. However; we found that some IT systems were not effective in enabling the monitoring and improvement of the quality of care, although plans to resolve this were being identified. The views of people using the service were considered, as were those of staff and stakeholders. The trust was committed to quality improvement and innovations. However; it is important that improvement principles and practices are given pace and prioritisation in order to be embedded within the organisation. The arrangements for the Freedom to Speak-up Guardian did not reflect the recommendations of the National Guardian’s office. Work is needed on producing an integrated performance report that identifies where there may be variations and/or a need for change or improvement.
  • Urgent and emergency services (alternatively known as accident and emergency services or A&E) were rated as good and had gone up one rating since the last inspection. We have rated safe, effective, caring and well-led key questions as good. Responsiveness remains requiring improvement. We had previously rated safe, responsive and well led as requires improvement. The service had made many improvements in response to the concerns we raised at our last inspection. For example, assurance systems had been implemented to ensure the identification and management of risks was undertaken and appropriate actions taken. We found staff had the right skills and knowledge to provide safe care and treatment for patients. Clinical education was used to support staff and patients. However, we found staffing challenges meant dedicated areas of the department designed for children and young people could not be opened. A lack of a standard operating procedure for the short stay assessment (SSAU) unit meant there was ambiguity over who should be referred to the unit. There were occasions when mixed sex accommodation breaches occurred within the short stay assessment unit, but these were not always recognised by staff and therefore not always reported.
  • Surgical services were rated as good and had gone up one rating since the last inspection. We have rated all five key questions as good. We had previously rated safe and responsive as requires improvement at the last inspection. The service had made a number of improvements in response to the concerns we raised at our last inspection, we found that the service had improved compliance with The World Health Organisation (WHO) surgical safety checklist. Recent audits demonstrated that compliance for the general theatres was running at 100%. Staffing levels had improved following several initiatives which had been introduced to help aid recruitment of registered nurses across all wards. Staff were competent in meeting the assessed needs of patients. Staff took the time to interact with patients, and those close to them, in a respectful, compassionate and considerate way. Patients and their relatives/carers, where required, were actively involved in their treatment and care. We found patients could access care and treatment in a timely way.
  • Critical care services were rated as outstanding and had gone up two ratings since the last inspection. We have rated the safe and effective key questions as good and responsive, caring and well-led as outstanding. The service had made many improvements in response to the concerns we raised at our last inspection, these included; there were now comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training now exceeded the trust target. The team had improved practices around infection prevention and control. There were now more effective systems for cleaning equipment and staff now used personal protective equipment consistently. Staff consistently checked safety equipment and recorded this had been completed. The service had improved patient records and nursing staffing numbers now met recommended staffing ratios. Mortality and morbidity reviews had embedded and were well attended. Governance arrangements had been recently reviewed. These now reflected best practice and mirrored the trust wide reporting protocols. The risk register was updated and now included all evident risks. There was compassionate, inclusive and effective leadership at all levels. Staff at all levels were empowered and encouraged to be leaders.
  • Spinal services were previously rated as requires improvement. There has been no change in the overall rating, however; there have been some significant improvements. Safe and effective care remain requires improvement, caring remains good, responsive is now rated as good, this is an improvement from the previous rating of inadequate. Well led is rated as good which is an improvement from our previous rating of requires improvement. The service had made improvements in response to the concerns we raised at our last inspection, these included; systems, processes and practices were used to keep patients safe and these were understood by staff. Mandatory training targets were met by nursing and therapy staff and the service to control any risks of infection. Staff completed a holistic assessment of patients. Risk assessments were carried out and nursing and therapy care plans were completed to meet each identified area of need. There was a strong incident reporting culture in the spinal treatment centre. Staff had the right skills and knowledge to provide safe care and treatment for patients. However; concerns were identified at this inspection, included; staffing levels for medical, nursing, therapy and psychology staff. The spinal treatment centre had contributed to any databases for data collection and analysis purposes but not for measuring service quality.
Inspection areas

