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Provider: North Bristol NHS Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 25 September 2019

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

Caring and Well led at core service level were rated outstanding. Safe and Effective were rated good. Responsive at core service level was rated requires improvement. The rating for trust level management was rated good and for use of resources it was rated requires improvement. These combined to create an overall trust rating of good.

Our rating of well-led at the trust improved. We rated well-led as good because:

  • The trust board had the appropriate range of skills, knowledge, integrity and experience to perform its role and were dedicated to delivering high quality patient centred care. They had a clear vision, understood the challenges the organisation faced and were committed to sustainable care that extended beyond the borders of the hospital. We saw good evidence of collaborative working across the system. The trust had a clear structure for overseeing performance, quality and risk, with board members represented across the divisions. The leadership team worked well with the clinical leads and encouraged divisions to share learning across the trust and there was a strong emphasis on improvement. The introduction of service line management had been well implemented and received positively. The trust was working hard to sure that it included and communicated effectively with patients, staff, the public, and local organisations. The board reviewed performance reports that included data about the services, which divisional leads could challenge. We saw evidence of challenge in the board minutes.

However,

  • Board members recognised that they had work to do to improve diversity and equality across the trust and at board level, as well as keeping non-executive level clinical input under review. More needed to be done to strengthen the voice of allied health professionals at board level. The trust needed to maintain focus on culture, particularly in maternity, facilities management and the BME population and continue to promote freedom to speak up. There was more to do to ensure staff felt equality and diversity were promoted in their day to day work and when looking at opportunities for career progression.
  • The operational performance at the trust was meeting some but not all national targets or standards for treating patients and more needed to be done to improve this. Standards of infection control varied across the trust and results of the mandatory reporting were variable. Not all areas were following best practice and we were not assured the trust had full oversight of cleaning regimes in some areas. Improvements had been made to the financial governance of the trust, but there was still much to be achieved to bring the trust back to financial balance and address the non-achievement of key operational performance targets.

Urgent and Emergency services: (also known as accident and emergency services or A&E) were rated good overall. This was the same as our previous inspection in 2018. Caring and well-led ratings improved with a rating of outstanding. Safe and effective remained the same with a rating of good. Responsive remained the same with a rating of requires improvement.

People could not consistently access the service in a timely way and this was a continuing problem since our last inspection. While the department was frequently overcrowded staff followed systems and processes to ensure patients were safe. People were truly respected and valued as individuals and staff were highly attentive to patient’s individual needs. The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.

Medical care (including older people’s care): was rated good overall. This was an improvement from our last inspection in 2018. Safe, effective and well-led ratings all improved to good. Caring remained good. Responsive improved to requires improvement. Staff followed processes to keep patients safe and there were improvements in systems to manage safe staffing across wards. People received effective care that met their needs and staff understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards had improved since our last inspection. Multidisciplinary team-working to plan patient care was an area of outstanding practice. Patients received the right care at the right time and significant improvements to patient flow had been made since our last inspection, so patients moved through the hospital more quickly and safely. Patients were treated dignity and respect and the leadership, governance and culture promote the delivery of high-quality person-centred care.

Surgery: was rated good overall. This was an improvement from our last inspection in 2018. Well-led and safe improved to good. Effective, responsive and caring ratings remained good. Staff were clear about the processes they should follow to risk assess patients and respond to those who may deteriorate. Records were clear, up-to-date, and available to staff providing care. The service managed patient safety incidents well and staff were clear on how to report incidents. The service provided care and treatment based on national guidance and evidence-based practice. Staff monitored the effectiveness of care and treatment, using the findings to make improvements and achieve good outcome for patients. Care provided to patients was compassionate. Staff supported patients to make informed decisions about their care and treatment. Care was planned to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. Most patients could access the service when they needed it. Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. Staff felt respected, supported and valued. Leaders and staff actively engaged with patients, staff, the public and local organisations to manage services. All staff were committed to continually learning and improving services.

