During the visits we spoke with fifteen patients on four wards, including wards for older people, a stroke ward and a cardiology ward. We asked patients about the way they were treated by staff, specifically how their privacy and dignity was maintained, and about how they were involved in decisions about their care. Patients told us staff treated them well, in ways that maintained their privacy and dignity. Patients said staff were friendly and treated them with respect. Comments included, “they explain what is happening and are kind and helpful”, “I received good care right from the word go” and “the nurses have been out of this world”. Most patients said they had been involved in decisions about their care, although one of the fifteen patients we spoke with said they thought their treatment had not always been clearly explained to them.

We received positive comments from patients about the choice and quality of food and of support provided to eat meals where needed. On the stroke ward we spoke with three patients who said they had received assistance to eat and drink when they had needed it. On the wards providing care for older people we were told that staff provided assistance for patients who needed it to eat and drink.

We spoke to several patients about their medicines. All the patients we spoke to said that they were happy for staff to handle medicines for them.

Patients told us there were generally enough staff available to provide the care and assistance they required. Patients gave examples of their call bells being answered quickly and staff responding to requests for assistance. Of the fifteen patients we spoke with, one said there could sometimes be a delay in staff answering the call bell.

Patients told us they were aware of the hospital’s complaints procedures and how they could raise any concerns they had, for example through the PALS (Patient Advice and Liaison Service). Patients said they had been able to raise issues of concern or questions with the ward staff and were happy with the response they had received. Patients were confident that if they had to make a complaint it would be taken seriously and investigated.

People we spoke to told us they were happy with the standard of care they received at Southampton General Hospital, and that nursing staff were lovely and responded to their needs quickly. They said that they were treated with dignity and respect, and they were involved in making decisions about treatment. They said that they received sufficient information to make decisions, and had been asked to give written or verbal consent.

Patients on surgical wards told us that they had not had to wait long for their treatment. However patients in an outpatient clinic for people with cancer said they sometimes had to wait for treatment.

People we spoke to were generally happy with the quality of the food, and some said it was excellent. Some people we spoke to said the food could be improved by more choice, including multicultural menus. Some patients on the stroke ward said they did not always get the food they wanted.

People said that the wards were generally clean, and that staff washed their hands or used antibacterial gel before and after providing treatment.

Patients on the wards told us that there was not always enough non-medical equipment, including chairs and wheelchairs. One outpatient told us that the radiology equipment often broke down.

People said there were enough staff on duty during the day and at night. There were many positive comments about staff, including the high quality of care provided and the quick response from staff. Patients said that they trusted staff at the hospital.

Most people said they had nothing to complain about, but they would know how to make a complaint if they did, and would be happy to raise a concern directly with nurses.

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

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

• In the emergency department services, we found there were delays in triage of patients that could impact on the health and well-being of patients.
• In medicine we found that not all paper records were stored securely to protect patients.
• In outpatients, we found infection control procedures were not fully applied.
• There were challenges with the aging estates for fire, water, electricity, and ventilation maintenance. The patient environments were showing significant signs of wear and tear.
• In outpatients there was not always the capacity to meet the needs of patients and their relatives attending.
• In outpatients the risks were significant to patients due to delays for waiting for ophthalmology appointments.
• In several services not all staff had recent updated mandatory training.
• Complaint responses were very detailed and had contributed to delays responding to patients.

