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Provider: North Bristol NHS Trust Good

Reports


Inspection carried out on 25 June to 18 July 2019

During a routine inspection

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.


CQC inspections of services

Service reports published 6 April 2016
Inspection carried out on 8, 9 and10 December 2015 During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Service reports published 11 February 2015
Inspection carried out on To Be Confirmed During an inspection of Specialist community mental health services for children and young people Download report PDF (opens in a new tab)
Inspection carried out on 5-7 November 2014 During an inspection of Child and adolescent mental health wards Download report PDF (opens in a new tab)
Inspection carried out on 4-7 November 2014 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
See more service reports published 11 February 2015
Inspection carried out on 8 November 2017

During a routine inspection

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

  • We rated urgent and emergency services as good overall. This rating stayed the same. The overall rating took into account the previous good ratings in the effective, caring and well led domains. The safe domain was rated good because there were effective systems in place to assess and manage risks to patients. There were clear streaming and triage arrangements in place which identified and prioritised patients with serious or life-threatening conditions. A safety checklist provided a structured series of prompts for staff to ensure that all necessary steps were taken to ensure the safe care of patients, from arrival to discharge. There were clear pathways for addressing the particular risks associated with the care and treatment and referral of, for example, children, frail elderly or patients with sepsis, stroke or mental health conditions.
  • We rated medical care as requires improvement overall. This rating stayed the same. This was because the environments for patients were not always safe, especially during times of escalation when patients were accommodated in inappropriate areas on wards and in the interventional radiology department. Staffing levels and skill mix did not always meet patients’ needs. Staff understanding of Deprivation of Liberty Safeguards varied across the trust. We rated the responsive domain as inadequate. Flow within the hospital was poor due to insufficient medical beds. The hospital did not always ensure that appropriate patients were in escalation wards which meant some areas had unsuitable patients accommodated within them. Following our inspection the trust had updated the standard operating procedure to address concerns about the safety of placing patients in escalation areas.
  • We rated surgery as requires improvement overall. This rating stayed the same. This was because mandatory training rates did not meet trust targets. Infection control processes were not always followed. Care records were not always managed safely. Some people were not able to access the right care at the right time.
  • End of life care was rated requires improvement overall. This rating stayed the same. This was because incidents which related specifically to end of life care were not recorded consistently. Mental capacity of patients was not clearly recorded in their notes when it was assessed.
  • We rated outpatient services as good overall. This rating had improved since our last inspection. This was because there were processes to keep patients safe, which were supported by comprehensive staff training. There were sufficient staff to ensure outpatient clinics ran safely. Services provided by the outpatient clinics reflected the needs of the local population. Leaders within outpatients had the skills, knowledge, experience, integrity and enthusiasm to lead effectively. Governance processes were innovative, and focused on improving safety, quality, and patient experience specifically for outpatients.

Inspection carried out on 8, 9, 10, and 16 December 2015

During an inspection looking at part of the service

We carried out this focused inspection of the North Bristol NHS Trust to follow up on the areas that were rated as inadequate and requires improvement in our inspection in November 2014. Because we rated children’s services as good in November 2014 we did not inspect them. All services had been rated as good for caring in November 2014 so we did not re-inspect this area, although we observed how people were cared for during the inspection.

The announced part of the inspection was carried out on 8, 9 and 10 December 2015 and the unannounced part of the inspection was carried out on 16 December 2015.

Overall we saw improvements had been made at this hospital, although the rating remained requires improvement.

Our key findings were as follows:

Safety:

  • Although we rated safety as requires improvement in the trust, improvements had been made.

  • There were significant improvements within safety in urgent and emergency care services, with patients now receiving timely assessment on arrival.

  • Systems for investigating incidents were embedded in most areas. However, improvements were required in end of life care .

  • Nurse staffing levels were meeting national guidelines. A review of nurse staffing had been undertaken across the trust since our inspection in November 2014 and action taken as a result.

  • Although infection control procedures were followed across the trust, there were higher rates of infection for Clostridium difficile and methicillin resistant Staphylococcus aureus (MRSA) than the target for the trust for the year.There had also been an outbreak of Pseudomonas aeruginosa in the critical care unit. These had been investigated and improvements in cleaning were identified and actioned as a result.

  • In the community CAMHS service, young people had access to the staff kitchen at Monks Park House, which contained knives and hazardous cleaning products. The therapy rooms and waiting room were not clean.

  • Therapy rooms at Monks Park House had no alarm system and staff did not follow lone working procedures.

  • The trust was not meeting its target of 85% for the percentage of staff receiving mandatory training.

  • A new electronic records system had been implemented in the month prior to our inspection. Although training and support had been put in place for staff, some were hesitant and found the system difficult to navigate.

  • Staff within community CAMHS services had not consistently documented that they had assessed the risk to young people.