Maternity: was rated good overall. This was the same as our last inspection at Southmead hospital in 2016. Effective, responsive, caring and well-led remained good. Safe dropped to requires improvement. Some aspects of safety required improvement in relation to infection control, security and medicines management. The service managed patient safety incidents well and monitored safety performance. The service had enough medical, nursing and midwifery staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. We were not assured that the care provided was always as safe as it could be. The service did not follow procedures to ensure cleanliness as a measure of infection prevention and control. Staff provided care and treatment based on national guidance and evidence-based practice. Staff treated patients with compassion and kindness and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress. Staff supported and involved patients, families and carers to understand their condition. The service planned and provided care in a way that met the needs of local people and worked with others in the wider system to plan care. Staff took account of patients’ individual needs and preferences and coordinated care with other services and providers. Leaders understood and managed the priorities and issues the service faced. Leaders collaborated with partner organisations to help improve services for patients. Staff felt respected, supported and valued and were focused on the needs of patients receiving care.

End of life care: was rated outstanding overall. Safe improved to good. Caring remained outstanding and effective, responsive and well-led all improved to outstanding. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff worked well together for the benefit of patients, and supported them to make decisions about their care, and had access to good information. Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. In all areas of end of life care we visited, we saw that staff were truly person centred. As much emphasis was placed in the caring for and about those close to patients as patients themselves. There was a clear drive to increase the presence of the palliative care team at the trust, and clear actions were planned to achieve this. Leaders had a deep understanding of issues, challenges and priorities in their service, and beyond. All staff we met were clearly inspired and motivated by the clinical lead for end of life care, and this translated into the delivery of high-quality end of life care. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

On this inspection we did not inspect critical care, children and young people’s services, outpatients, diagnostic imaging. The ratings we gave to these services on previous inspections in 2015, 2016 and 2017 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/RVJ/reports.

Inspection areas

Safe

Good

Updated 25 September 2019

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

Patients were protected from harm. Incidents were reported and well managed when something went wrong. Recruitment and retention of staff was improving. The staff and the organisation was prepared to learn and improve. Staff were well trained, and services were safely staffed most of the time.

However, staff did not always use equipment and control measures to protect patients, themselves and others from infection in surgical theatres and maternity areas. In maternity we found some concerns about the environment relating to security and privacy for women. Within maternity, medicines management needed to improve as we found examples of out of date stock on nurse medicines trolleys.

Effective

Good

Updated 25 September 2019

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

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

However, recording of mental capacity assessments when making resuscitation decisions needed to improve across the trust. In the emergency department were concerns about the level of support available for patients with mental health problems overnight and at weekends.

Caring

Outstanding

Updated 25 September 2019

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

Staff were kind and caring to their patients. Staff were consistently compassionate to the family and carers of patients.

The caring approach staff took to patients at end of life was outstanding. We saw that staff were truly person centred. As much emphasis was placed in the caring for and about those close to patients as patients themselves. We witnessed on numerous occasions staff from all teams taking time to provide care and support in an unhurried, calm and caring manner.

The emergency department staff looked after people with kindness and respect, often under difficult circumstances and high-pressure situations. They were an especially committed team who often took part in fundraising events for the department. They supported their families as well. Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Feedback from patients and those close to them was consistently positive. Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs.

Responsive

Requires improvement

Updated 25 September 2019

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

The emergency department continued to be challenged. Demand for services frequently outstripped the availability of appropriate clinical spaces to assess and treat patients. This meant the major treatment area frequently became crowded and patients had to be accommodated in the corridor.

In the emergency department, people could not always access the service when they needed it and did not always receive the right care promptly. Waiting times for treatment and arrangements to admit, treat and discharge patients were not in line with national standards. The trust was consistently failing to meet national standards in relation to the time patients spent in the emergency department, the time they waited for their treatment to begin and the time they waited for transfer to an inpatient bed.

Within medical care the service was restricted by the challenges faced with capacity and flow. Demand was outweighing capacity, and escalation areas were being used frequently. Delayed transfers of care were not meeting targets.

However,

In surgery, medical care, and end of life care, services planned and provided care in a way that met the needs of local people and the communities served.

Patients were treated as individuals and care provided to meet different needs. We found outstanding practice to meet individual needs in the emergency department with adapted rooms for people living with dementia and ‘bags of calm’ distraction aids to support patients with autism or learning disabilities.

Well-led

Outstanding

Updated 25 September 2019

Our rating of well-led improved. We rated it as outstanding because:

The leadership, governance and culture promote the delivery of high-quality person-centred care. Governance processes had improved since our last inspection. Leaders were experienced and approachable with a clear vision for the services they delivered. Staff were encouraged to report incidents and there was a good learning culture. In end of life care and the emergency department we found the leadership was outstanding, with a strong focus on staff wellbeing all staff felt supported and valued despite the significant pressures of the job.