Safe

Requires improvement

Updated 1 March 2019

Effective

Good

Updated 1 March 2019

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

Caring

Good

Updated 1 March 2019

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

  • We observed staff were friendly and caring towards patients. Patients told us they had found staff at all levels were approachable and kind. We observed staff protecting patients’ dignity.
  • Staff communicated with patients so they understood their care, treatment, condition and any advice given.
  • Staff showed care and compassion to patients. Staff kept patients’ needs at the centre of the care they delivered and went to great lengths to determine patients’ preferences of care.
  • Staff provided emotional support to patients to minimise their distress. Staff showed awareness of the emotional impact a patient’s care, treatment or condition would have on their well-being.
  • Staff involved patients and those close to them in decisions about their care and treatment. They explained procedures in a way they could understand.

Responsive

Good

Updated 1 March 2019

  • The trust planned and provided services in a way that met the needs of local people.
  • There was good access to emergency and urgent care. People attending the department received care personalised to their needs, and accounted for their choices and decisions. The triage process focused on assigning patients to the right area and included consideration of ‘fitness to sit’ while waiting to be reviewed.
  • There was a clear recognition for the need to review the size and scale of the emergency department to ensure it met the future needs of the population.
  • We rated responsive in critical care as outstanding. During the 12 months preceding our inspection, the critical care team cared for five patients admitted to the unit via the emergency department with a condition later diagnosed as nerve agent poisoning. These admissions were categorised as major incidents, lasting 5 months in total.  This was the first time that patients with this diagnosis had been treated anywhere in the world. Critical care services were delivered flexibly and all avenues were explored to accommodate patients who needed care in the unit. Staff worked to overcome barriers between services and agencies to provide care that best suited patients. There were well-established communication channels between critical care, the trust leadership team, other services and wards within the trust, and other critical care units. Care was provided in a person-centred way and individual needs of patients and their relatives were considered and met wherever possible. Every decision made about patient care was centred on the patient experience and how it could be improved.

However:

  • We found staffing challenges meant dedicated areas of the department designed for children and young people could not be opened.
  • A lack of a standard operating procedure for the short stay assessment (SSAU) unit meant there was ambiguity over who should be referred to the unit. There were occasions when mixed sex accommodation breaches occurred within the short stay assessment unit, but these were not always recognised by staff and therefore not always reported.
  • Patient flow challenges and a lack of timely response from some specialities sometimes meant patients were referred to the short stay assessment unit inappropriately, sometimes in order to ‘stop the four-hour clock’.

Well-led

Good

Updated 1 March 2019

  • The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. Staff felt supported and valued in their role by their managers.
  • There were systems for performance management of staff through the annual appraisals which were aligned to the trust’s values. There were processes and procedures for managers to follow if staff did not meet performance expectations
  • The governance arrangements across most areas provided assurance that quality was central to the delivery of care to patients.
  • The division leads acted to proactively identify risks to the service which could impact on the quality for the care required. Staff took responsibility to ensure risks were minimised wherever possible without compromising the quality of care.
  • The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
  • The service engaged with patients seeking feedback to improve the quality of the services provided.
  • There were good systems of accountability from pharmacy management to support governance and management of medicines throughout the trust.
  • Medicines safety risks were identified, actioned and shared appropriately within the trust and with external partners. Learning actions from medicines incidents and audits were shared and reviewed by service leads.
  • Medicines optimisation was thought of as part of an integrated system across the county, with the pharmacy department working closely with other providers to ensure patients received safe and effective medicines support.

However:

  • The IT systems were not always easy for staff to use, and information across the different systems could not always be linked.
  • It is important that improvement principles and practices are given pace and prioritisation in order to be embedded within the organisation.
  • The arrangements for the Freedom to Speak-up Guardian did not reflect the recommendations of the National Guardian’s office.
  • Work is needed on producing an integrated performance report that identifies where there may be variations and/or a need for change or improvement.
  • We found that Non-Executive directors would benefit from development and support to provide constructively challenge to the executive team.
Assessment of the use of resources

Use of resources summary

Good

Updated 1 March 2019

Combined rating