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Provider: Brighton and Sussex University Hospitals NHS Trust Good

On 08 January 2019, we published a report on how well Brighton and Sussex University Hospitals NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires Improvement  
  • Combined rating: Good  

Read more about use of resources ratings

Read our reports of listening activity in December 2013 and January 2014 and for Community health services for children, young people and families, published on 8 August 2014.

CQC carried out a period of listening activity at Brighton and Sussex University Hospitals NHS Trust in December 2013 and January 2014. The report from that exercise, which informed our inspection in May 2014, is available below.

In August 2014, we published the results of our inspections into the trust. The report for the Community health services for children, young people and families is available to download below.

Inspection Summary


Overall summary & rating

Good

Updated 8 January 2019

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

  • The trust had made huge improvements since the new executive team had introduced improved systems of working. The trust had a new strategy, vision and values which underpinned a culture which was patient centred. The ‘Patient First Improvement System’ had empowered front line staff by equipping them with the lean tools, methods and a structured process which had helped to build and promote a culture of continuous improvement across the whole trust.
  • A new divisional structure had been created around the pre-existing directorate structure. This had strengthened the existing leadership and management arrangements of the clinical services.
  • Quality was a ‘golden thread’ running through the trust Patient First Strategy. In all the interviews undertaken on inspection this was evident in the use of data both quantitative and qualitative and how this was triangulated and reported through the Quality Steering Group to the Quality Assurance Committee and the trust board.
  • All staff we spoke with on inspection were clear about the trust's approach and priority to deliver high quality sustainable care to patients. Staff knew and understood the trust’s vision, values and strategy and how achievement of these applied to the work of their team. To support the roll-out of Patient First across the trust, a communications plan was developed and implemented. The plan was tailored to different audiences to best reach staff in different parts of the organisation. Staff spoke about feeling that the Patient First Strategy had given them the ability to all speak the same language.
  • The board received holistic information on service quality and sustainability. There was a programme of board visits to services and staff we spoke with told us that that leaders were approachable.
  • Staff felt equality and diversity were promoted in their day to day work. We spoke with the newly formed Black and minority ethnicity working group. The trust had held an event in May where over 200 members of staff had come together to discuss equality and Black and minority ethnicity issues and start the forming of a new strategy. The output of this meeting was three workstreams; communication, recruitment, and education. The group we spoke with told us that they had seen a dramatic change in the past 6-9 months. They described this as powerful, positive and feeling included in the strategy and change. Staff told us that although they had not always felt supported in the past since the new executive team had arrived they now felt confident that they could raise any concerns about staff behaviours towards them with their line managers, and they felt assured that their concerns would be listened to and acted on appropriately.
  • Staff felt respected, supported and valued. The executive teams and divisional leaders told us how they felt that improving the experience and engagement of their staff was fundamental to delivering a culture of high sustainable care and trust strategic objectives.
  • The trust’s Patient First Improvement System empowered staff to make improvements and to be listened to and respected. In areas where ‘Patient First’ had been introduced the level of engagement and motivation had significantly improved as staff felt empowered to make improvements in their work. This was evident both on CQC engagement events at the trust and on inspection.
  • A clear framework set out the structure of ward/service team, division and senior trust meetings. Managers used meetings to share essential information such as learning from incidents and complaints and to act as needed. The trust had governance and management arrangements had been strengthened significantly since the management agreement with Western Sussex Hospitals Foundation Trust and NHS Improvement. These arrangements enabled all clinical and management staff to function in an effective and efficient manner through both line management arrangements and governance arrangements.
  • The board had invited the Good Governance Institute (GGI) carry out a review of the trust’s quality governance structures, which resulted in 31 separate recommendations being made. The trust acted to address these issues and the Good Governance institute carried out a further review reporting on progress against these actions. A focus of this work has been to strengthen quality governance arrangements at divisional level.
  • The trust had effective structures, systems and processes in place to support the delivery of its strategy including sub-board committees, divisional committees, team meetings and senior managers. Leaders regularly reviewed these structures. The trust reported regularly through its governance arrangements on progress against delivery of its strategy to the board, Trust Executive Committee and to other relevant committees. However, the structure needed more time to become fully embedded.
  • The trust executive team had worked hard to roll out Patient First Strategy across the trust. They had done this in a structured way by considering which areas of the trust would benefit the most from the methodology and training. There was no doubt that areas who had imbedded Patient first had made the largest impact on improvement. Although we were impressed at the speed and spread of improvement the trust needed more time to embed this methodology across the whole trust.
Inspection areas