  • In most areas of the trust, paper records were stored securely. However, in the theatre department and outpatients areas, some were stored in rooms which were not secured.

Effective:

  • We rated the overall effectiveness of services in the hospital as requires improvement. However, improvements had been made in urgent and emergency care services, which we rated as good.

  • Across the trust there was involvement in audit and benchmarking both internally and externally. There were clear links to improvement in care within most areas.

  • Mortality rates were significantly lower than expected when compared with other hospital trusts, as measured by the Hospital Standardised Mortality Ratio and the Summary Hospital-level Mortality Indicator.  However, improvement was required in patient outcomes as they were below the England average in many areas.

  • Improvements had been made in supporting staff within their roles, through the appointment of nurse education practitioners and education programmes in the emergency department and in critical care. Further support was required in the theatre department for newer staff.

  • Staff appraisals were undertaken across the hospital, but improvements were required within medical and community CAMHS services.

  • Staff, teams and services worked well together to deliver effective care and treatment. We observed collaborative working from all staff contributing to patient care.

  • Consent was obtained for any procedures undertaken by the staff. This included both written and verbal consent. In most areas documentation relating to a patient’s capacity to consent and those relating to the mental capacity act were completed appropriately. However, in some areas there were was not clear evidence that account had been take of a patient’s ability or lack of ability to make specific decisions and there were omissions in the assessment and documentation of capacity.

Responsive:

  • Although there was a trust wide focus on patient flow within the hospital and improvements had been made this still required improvement. Bed occupancy within the hospital was consistently high at 96% and within critical care was above 80%. Research has shown that bed occupancy of both 85% (and above 70% within critical care services) could start to affect the quality of care provided to patients.

  • The four hour target, within the emergency department, to admit or discharge patients to the hospital had been achieved for a three month period between June and August 2015. However this had deteriorated from September 2015 and in November 2015 only 82% of patients met this standard.

  • There was a high level of delayed transfers of care which was frequently above 100 patients per day and at the time of the inspection was 114.However, there had been significant work undertaken since the inspection in November 2014 to facilitate patient discharges. This included the implementation of an integrated discharge lounge in October 2015.There was a focus on embedding discharge pathways and gaining pace in discharge activity.

  • Within surgical services there was not timely access for patients to treatment and operations. There were long waiting times, delays and cancellations ongoing. Action to address this was not always timely or effective and had resulted in a high number of complaints. The trust performed worse than the England average for most national targets, this included the Admitted Adjusted Referral to Treatment time (where the time from referral to treatment should be less than 18 weeks). The trust was also not meeting standards for referral to treatment pathways within outpatient services.

  • The number of cancelled operations was worse (higher) than the England average and the percentage of patient not treated within 28 days of a cancelled operation was above (worse than) the England average.

  • This had an impact on the critical care unit which had a high number of delayed discharges from the unit and the length of stay for patients was higher than the NHS national average. This was not optimal for patient social and psychological wellbeing.

  • Within maternity services, ‘flow midwives’ had been introduced to provide an overarching approach to flow within the service. This enabled midwives to focus on providing direct patient care. Although bed occupancy remained high within maternity services (excluding the central delivery suite) this had improved flow within the service.

  • The needs of patients with complex needs were well understood within all areas of the hospital. Patients with dementia received care and treatment that was sympathetic and knowledgeable. The work undertaken by the dementia care team within medical services was seen as outstanding. There were 100 dementia champions within the trust (including the director of facilities) and a focus on environmental changes to support patients.

  • Useful information was provided to patients and visitors and communication aids including interpreters were readily available.

  • Complaints were dealt with in line with trust policy. It was easy for people to complain or raise a concern and they were taken seriously when they did so. Improvements were made to the quality of care as a result of complaints and concerns.

Well Led:

  • The leadership, governance and culture of the trust promoted the delivery of high quality patient centred care.

  • The vision and values within the trust were clearly articulated by staff and board members alike. There was alignment between service and trust plans. Significant work was being undertaken on the trust strategy which was being led by the medical director. This work was to be completed in early 2016.

  • The board had developed significantly since our last inspection. A development plan had been initiated and coaching was ongoing. This was being cascaded to directorate leadership.

  • Relationships with commissioners had improved and matured. The trust saw the development of external relationships as an area for further development.

  • Governance systems had developed since our last inspection. The board and other levels of governance within the organisation functioned effectively and interacted with each other appropriately.

  • The quality and safety of patient care received sufficient coverage within board meetings and other associated meetings within the trust. There was clear visibility of risks at board level.

  • The leadership of the trust was knowledgeable about quality issues and priorities, understood the challenges are and took action to address them.

  • Financial pressures were managed so that they did not compromise the quality of care.

