Our rating of services stayed the same. We rated it them 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.

This was a follow up visit to look at patient records held at the bedside. This was because when we visited in January 2013, the records we saw were not fit for purpose. Although we spoke with some of the patients we met on wards 1 and 4, we did not ask them about their care records.

We looked at bedside and electronic records. We found that accurate records in respect of each patient were in place and that the Trust had implemented robust audit arrangements to ensure that the improvements were maintained.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

Five inspectors visited eight wards during our three day visit to Southmead Hospital. These included maternity services, a stroke ward, general medicine ward, a surgical ward, a cardiac ward, a dementia care unit and a day assessment unit.

We spoke with at sixteen people who were users of the service, four relatives, eighteen members of staff, eight ward managers, three matrons and two doctors.

People told us that staff treated them with respect and that they were involved in decisions about their care.

People we spoke with told us that they understood the care and treatment they were receiving. Medical staff and nurses took their time to explain to people about their care before surgery, what would happen during surgery and what care they would receive following surgery to aid recovery.

Comments from people using the maternity services of North Bristol Trust were generally positive. These included “the medical staff team are excellent”, “The midwifery staff are excellent very courteous”,” The ward is very clean”,” Everything was perfect”.

People told us that staff were responsive to their needs and responded in time when they used the call bell.

The wards that we saw were visibly clean and had suitable facilities available for hand washing. There was alcohol gel available at the entrance of each ward and signs alerting visitors to use it. People who use the service told us that they felt that the wards were cleaned regularly. We observed cleaning of areas being carried out during the visit.

Staff supported and encouraged family members to be involved with care as confirmed in conversations with relatives and staff working on the wards.

People who use the service told us that they felt or were aware that the wards were short staffed and that care staff were working very hard to ensure that everyone’s care is delivered. One person said "I am aware the ward was short staffed but this has not impacted on the care I have received", another person said "they were short staffed yesterday and the ward manager assisted with the care", another person said "I was told that they [staff] were busy and I would have to wait for half an hour before could be assisted I was not happy".

Generally people told us the nurses were good and responded to their needs and were knowledgeable about what they were doing. One person said "the younger nurses are very patient", another person said "the surgeons appeared rushed".

North Bristol Trust seeks the views of people, using in-patient surveys. The Trust uses the information gathered to monitor and improve the quality and safety of services. This was confirmed in quality audits we saw completed on wards. We were told by the senior management team that where common trends had been identified matrons would then liaise with the wards to devise an action plan to address the issues.

Most patients and their relatives told us that they were very satisfied with the care and treatment they received at Southmead Hospital. They said they had been treated with courtesy and respect and that their privacy and dignity had been well-protected.

We observed personal care being provided behind closed curtains including examinations and discussions with medical staff. Although some of the discussions could be heard throughout the bay area as observed on the day of our visit.

We observed staff that were polite, friendly and sensitive. They were involving people whilst undertaking a range of care tasks. The atmosphere on one of the wards we visited was calm and welcoming in contrast to the other that appeared busy although welcoming.

Men and women did not have to share accommodation or bathroom facilities. There were signs in place to promote awareness. There is a dignity policy which includes reporting breaches on where people have had to share accommodation with the opposite sex.

Some people told us they had been asked what they wanted to be called on their admission to hospital and that this was respected throughout their stay. However, one person said “I was not asked what I wanted to be called as I would prefer to be called by my title (Mrs) and surname”. We found that some people did not have their full names written up over their beds or what they preferred to be called by.