However,

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

We saw several areas of outstanding practice:

In Urgent and emergency care for example:

• The trust was actively engaged in research across a wide spectrum of clinical conditions. Further, the service was also participating in research associated with the psychological impact of bereaved families whose relatives had been lost due to major trauma incidents.
• Careful planning and consideration had been given to meeting the needs of the local population. Environmental changes including the development and building of the new enhanced care suite and the children’s emergency department were exemplar examples.
• The arrangements for supporting vulnerable patients and other service users was exceptional. The knowledge and resources within the vulnerable adult support team ensured patients were supported in line with national best practice standards.
• Staff were supported to access post-graduate training. This ensured the skill mix and competency of staff was of a level which promoted excellent multi-professional led care.
• The department had recently introduced a comprehensive care bundle which was observed to be consistently used. The care bundle prompted staff to complete rapid assessments across a range of health measures including physical observations, falls risks and skin integrity, sepsis screening, peripheral cannula insertion records and visual infusion phlebitis management. Staff also consistently used hourly safety checklists which prompted staff to consider pain management, vital signs, level of consciousness, nutrition and hydration needs and speciality referrals for those who were identified as being vulnerable for example.
• We observed rapid attendance of clinical specialities to the emergency department when pre-alert calls were received from the ambulance service. Health professionals were well prepared and were aware of their roles and responsibilities for managing specific conditions.
• The trust had undertaken extensive work to ensure patients arriving by ambulance were handed over as quickly as possible in order ambulances could return to service to treat pre-hospital patients. Nurses were trained to undertake rapid assessments of patients, supported by a consultant.
• There were several patient groups with a mixture of mental health, substance misuse and chronic medical problems that benefited from a consistent response from health professionals. To help frequent attenders to the emergency department (ED), monthly meetings called, “The high intensity service users’ group”, chaired by an ED consultant had been established. In the meeting, patients were discussed and a care plan was agreed which may alter behaviours and contribute more constructively to the patient’s needs.
• The hospital had developed a frailty team who provided rapid assessments of patients in the ED who met certain referral criterial.
• We observed episodes of care during which patients were truly respected and valued as individuals. Patients were empowered as partners in their care both practically and emotionally.
• We considered the leadership team to be cohesive, with heightened visibility and presence across the department and well respected by peers and colleagues.

In Medical care services:

• The trust introduced registered 18 pets as therapy dogs for both child and adult services. These pets visited the stroke and dementia wards regularly.
• The trust had introduced ‘Eat, Drink, Move” initiative which had improved patient outcomes.
• The trust achieved best practice tariff status in quarter 3 of 2017. A Best Practice Tariff (BPT) is a national price paid to providers that is designed to incentivise high quality and cost-effective care. The aim was to reduce unexplained variation in clinical quality and to encourage best practice. Only 42% of the NHS trust in England achieved this.
• The trust met all the four key national standards to enable it to provide a seven-day medical service.
• The proportion of patients reviewed by a consultant within 14 hours of admission at hospital improved from 76% in 2016 to 92% in 2018.
• All cardiology patients received a 365-day echo cardiogram service and seven-day consultant. This meant that all new patients and those with complex conditions received a consultant review seven day a week including weekends.
• Reduced admissions were achieved through the consultant-led ambulatory care unit (ACU) where patients were admitted via several different routes, including GPs helped identify patients in the community who required medical intervention without the need to be admitted to the hospital.
• There was a specialist emergency assessment unit for older patients with a new frailty unit, where patients received rapid assessment by a team led by consultant geriatricians.
• The care of the elderly consultants’ locality based model improved the continuity of inpatient care, and with communication with patients and families, and with other healthcare services in the community.

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

Importantly, the trust MUST:

In outpatient services:

• Ensure the outpatient service environment is kept clean and fit for purpose. Infection control procedures are in place and adhered to.
• Ensure systems and procedures are in place to monitor and manage patient’s care and outcomes. Thus, avoiding delays in patient appointments which has resulted in patient harm.
• Ensure complete oversight of outpatient services across the trust sites for the management and leadership, governance, risk and consistency of services.
• Ensure there is a finalised strategy for outpatient services.
• Ensure staff personal property is stored appropriately and securely when on duty.
• Ensure patients are kept safe from harm such as by having working emergency call bells and observation of patients left in waiting areas.
• Ensure the physical capacity of the outpatient environments meet the needs of the number of patients waiting and being treated.

In Medical care services:

• Ensure records are stored securely.