Safe

Good

Updated 8 January 2019

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

  • We found a culture of openness and transparency about safety. Staff could raise concerns and report incidents, which were regularly reviewed to aid learning. Lessons learned were effectively shared and we saw changes implemented within the wards as the result of investigations.
  • Substances subject to Control of Substances Hazardous to Health Regulations 2002 were stored securely and staff knew where to find safety information regarding these products. An inspection undertaken in October 2017 specifically in relation to these regulations had identified issues in the management and storage of products. At this inspection we saw the trust had taken effective action to address these concerns. For example, all cleaning cupboards had swipe card access so only authorised staff could access these areas.
  • The trust had introduced several safety programmes to improve the monitoring of deteriorating patients and the reduction of potential harm. For example, the sepsis bundle and NEWS2, the availability of a clinical nurse specialist lead for sepsis, safeguarding huddles and safety huddles.
  • The sepsis bundle and NEWS2 scoring sheets had comprehensive sections on a full range of patient safety areas including pressure area monitoring, acuity, environment and equipment and risks and falls assessments. The huddles aided the sharing of patient information to ensure holistic, multidisciplinary care was provided. We saw that huddles were also an opportunity to focus on a topic of the week. The topic of the week during our inspection was sepsis, thus giving an opportunity to remind staff about the use of the sepsis bundle.
  • The trust controlled infection risk well. Staff kept themselves, equipment and the premises clean through the use of effective control measures such as daily and weekly checklists, to prevent the spread of infection. All staff had a good understanding of control of substances hazardous to health regulations. The service had suitable premises and since the last inspection had introduced effective processes for managing fire risk assessments. Fire risk assessments were complete and mostly up to date and practice fire drills and evacuations had become routine
  • The trust had adequate staff to keep people safe from avoidable harm and abuse and to provide the right care and treatment. Staffing levels and skill mix were planned, implemented and reviewed to keep people safe. While the lack of registered nurses remains a significant challenge, any staff shortages were responded to quickly and adequately. There were effective handovers and shift changes, to ensure staff managed risks to people who use services.
  • Statutory and mandatory training compliance had improved since the last inspection. Staff understood how to protect patients from abuse and the service worked well with other organisations to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • Managers made sure staff had the right skills to perform their role. They met with staff regularly to appraise performance and encouraged continued professional development. Practice educators on all wards and departments supported staff training within a positive learning environment.

However:

  • The printed copies of NEWS2 and sepsis assessment sections showed different trigger scores for escalation. The NEWS2 form showed a trigger score of five or more and the sepsis form showed a trigger score of three or more. Managers we spoke with reported the trust was in the process of replacing the forms. Records we reviewed and staff we spoke with provided assurance that patients were not meanwhile put at risk as staff had escalated at the lower trigger score for escalation.
  • In some areas some pieces of equipment that had not been serviced in line with the schedule. The trust had identified this as a risk and had a plan in place to mitigate this.

Effective

Good

Updated 8 January 2019

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

  • The trust provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance.

  • Staff carried out comprehensive assessments to meet people’s needs and improve their health. This included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs. They used special feeding and hydration techniques when required. They adjusted to patients’ religious, cultural and other preferences.

  • The trust monitored the effectiveness of care and treatment and used the findings to improve them. They participated in relevant local and national audits, and other monitoring activities such as service reviews, benchmarking, peer review and service accreditation. Staff shared up-to-date information about effectiveness internally and externally. Staff understood the information and used it to improve care and treatment and people’s outcomes.