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 reinspect 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 at Southmead Hospital, 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 as not all incidents had been reported, for example, those from mortuary and bereavement services.
• There had been a review of nursing and midwifery staffing in all areas of the hospital and numbers had increased in urgent and emergency care, medical services, critical care, surgical services and maternity services.
• In places this increase in numbers had been through the recruitment of staff requiring development and in most places, notably urgent and emergency care and critical care, training and development support had been put in place. However, in the theatre department, improvements were required in ensuring that new staff were developed sufficiently to support the flow of patients through theatre lists.
• Wards and departments were visibly clean, and equipment had ‘I am clean stickers’ on them. Staff were observed to observe the ‘bare below the elbows’ policy in the trust. Handwashing facilities were readily available at the entrance to each ward and alcohol hand sanitising gel was available. Staff were seen to be using the personal protective equipment (gloves and aprons) in all areas.
• The hospital did, however, have higher than expected levels of Clostridium difficile infections and MRSA infections reported.
• Following a Pseudomonas aeruginosa colonisation in the critical care department, the trust reviewed the cleaning regimen and replaced all of the tap faucets in the department. A full investigation was undertaken and actions identified to prevent further incidents occurring.
• 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. The new system involved more steps for emergency department staff to complete when a patient attended the department and this was having an effect on the time taken with each patient.
• In most areas of the hospital, paper records were stored securely. However, in the theatre department and outpatients areas, some were stored in rooms which were not secured.
• Improvements had been made in medicines management. However, some controlled drugs cabinets were not of sufficient size to accommodate all medications and in surgical services it was not clear if the temperatures of medicines fridges had been checked or actioned if outside of range.

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 hospital there was involvement in audit and benchmarking both internally and externally. There were clear links to improvement in care within most areas. However, within end of life care the results of audit and monitoring had not yet enabled objective improvements in quality.
• 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 services.
• In urgent and emergency care and surgical services assessments of patient need were clearly undertaken and recorded within patient records. However, within medical and end of life care services assessments were not always complete or recording the full range of patient needs. Within medical services this was due to omissions in the completion of the electronic patient record via the new electronic recording system.
• Within medical services there were omissions in the assessment and documentation of patient capacity to consent to care and treatment. Within end of life care staff completing do not attempt resuscitation documentation were not always recording in line with the Mental Capacity Act 2005 Code of Practice.
• Throughout the hospital we saw patients receiving timely pain relief.
• Patients’ nutrition and hydration was well managed in all areas, including the emergency department where housekeeping staff provided regular hot drinks rounds.

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 standard, 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 standards, 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 was 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:

• Improvements had been made in leadership across the hospital. In urgent and emergency care and medical services we rated the well led domain as good. However, we rated the well led domain in surgical and end of life services as requires improvement.
• There was strong clinical leadership within urgent and emergency care services which had led to improvements in safety, effectiveness and some improvements in the responsiveness of the emergency department. The vision and values were clear and focused on safety and quality. Governance arrangements had been strengthened since our inspection in November 2014 and risks and quality were regularly monitored and escalated when necessary.
• The medical directorate had gone through a period of consolidation by embedding governance and having a greater focus on learning change and improvement.
• There was a culture of candour openness and honesty within the hospital. However, within the theatre department staff did not always raise concerns or report incidents because they were not always taken seriously or treated with respect when they did.
• Governance arrangements in the theatre department required improvement and did not identify when important safety checks were not carried out.
• Improvements in leadership for the specialist palliative care team had occurred since the last inspection. Governance and performance management arrangements within end of life care across the trust did not always operate effectively. Risk registers were not in place for end of life care and risks did not appear on the hospital or trust risk register. Quality issues and priorities were understood but the actions required to ensure change were not yet fully embedded.
• In most areas of the hospital staff felt supported. However, within the end of life care formal substantive leaders were absent for chaplaincy and bereavement services, although temporary leadership arrangements were in place for staff in bereavement services. In the theatre department staff did not feel that leaders were visible or provided the guidance they needed.

We saw several areas of outstanding practice including:

• As the major trauma centre 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 centre 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 was one of several in the country to join acute medicine unit board rounds to ensure patients’ needs were identified to access end of life care. We saw evidence that the specialist palliative care team had worked with the acute medical unit with complex end of life patients to improve patient outcomes.

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.

• The medical directorate must improve access and flow in order to reduce occupancy to recommended levels.

• Records must be fully completed and provide detailed information for staff regarding the care and treatment needs of patients.
• Ensure there is capacity in the hospital so that patients can be admitted to and discharged from critical care at the optimal time for their health and wellbeing. This includes a robust hospital-wide system of bed management
• 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.

