During this inspection we looked at the care for people with dementia in the Bristol Royal Infirmary. This is an acute hospital which forms part of the Trust’s location called ‘University Hospitals Bristol Main Site’. We spent time in the hospital's Medical Assessment Unit (MAU), the Accident and Emergency Department (A & E) and in two wards for older people. Our findings were limited to the scope of the inspection programme and were not indicative of standards in other areas of the hospital and the location as a whole.

Patients and relatives we met with were mostly positive when talking about the staff. They commented, for example, that staff were very “very attentive” and “look after us very well”. We observed examples of good practice, such as when staff interacted well with people and were able to establish a good rapport. However we also saw occasions when staff missed opportunities to engage with the individual or did so in an uninterested manner. Where procedures and guidance had been introduced to support staff, these were not being applied consistently across the hospital.

The Trust had identified a number of areas where improvements were needed in the care of people with dementia. Some key actions had been taken, such as training for staff about dementia and developing systems for ensuring that there was good communication with other providers. However further developments were needed in order to ensure that people with dementia experienced a well planned and person centred approach to their care.

We carried out this inspection in response to concerns that were raised with us about the operating department at the Bristol Royal Hospital for Children. This hospital is part of the Trust’s location known as ‘University Hospitals Bristol Main Site’. The Trust is registered to provide a number of regulated activities from this location; the regulated activities ‘Surgical procedures’ and ‘Treatment of disease, disorder or injury’ were relevant to this inspection.

A number of the concerns related to a lack of good housekeeping and how this was being managed within the department. For example, we were told that areas of the department were “a mess” and were not being kept clean and tidy. There were also concerns about shortcomings in routines that could have an impact on the safety of patients and staff and which were not being addressed.

The inspection was limited to checking certain aspects of the operating department at the Bristol Royal Hospital for Children. The concerns we received did not relate to the care of patients and we did not look at the clinical outcomes for children who underwent procedures in the department.

We visited the department accompanied by one of our specialist advisors, a practising theatre manager. We found that there were risks relating to the premises and facilities that were not well managed. This meant that the safety of patients and standards in relation to the environment were compromised.

We went to the Bristol Royal Hospital for Children (Ward 32) and to St. Michael’s Hospital, which are part of the ‘University Hospitals Bristol Main Site’. We had visited these hospitals during inspections in 2012. The trust had not met all the standards that we inspected at the time. We were sent plans which set out the steps the trust was taking in order to meet the standards.

We saw that changes had been made at the Bristol Royal Hospital for Children. This meant that staff were better able to meet the needs of children on Ward 32. Parents said that they felt included in their children’s care. One parent told us “the support has been wonderful”.

Parents said that the staff on Ward 32 were knowledgeable and carried out their work in a friendly way. This made them feel confident about the care their children received. Staff told us there was a more planned approach to training. There had been other developments which meant that staff were being supported in their roles and had better information about the children’s needs.

The trust’s plan in relation to St. Michael’s Hospital showed how the staffing of the maternity department was being improved over time. People told us that assistance was available when needed. One person commented “there are always staff available; some are more approachable than others, but you know who to ask”. We found that the arrangements were being kept under review to ensure that safe staffing levels were maintained.

We issued a warning notice to the trust following our inspection on 5 September 2012. We had found that children on Ward 32 were at risk because there were not enough suitable staff to meet their needs. The notice required the trust to take action by 18 October 2012 to ensure that there were sufficient numbers of suitably qualified and experienced staff at all times. The trust submitted a plan to us setting out the actions they would be taking by this date.

We returned to the hospital on 19 November 2012. The inspection team included a consultant surgeon and a nurse, who were both experienced in paediatric cardiology.

We found that Ward 32 was now designated as a specialist cardiac ward. We were told that the number of beds on Ward 32 had reduced and two high dependency beds created on the Paediatric Intensive Care Unit (PICU). Other developments included a new system for assessing if children could stay on Ward 32 or needed care in a high dependency bed.