  • Staff had the right qualifications and skills to carry out their roles effectively and in line with best practice. Staff received timely supervision and appraisals of their work performance and they had access to learning and development, including mandatory training. The trust had a clear and appropriate approach for supporting and managing staff when their performance is poor or variable. We saw marked improvement of appraisal completion rate from the previous inspection. The continuing development of the staff’s skills, competence and knowledge was recognised as being integral to ensuring high-quality care. Staff were proactively supported and encouraged to acquire new skills, use their transferable skills, and share best practice.

  • There was effective multi-disciplinary team working across the trust. Staff of different disciplines worked together as a team to assess, plan and provide people coordinated care. Doctors, nurses and other healthcare professionals worked collaboratively to understand and meet the range and complexity of people’s needs when planning people’s discharge or transition. People were discharged at an appropriate time and when all necessary care arrangements were in place.

  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care. Staff understood and monitored the use of restraint and used less restrictive options where possible.

  • Staff understood and recognised that the deprivation of a person’s liberty only occurred when it was in that person’s best interest, was a proportionate response to the risk and seriousness of harm to the person, and there was no less restrictive option that could be used to ensure the person got the necessary care and treatment. Staff used the Deprivation of Liberty Safeguards, and orders by the Court of Protection authorising deprivation of a person’s liberty appropriately.

  • The trust was working toward seven-day services in line with National Health Service Improvements (NHSI), Seven-day services in the NHS. We saw in the trust operational plan 2018-2019, that they plan to deliver the Seven Day Service standards for all admitting specialities by 2020.

Caring

Outstanding

Updated 8 January 2019

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

  • The trust had a strong, visible person-centred culture. Despite staff and financial challenges, staff were highly motivated and inspired to offer care that was kind and promoted people’s dignity. Relationships between people who use the service, those close to them and staff were strong, caring and supportive. These relationships were highly valued by staff and promoted by leaders.
  • Staff had support to initiate improvements in quality of care. We saw a ward manager’s innovation such as the ‘blanket project’ promoted people’s dignity and individual needs for the care of the elderly. Individual blankets were used to allow patients to recognise their own bed space and protect them from falls.
  • We saw staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Feedback from people who use the service, those who are close to them and stakeholders was continually positive about the way staff treat people. People described that staff “go the extra mile” and the care they received exceeds their expectations. We found many examples of this across all the services we visited on inspection
  • Staff involved patients and those close to them in decisions about their care and treatment. We found people who use services were active partners in their care. Staff were fully committed to working in partnership with people and making this a reality for each person. Staff empowered people who use the service to have a voice and to realise their potential. They showed determination and creativity to overcome obstacles to delivering care. People’s individual preferences and needs were always reflected in how care was delivered.
  • Staff provided emotional support to patients to minimise their distress. We also observed staff provided each other emotional support to ensure they received good health and wellbeing. Staff highly valued people’s emotional and social needs and we saw these were not only embedded in their care and treatment, but they went over and beyond to innovate the “Small Acts of Friendship” programme to help elderly patients retain dignity, social activity, mobility and well-being whilst in hospital. Feedback from patients and staff were positive.
  • There was a strong sense of togetherness amongst staff from all different grades despite facing challenges outside their control. Overall, we observed staff truly respected people and valued them as individuals, and empowered people as partners in their care. Staff recognised and respected the totality of people’s needs. They always considered of people’s personal, cultural, social and religious needs.
  • We saw a significant number of plaudits from patients, relatives and loved ones describing how exceptional the care provided by trust staff had been both for the physical wellbeing of the patient and the emotional wellbeing of their loved ones.

