We did not speak to patients as part of this review. We asked the trust to send us information to tell us what improvements they have made with management of patient records since we visited in March 2011.

We carried out this focused review of the Emergency Department (ED) and the two assessment wards (105 and 107) because concerns had been raised with us about difficulties with patient flow in and out of the department. The main issues of concern were that patients were being kept waiting in ambulances outside of the ED, that patients were waiting longer than they should in waiting areas, and that hospital beds were not available when patients needed to be admitted to wards.

We spent time with nursing and clinical staff in the ED and visited both wards and spoke to staff and patients. We were told nursing and medical staff treated people with respect and staff included them in the decision making process. Comments included, “We are waiting to see what the X-ray results are and then the doctor will come back and tell us what happens next”, “I have been waiting for a while but you expect to wait in A&E. The staff are all very helpful” and “The staff are always cheerful and helpful even though it is very busy in here”.

Trust staff reported that there had been recent occasions when the department had experienced exceptional surges in demand. Appropriate escalation measures were taken when there were higher than normal numbers of patients visiting the department. We were assured that all patients had received the care, treatment and support that they had needed and the Trust had not received any concerns as a result of these situations.

We found that ED provided care and treatment to a significant number of people who could have been seen by healthcare professionals from other services, for example minor injuries units or walk in centres. Despite this the care delivered by ED staff was professional and appropriate.

We found that all staff we spoke with were committed to their jobs, were hard working and competent. The Trust had protocols in place to deal with fluctuating demand for the services the department provided and these measures had been instigated when needed.

North Bristol NHS Trust is an acute trust located in Bristol that provides 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, trauma and plastics/burns to people from across the South West and beyond.

The trust has five main locations that are registered with the Care Quality Commission. It provides healthcare from Southmead Hospital, Cossham Hospital, the Frenchay Hospital site, the Riverside Unit and Eastgate House. The main hospital at Frenchay closed in May 2014 when the new hospital at Southmead opened, but the Head Injury Therapy Unit still provides outpatient services at the Frenchay site. The trust also provides community healthcare for children and young people across Bristol and South Gloucestershire.

The Head Injury Therapy Unit is a specialist outpatient multidisciplinary rehabilitation service for people who have had a brain injury. It is the only service remaining at the Frenchay Hospital site and has 13 staff who provide a range of therapies for 63 patients.

We inspected the Head Injury Therapy Unit as part of the North Bristol NHS Trust inspection. The trust was selected because it was an example of a medium risk trust according to our ‘Intelligent Monitoring’ model. This model looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations. Overall, we rated the Head Injury Therapy Unit as good. We found safety required improvement. Patients were treated by caring staff who were responsive to the needs of patients and the unit was well led. Our key findings were as follows:

• The unit was fully staffed with a team of specialised staff who adopted a multidisciplinary approach to patient care. Their approach to care was adapted to suit the individual needs of the patient.
• There were shortfalls in the management of safety in the department. There were issues with infection control, equipment maintenance and understanding the importance of reporting and learning from incidents.
• Staff were aware of the incident reporting tool but were unsure what would be a reportable incident.
• Staff felt well supported by their individual discipline-specific managers and the Head Injury Therapy Unit manager.
• Referral to treatment times were within 10 weeks below the 18 week target.

• Signposts were not clear on the hospital site which made the unit difficult to find. Patients were not offered transport unless they lived a certain distance away.

• The unit required refurbishment, although we were told they were moving soon. Some staff said that some of the rooms were not fit for purpose, they were cluttered, had to share with other staff and they were small.

There were areas of poor practice where the trust needs to make improvements. Importantly, the trust must:

• ensure that all staff at the Head Injury Therapy Unit understand the incident reporting policy and report all incidents
• ensure that equipment and supplies are monitored and serviced appropriately to ensure that patients are not at risk of receiving treatment and care using defective or out-of-date equipment
• ensure that infection control procedures are followed and monitored in the Head Injury Therapy Unit so that patients are not put at risk.
• ensure that the rooms remain free from clutter.

Professor Sir Mike Richards

 Chief Inspector of Hospitals