However, in medical care we found leaders were stretched across all specialties which sat within the division, compromising the time they had to support staff, and some staff told us they did not feel confident to raise concerns which related to leadership to the medicine division’s Freedom to Speak up Guardian, due to their level of seniority.

Within maternity, managers at a local level did not have adequate oversight of safety systems and processes such as security, infection prevention and control and medicines management.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 25 September 2019

Combined rating
Checks on specific services

Community health services for children, young people and families

Outstanding

Updated 11 February 2015

The Community Children’s Health Partnership (CCHP) had systems in place for incident recording, investigating and monitoring. Lessons were learnt when necessary to prevent similar incidents from happening again.

Safeguarding procedures were in place with clear lines of reporting. Staff were aware of these procedures and their own responsibilities for the safeguarding of children and young people.

Staffing was stretched at times because of a growing child population in Bristol and South Gloucestershire. Plans were in place to review staffing and caseloads to manage this increase.

Involving children and young people was routinely undertaken across the CCHP and was seen as an example of outstanding service nationally. The feedback we had from children, young people and their parents or carers was extremely positive in all the locations and programmes we visited.

Staff were well trained and competent. Staff were kind and caring and we observed excellent interactions between them and children and young people and their parents or carers.

The CCHP worked in partnership with other agencies such as the local authority, education and Barnardos. We saw evidence that partnership working was routinely included in every aspect of their work. The sole purpose of the CCHP was to improve services for children and young people.

The CCHP provided some unique services to children and young people. These included the Be Safe project and a project managed by Barnardo’s Child Sexual Exploitation (BASE) to which the CCHP second a CAMHS nurse. These were recognised nationally as areas of outstanding practice.

The service was well led and staff had a clear vision of the future of the CCHP.

Governance arrangements were in place, with clear lines of reporting from clinical hubs through to the trust board.

Specialist community mental health services for children and young people

Requires improvement

Updated 6 April 2016

We rated North Bristol NHS trust specialist community mental health services for children and young people as requires improvement because:

  • Staff did not consistently complete risk assessments. The trust partially met the previous requirement notice

  • The environment at Monk Park House was not clean and young people had access to hazardous cleaning products and knives.

  • Staff did not consistently use safe lone working practices.

  • The rate of completion of staff appraisals was inconsistent between teams.

  • The systems in place to monitor the completion of mandatory training were not effective.

  • Staff morale was variable between teams.

  • There were breaches of regulations 12 and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. As the trust has not provided the service since 1 April 2016 these issues will be followed up with the new providers.

However:

  • The trust had met the previous requirement notice regarding staffing by reviewing the staffing levels and skill balance in the CAMHS teams. The trust had employed additional staff and the service was in the process of agreeing more funding for staff posts. Existing staff had moved teams to help meet the needs of children and young people.

  • The trust had governance structures to monitor the effectiveness of changes in the service design. These included monitoring the waiting list for the newly established central intake team fortnightly. Staff also had monthly meetings to feedback on the service.

  • The trust had introduced new roles to improve communication between senior management and staff. This included a new integrated CAMHS lead and local teams had nominated lead roles within themselves.

Child and adolescent mental health wards

Good

Updated 11 February 2015

The service for young people and their families at Riverside was good. Admissions to the unit were appropriate and there was a system in place to triage referrals. The service was able to respond to urgent referrals. Families were involved in the referral and assessment process. There were good systems in place to safeguard vulnerable young people and clear procedures for involving child protection services. 

Riverside Unit ran as a therapeutic space, which meant all aspects of the service and all relationships between young people and staff and young people and each other were part of inpatient treatment. Staff had a clear understanding of the therapeutic model and worked within this in a consistent and ethical manner. Staff we spoke with were enthusiastic about their work and it was evident they were committed to providing the best service they could. There was strong clinical leadership and direction within the service. 

Young people who were at the beginning of inpatient treatment were not always able to tell us about their care and treatment plan; however, young people further along in treatment had good knowledge of this. 

Riverside had worked closely with Barnardo’s to give young people and their families a voice in how services ran. The service was working towards Young People Friendly accreditation. This is the South West version of the Department of Health “Your Welcome standards”. 

While leadership and governance within the unit were effective, we found that the service was not as integrated in North Bristol Trust as it could be. There was no access to the trust’s online records system, for example. Records within the service were in paper format, sometimes disorganised, and it was difficult to find information within them.