Responsive

Requires improvement

Updated 8 January 2019

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

  • The trust was open and transparent about the issues they had and would continue to have with capacity until the new 3Ts building project was completed. This would give the trust additional capacity. The trust had effective strategies in place to address capacity, performance and flow challenges. However, they were dependant on building work completion to create more capacity within the emergency department and the creation of additional bed capacity within the hospital.
  • Funding had been made available to secure the building of a new acute floor, which was expected to provide additional capacity to cope with the increased volume of patients who attend the emergency department. Building work was due to commence within the next couple of months.
  • This meant that in the emergency department the service took account of patients’ individual needs but was not always successful in meeting them. During busy times it was not always possible to manage individual needs if patients were cared for in ‘the cohort area’. This was the same as our last inspection. Issues around the departments inability to meet surges during demand remained a concern. The service had undertaken a number of changes since our last inspection to improve efficiency and the performance against national standards. However, performance against national targets still required improvement.
  • From June 2017 to June 2018 the trust’s referral to treatment performance was consistently worse than the England average.
  • Cardiology and gastroenterology medical specialties at the trust were below the England average for admitted RTT pathways (percentage within 18 weeks).
  • Patients were staying longer than their required recovery time in theatre due to a lack of bed availability in critical care and some ward areas.
  • Waiting times for referral to treatment within 18-weeks were below the England average in three out of the eight surgical specialities provided at the trust. Out of the remaining five, three were similar to the England average, and two were better. This was an improvement on the previous inspection when all specialties were below the England average.
  • Patients could not always access the service when they needed it. Overall waiting times from referral to treatment were worse than the national average.
  • Patients referred on a cancer pathway were not always treated within 62 days of referral from their GP. The trust was performing worse than the England average in this area.
  • The patient led assessment of the care environment audits for dementia and disability scored significantly worse than the national average across four outpatients areas that were assessed. The trust wide dementia strategy did not have any outpatient related actions.

However:

  • Since our last inspection, we saw a range of implemented initiatives designed to improve referral to treatment times and the impact this had on patients.
  • Staff provided coordinated care and treatment with other services and other providers.
  • Staff made reasonable adjustments and removed barriers when people found it hard to use or access services.
  • Managers planned and provided services in a way that met the needs of the local people. They were flexible and had made changes to improve services and support patients more effectively. The hospital had a significant redevelopment programme underway, directions to the surgical wards and departments were clear and easy to follow. Information about the building work and services was clearly available to visitors at the main entrances of the hospital.
  • Initiatives had been taken to review all patients on the waiting list for specific bowel surgery which meant no patient was waiting 52 weeks. This was an improvement since the last inspection when there was a backlog of patients waiting for surgery. Theatre utilisation rates were monitored to make sure the theatre was used efficiently.
  • Staff took account of patient’s individual needs and had access to specialist nurses and other staff to support patient specific needs. Support was available for patients with dementia, learning disabilities and mental health problems with lead practitioners and link persons at department level.
  • The trust had improved the provision of information for patients and visitors that did not speak English as a first language.
  • Where people’s needs, and choices were not being met we saw this was identified and used to inform how services were improved. An example of this was the development of a transgender and non-binary protocol. This included building the teams presence at relevant local events and working alongside local transgender support groups to encourage and support those who wished to have a family.
  • Patients referred on a two week wait pathway for suspected cancer could expect to see a specialist within two weeks of referral from their GP and the trust was performing better than the England average in this area.
  • Once a decision to treat had been made for a patient with a cancer diagnosis, they could expect to be treated within the operational standard of 31 days, and the trust was performing better than the England average in this area.