We saw several areas of outstanding practice including:

  • As the major trauma unit for the Severn region the department was required to report all treatment results of major trauma patients to the national trauma audit and research network (TARN). Results for 2015 showed that the emergency department at Southmead Hospital had the best survival rate of any trauma unit in England and Wales.

  • Frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

  • Managers were strong and committed to the patients and also to their staff and each other.

  • There was an outstanding example of responsiveness with the work of the dementia care team and the availability of 100 dementia champions in the trust including the Head of Facilities who was focussing on environmental changes.

  • In the pre-admission clinic they had a pharmacist working full time who reviewed elective patients. They made sure their VTE assessment was completed. They reviewed patients’ medications, wrote them up on the medication chart and gave advice to patients about their medication (what needed to be stopped prior to admission). The purpose for this was to reduce the amount of operations cancelled due to medication issues.

  • The bereavement midwife visited women in the CDS and also followed women up at home at any time, even beyond the normal time limit for postnatal midwifery care. Family support was also offered for subsequent pregnancies

  • The trust had developed some good training for staff in caring for patients living with dementia. Staff explained how they were able to offer extra time to this group of patients to ensure they were well cared for and made to feel relaxed and calm in an unfamiliar environment. Staff in the pre-operative assessment clinic were able to assess patient’s cognition and report back to GPs if it was below expected levels.

  • The specialist palliative care team had worked with the acute medical unit with complex end of life patients to improve patient outcomes.

  • CCHP started the central intake team (CIT) to manage the risk of service users new to the service and subject to urgent referrals. This team managed new referrals for young people up to the age of 13 who were at risk of self-harm or were in need of urgent help to stabilise their mental state. Staff then referred the young person to their local team for on-going work once the crisis had passed. The young person and their carer received contact information for the C.I.T. team and the Samaritans should they enter crisis again before their follow up appointment.

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

Importantly, the trust must:

  • Improve patient flow within the hospital and ensure that there is a robust hospital-wide system of bed management so as to: significantly reduce delays in patient flow through the emergency department; reduce occupancy to recommended levels within medical services; and, ensure that there is capacity within the hospital so that patients can be admitted to and discharged from critical care at the optimal time for their health and well-being.

  • Records must be fully completed and provide detailed information for staff regarding the care and treatment needs of patients.

  • Take action to improve the safe storage of medical notes

  • Ensure patient information remains confidential through appropriate storage of records in the outpatient clinics and theatre departments to prevent unauthorised people from having access to them.

  • Ensure that risk assessments in care records are consistently completed for all of the young people who use the community CAMHS service

  • Ensure that the environment at Monks Park is safe for the people who use the service and staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 4-7 and 17 November 2014

During a routine inspection

North Bristol NHS Trust is an acute trust located in Bristol that provides acute hospital and community services to a population of about 900,000 people in Bristol, South Gloucestershire and North Somerset. It also provides specialist services such as neurosciences, renal, traumaand plastics/burns to people from across the South West and in some instances nationally or internationally.

In May 2014, the Brunel building on the Southmead Hospital site opened. This was a significant event with the majority of services moving from the 'old' Southmead and Frenchay Hospitals into this newbuilding.

We carried out a comprehensive inspection as part of our in-depth inspection programme. The trust had been identified as a medium-risk trust according to our ‘Intelligent Monitoring’ system and had moved from the low to the medium-risk category between October 2013 and July 2014. Our inspection was carried out in two parts: the announced visit, which took place on 4, 5, 6 and 7 November 2014; and the unannounced visit, which took place on 17 November 2014.

Overall, North Bristol NHS Trust has been judged as requiring improvement. In reaching this judgement we have taken account of the fact that the vast majority of services are provided at the Southmead site. All services provided were caring. Improvements were need in safety, effectiveness, responsiveness and leadership. The team made judgements about 14 services. There was a wide variety in the ratings with two services, maternity at Cossham Hospital and the services for children and young people rated as outstanding and the emergency services rated as inadequate. Of the other services four were rated as good and the remaining seven as requiring improvement.

Our key findings were as follows:

  • Every service was found to be caring and we observed positive interaction with patients. Staff at all levels were very committed to providing good patient care and frustrated when they felt they could not achieve this.
  • Although we had some concerns regarding the privacy and dignity of some patients in the Brunel building the majority of patients and relatives told us they felt their privacy and dignity was respected.
  • Patients felt involved in their care. This was particularly strong in the maternity services at Cossham and the community services for children and young people.

  • Mortality rates were below (better than) than the national average as measured by the Hospital Standardised Mortality Ratio.
  • The move to the Brunel building had been managed well and the trust was aware that work was now required to further develop new ways of working and a clear strategy for the future of the whole trust.