In addition the trust should:

• Check equipment in the emergency department resuscitation room to ensure that it is ready to use.
• Review patient group directives in the emergency department to ensure they reflect current best practice.
• Ensure that psychiatric patients attending the emergency department at night have timely access to appropriate treatment.
• Ensure that the emergency department computer system is easy for staff to use and can provide information needed to manage current and future performance.
• Integrate new emergency department triggers for escalation action into the hospital full capacity protocol.
• Chemicals and substances that are hazardous to health (COSHH) should be secured and not accessible to patients and visitors to the medical wards.
• Opening dates or in used expiry dates should be added to medicines where appropriate.
• Controlled drugs cabinets should be of an adequate size for the required controlled drugs.
• Medicines refrigerator temperatures within surgical services should be monitored, recorded and actions taken in accordance with trust procedures.
• Equipment and medicines required in an emergency should be tamper evident.
• Make sure any changes to practice should be shared with bank and agency staff who work a number of shifts so they are update to date.
• Make sure auditing of safety checks of anaesthetic machines takes place to make sure they are being done.
• Make sure cleaning of all theatre equipment takes place and provide evidence to support this.
• Increase staff locker capacity in theatres to prevent storage of personal bags in the theatre room and to improve infection control practices in theatres.
• Review the cleaning of laryngoscope handles to make sure they are in line with the current guidance.
• Review the orange bags being used, as they were prone to leaking onto the cages used to transport clean linen in theatre.
• Look at ways of making theatre management more visible to staff and improving staff morale.
• The trust should improve the facilities for patients in interventional radiology if this is to be used as the escalation ward.
• Continue to work on improving the WHO safe checklist score to meet their target.
• Use the information from themes of complaints to make changes to practice to reduce the number of complaints received.
• Ensure mandatory training is given suitable priority so that compliance rates across the hospital meet trust targets.
• The system for checking resuscitation equipment should be consistent across the directorate.
• Staff should ensure patient notes have clear records of assessments and best interest decisions for patients who lack the mental capacity to make their own decisions.
• The security of confidential patient records should be reviewed to ensure they are safe from removal or the sight of unauthorised people.
• Continue to support new staff in critical care to attain a post-registration award in critical care to ensure a minimum of 50% of nursing staff hold such a qualification.
• Continue the recruitment programme in the critical care unit to ensure the recommended numbers of safe staffing, including supernumerary coordinators, are achieved at all times.
• Ensure store rooms in critical care are kept locked at all times when unattended.
• Ensure care records are available in a timely manner to allow useful mortality and morbidity reviews to take place.
• Review the critical care response to deteriorating patients within the hospital, and follow-up of patients discharged from critical care.
• Monitor the numbers of elective surgery that are cancelled as a result of no critical care beds being available.
• Consider instructions for cleaning baths between uses are readily available for staff use.
• Make available antibacterial hand disinfectant at the entrance from Quantock Ward to the Central Delivery Suite.
• Consider how they are to progress towards meeting the Royal College of Obstetricians and Gynaecologists guidance for dedicated consultant hours on the delivery suite
• Consider auditing the completion and submission of HSA4 forms in accordance with the legal requirements for termination of pregnancies.
• Ensure sufficient staff within the recovery area in the maternity theatre department to meet the Association of Anaesthetists of Great Britain and Ireland guidance which states that no fewer than two staff (of whom at least one must be a registered practitioner) should be present when there is a patient in the post anaesthetic recovery area who does not fulfil the requirement for discharge to the ward.
• Ensure that risk registers include risks associated with care for end of life.
• Ensure that care plans for end of life care and associated supporting documentation including resuscitation information demonstrate complete and consistent recording to provide staff with full detail regarding the patients’ assessed care needs.
• Ensure that patient records for patients at end of life care demonstrate complete and consistent recording including the relevant consent and decision making assessment requirements for specific decision making in relation to the Mental Capacity Act 2005 and resuscitation decisions.

Professor Sir Mike Richards

Chief Inspector of Hospitals