Well-led

Good

Updated 8 January 2019

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

  • The leadership team had the right skills and abilities to run a service providing high-quality sustainable care. We observed leaders working seamlessly together across departments. They were knowledgeable about clinical issues and about priorities for the quality and sustainability of the service. There was a clear management structure at directorate and departmental levels. Matrons and ward managers were visible, and ward managers told us they were well supported by the matrons, and divisional leads.
  • There was a systematic approach to continually improving the quality of services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. A robust governance system was in place with detailed information about performance this was discussed at regular governance meetings and used to demonstrate effectiveness and progress.
  • The leadership team promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff morale had improved since our last inspection.
  • There were effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. There was an up-to-date and detailed major incident plan. There had been a recent joint exercise with the ambulance service to assess the effectiveness of the plan.
  • There was a commitment to improving services by learning from when things went well and when they went wrong, promoting training and innovation. There had been a significant number of improvements across the trust since our last inspection. Professional development and high levels of staff competency were priorities for the leadership team.
  • Leaders across the trust promoted a positive culture that supported and valued staff. The staff survey showed that all questions relating to management had shown improvement since the 2016 survey. There was a significant change in the culture since the last inspection. Bullying and acceptance of poor behaviour was no longer recognised by staff. Since our last inspection the trust had introduced short monthly surveys in order that they could regularly monitor staff culture rather than waiting for the annual national staff survey. The trusts survey showed improvement in all areas. Management felt supported in dealing with under performance as there had been a focus on retraining Human Resource staff and ensuring they followed standardised policies and procedures in a timely manner.
  • The trust engaged well with patients. Several wards organised regular carers groups, where family and friends could meet and support each other.
  • The trust used a systematic approach to continually improve the quality of its services, by creating an environment in which clinical care would flourish. There were clear lines of accountability form the department to the board through the directorate governance structure. Staff we spoke with were clear about their roles and responsibilities and who or what they were accountable to or for.
  • The department had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Departments maintained a risk register, which defined the severity and likelihood of risks in the department causing harm to patients or staff. It documented the measures to be taken to reduce the risk. We saw that the risks described accurately reflected the concerns described by staff.
  • The service collected, analysed, managed and used information to support all its activities, using secure electronic systems with security safeguards. Staff had access to up to date information on patient care and treatment and were aware of how to use and store confidential information.
  • The trust engaged with patients, staff and the public to plan and manage services. We saw the staff encouraged patients to complete the family and friends test on their care and treatment. They used social media mechanism for engaging with staff and patients, they also answered, complaints, concerns and compliments on the NHS choices website. At our previous inspection we required the trust should ensure the plan to improve staff engagement is fully implemented. We saw there was an upward trend in engagement with the most significant improvement in how likely staff would be to recommend the trust to friends and family as a place to work.
  • The trust was committed to improving services by learning when things go well and when they go wrong, promoting training, research and innovations. The service and its staff demonstrated a willingness to develop and improve the service provided. The trust’s strategy, was a process of continuous measurable improvement through existing pathways, to put patients first. The trust recognised and rewarded its staff for the work they did to improve quality.
  • There was a culture of collective responsibility between teams and services. There were positive relationships between staff and leaders, where conflicts were resolved quickly and constructively, and responsibility was shared. The trust proactively engaged and involved all staff ensuring that the voices of all staff were heard and acted on to shape services and culture.

However:

  • In the outpatient’s department whilst the service had managers with the right skills and abilities to run a service providing high-quality and sustainable care, there were key vacancies in the division, and the management structure had not yet been embedded, nor was it known or understood to all staff. Staff did not feel that the divisional leadership team were visible.
Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 8 January 2019

Combined rating
Checks on specific services

Community health services for children, young people and families

Good

Updated 8 August 2014

We found children and their families were cared for by caring and dedicated staff who were supported to acquire further skills and qualifications by their team leader and manager. Staff told us they had annual appraisal and we saw evidence of this. All staff had received safeguarding training and knew how to report the signs and symptoms of potential abuse. Staff were aware of the relevant safety policies for lone workers and the provider had made every attempt to maintain the safety of staff who were working in community settings. The Children’s Community Nursing Team had recently received a Best Practice Team Award from the trust. The national audit team visited on 22 May 2014 and gave positive feedback about the service that the Children’s Community Nursing Team provided to children and families in the Brighton and Hove area.

It was evident that the team leader and manager were supported by the wider children’s services and the overarching clinical governance framework provided by the Royal Alexandra Children’s Hospital. There was a strong commitment in the Children’s Community Nursing Team to promote the care and independence of children in the care setting of their choice (home) in the Brighton and Hove area.