  • There was good multidisciplinary working across the trust. In the community services for children and young people such working was excellent, with work with Barnardo’s Child Sexual Exploitation (BASE) project which focused on young people who were at risk of exploitation being recognised nationally as an area of outstanding practice.
  • There was excellent working with Barnado’s with a clear ethos of engagement with and involvement of children, young people and their families in developing and delivering services.

  • Although the trust was meeting its target for the number of staff receiving safeguarding training there were large variations in compliance with this.
  • There were examples of learning as a result of incidents however feedback to staff who reported incidents was lacking.
  • Staffing levels varied across the trust. As well as shortages in some areas there were also issues, particularly in theatres and critical care, with regard to the skill mix of staff as a high proportion of staff were new and inexperienced in those areas.
  • All the hospitals were clean. Infection rates had reduced since the move to the new hospital. There were however some concerns that hand washing audits were not meeting the compliance target of 95% and some staff were seen not to be bare below the elbow.
  • Medicines were not appropriately managed with weaknesses in storage and accurate recording of administration.
  • There were concerns regarding theavailabilityof equipment in theatre which was causing delays in operations and cancellations.

  • There were significant issues with the flow of patients into, through and out of the hospital. Targets in the emergency department were not being met for a maximum wait of four hours to be admitted, discharged or transferred, (in October 2014 this was 80.7% against a target of 95%); triage within 15 minutes of arrival and for patients remaining on a trolley in the department or more than 12 hours. Due to the demands on the emergency department patients were not being cared for in the most appropriate place to manage their needs with a corridor often being used inappropriately.
  • Patients were not being cared for in the most appropriate ward, reviewed in a timely manner or supported to leave hospital when ready to be discharged.
  • The national target time was not being met for the 18 week pathway for referral to treatment waiting times for outpatient services.
  • There were 107 operations cancelled on the day of operation in October 2014, 50 of these were due to the lack of a bed due to emergency pressures. Nine patients were unable to have their operation rebooked with 28 days. One patient had their operation cancelled on the day of operation for the second time.
  • There were backlogs in unreportedimages (4,642) and in appointment requests (49,000). Actions had been instigated to address both of these.
  • There were issues of concern with the availability of medical records and the use of temporary sets of records.
  • The maternity service at Cossham Hospital was meeting the needs of each individual woman who attended, services were flexible and choices offered.

We saw several areas of outstanding practice including:

  • The dedication and commitment of staff particularly in the emergency department where they displayed excellent teamwork despite the significant demands on their service that they were struggling to manage.
  • Participation in research and improvement in clinical outcomes as a result of obstetric skills training.
  • The involvement of children and young people in their care and the development of the service in particular the work with Barnado’s.
  • Involvement of woman and their partners in their maternity care at Cossham Hospital. Staff were reaching out to promote the use of the unit and natural births not excluding woman who traditionally may have not been thought suitable to have their birth in a midwifery led unit.
  • The introduction of move makers. Originally brought into help with the move to the new building their value was quickly realised and they are now an integral part of the service. They are volunteers who are highly experienced at their task

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

Importantly, the trust must:

  • take action, with others as needed, to improve the flow of patients into, through and from the hospital. This includes ensuring that patients are cared for in the most appropriate place and are supported to leave hospital when they are ready to do so.
  • patients in the emergency department must be assessed in a timely manner and cared for in a suitable environment.
  • ensure the staff attend mandatory training, for example, safeguarding training.
  • ensure that the privacy and dignity of patients in the Brunel building is maintained.
  • improve feedback to staff following incident reporting.
  • review staffing levels to ensure they reflect current demand
  • improve compliance with hand washing and ensure that all staff are bare below the elbows in clinical areas.
  • ensure that medicines are stored appropriately and administration is recorded accurately.
  • ensure that actions planned to reduce the backlog ofimages to be reported and appointments requested are effective and that systems are in pace to prevent such a backlog occurring in the future.
  • ensure that all patients medical records are available when the patient is being seen and that the reliance on temporary records is reduced to a minimum
  • ensure that equipment in theatre is sterile and available for use when required.
  • reduce the number of operations cancelled
  • improve the referral to treatment times
  • ensure that staff understand when a deprivation of liberty application should be made and that they are clear which patients are subject to such a restriction.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.


Mental Health Act Commissioner reports

Each year, we visit all NHS trusts and independent providers who care for people whose rights are restricted under the Mental Health Act to monitor the care they provide and check that patients' rights are met. Immediate concerns raised by patients on those visits are discussed, if appropriate, with hospital staff.

Our Mental Health Act Commissioners may carry out a number of visits to each provider over a 12-month period, during which they talk to detained patients, staff and managers about how services are provided. In the past, we summarised themes from the visits and published an annual statement followed by the provider's response where applicable. We are looking at different ways to indicate the outcomes of our monitoring in the future.