Parents on Ward 32 told us that staff were available to them when needed. One parent said “the ward seems quieter than it was in the summer and more controlled”. Staff made comments such as "it feels less anxious" when talking about the changes they had seen on Ward 32.

Overall the risk to children on Ward 32 had reduced because staff were caring for fewer children with a lower level of dependency. We found that the trust had complied with the warning notice.

We carried out this responsive inspection as a result of concerns raised with the Care Quality Commission about the care and staffing levels on Ward 32. The inspection did not look at the clinical outcomes for children whose stay in hospital included time spent on Ward 32.

Children were cared for on Ward 32 with a spectrum of treatment ranging from medical management, day case /short stay interventions, and pre/postoperative cardiac surgery. Children were treated from the southwest region and South/West Wales regions as part of an established cardiac network.

We contacted commissioners prior to our visit to Ward 32. They raised no concerns with us about the service being provided on Ward 32.

During our visit we focused on Ward 32, but we also spent time on the Paediatric Intensive Care Unit (PICU) so we could understand the working relationship between these two services. Both services were located in Bristol Royal Hospital for Children which is part of the University Hospitals Bristol main site.

During our visit to Ward 32 we spoke with six parents, five registered nurses, two health care assistants and two doctors. The majority of parents we spoke with on Ward 32 told us they had the information they required about their child’s care and treatment. One parent said “This is an amazing place. Lovely staff, lovely doctors. It is reassuring for our child. They really try to be supportive. They treat the whole family. You can ring the ward from home especially in the run up to the operation. Communication is good. There is always somebody you can ask”.

Another parent told us “care is excellent on Ward 32, but the first time we visited Ward 32 which was about a month ago, we were told the wrong information about the operation day. Our child had a cold so they could not operate. We saw five different doctors at the time who gave us different information. The second time our child was admitted we found the communication was much better. The surgeon explained everything he was going to do step by step. We were reassured”.

Staff we spoke with were committed to ensuring that children and their parents were involved in the decision making process about their care and were constantly aware that they needed to ensure dignity and privacy was maintained at all times.

All parents we spoke with on Ward 32 told us that their child had received good treatment and care and they had received good support.

One parent said that their child had never had to wait for feeds. They told us “if my child’s named nurse was busy, then another nurse would take over. It is good team work. They all muck in together. Even after a 12 hour shift, one nurse still came to see me. They wanted to show me how to wind my baby another way. They had agreed to do that earlier in the shift but did not have time”.

Another parent told us “three to four weeks ago there was a bank nurse on duty for two nights as they were short of staff”. They said that “this bank nurse was fine, but there was no continuity or communication. They did not understand our routine and woke us up when myself and child were settled for the night”.

On the day of our visit to Ward 32, parents we spoke with did not report a staff shortage. They did however comment that the staff on Ward 32 were very busy. They also commented on staff shortages on other days they had been present on the ward.

When we visited Ward 32 we found that the trust was not reducing the risk of children receiving unsafe or inappropriate care, treatment and support. This was due to the fact that ‘high dependency care’ was being delivered on Ward 32 without adequate staffing levels over a sustained period of time. The trust had established registered nurse staffing levels, but these did not reflect the high dependency of some children cared for on the ward.

Medical and nursing staff told us about the impact that the current staffing levels were having on the care and service being provided. They told us that at times observational checks do not get done or are reduced and “because of the overstretched nature of Ward 32 there was not enough time for staff to communicate with families”.

Staff told us how they tried to alleviate staffing difficulties, for example by working flexibly and taking fewer breaks. Also that the children’s needs fluctuated so allocations were arranged so that the less experienced staff cared for those children who had a lower level of dependency.

We carried out this inspection as part of our scheduled inspection programme. We visited the emergency department, medical assessment unit, ward 51 in the Bristol Heart Institute and the central delivery suite and wards 71, 74 and 76 in the maternity department of St Michael's Hospital.

We spoke with four patients on the medical assessment unit, five patients in the maternity department, five patients, one care worker supporting a patient in the emergency department and three patients on ward 51. We also observed care being delivered in the areas we visited at University Hospitals Bristol Main Site.

Overall people told us they received good care and received the information they needed about their care and treatment.

One person in the emergency department told us “I just came straight in from the ambulance and didn’t have to wait”. They said “on the whole, my treatment has been really good”. Another person we spoke with said they had a quick transfer from the ambulance to the emergency department. They said the staff were marvellous.

All five of the people we spoke with said that staff kept them informed of what was happening, although one person said that as the department got busier they had to ask.

One relative said that care on the medical assessment unit had been superb and staff had explained things to them. Another relative of a patient on the medical assessment unit contacted us following our inspection to tell us their concerns about the care provided to their family member following our inspection and a previous inspection. The concerns raised were not observed by us during out inspection and we advised the person to complain directly to the trust.

Patients on ward 51 told us the staff were very good on the ward. One person who had been a patient for five days said "so far I'm impressed".

Patients we spoke with in the maternity department felt that they had received good treatment and care. One woman on the transitional ward was completely satisfied with her care apart from one nurse/midwife making her feel pressurised into continuing breast feeding when she had already been supported by another midwife into undertaking a mixture of breast and formula feed as was her choice.

We found that the trust was non- compliant with outcome 13: Staffing. This was only for the regulated activity maternity and midwifery services. The trust provided evidence that they had a staffing level of one midwife to 38 births. Senior staff told us on the day of our inspection that they had a staffing level of one midwife to 39 births. The national guidance for midwifery staffing levels in a hospitals setting is one midwife to 28 births. We saw that staff were not able to take breaks in a timely manner. Staff throughout the maternity department said that although they were able to provide a safe service to all their patients they did not have time to give the extra care and support that some women might need. For example, staff having discussions about psychological issues or concerns that the woman might have in relationship to her birth, the baby or general care. One patient we spoke with said that she had not been shown how to bath her baby prior to leaving the hospital.

We observed patients in all areas we inspected, being supported in a professional manner. Patients were informed of their treatment. We saw that consent for surgical procedures was gained from patients. We were told that within the emergency department consent was sought verbally.

Staff spoken with were committed to ensuring that women in the maternity unit were involved in the decision making process about their care and were constantly aware that they needed to ensure dignity and privacy was maintained at all times.

We carried out this review to follow up on the improvement actions served following our review of the Histopathology service at the trust published in September 2011.

We spoke with four consultant histopathologists, one consultant surgeon, one consultant radiologist, one consultant oncologist, four cancer nurse specialists and the Joint Clinical Lead for Cellular Pathology.

We found that the trust had made improvements and were now compliant with all of the outcomes reviewed.

Processes had been put in place to ensure attendance of the core members of the multidisciplinary team (MDT) at meetings and the trust had audited compliance with this. The audit of compliance demonstrated high levels of attendance of core members of the MDT between December 2011 and March 2012.

A new policy for the management of discrepancies in cellular pathology had been put in place to clarify the procedure and criteria for reporting incidents relating to discrepancies in opinion of histopathology reports. We saw that there were low levels of discrepancies and subsequent issue of supplementary histopathology reports between July 2011 and January 2012.

We saw that the trust had taken steps to reduce the workload of consultant histopathologists through the recruitment to vacant posts within the trust and the creation of a new consultant histopathologist post. We also saw that the trust had committed to review workload within the histopathology service with a view to further recruitment. Three out of the four consultant histopathologists we spoke with said their workloads were more manageable than last year. However, one consultant histopathologist said their workload had increased in number and complexity. The consultant histopathologist did not know whether their workload was within the Royal College of Pathologists guidance.

The trust was in a position to provide raw data to evidence the ongoing review of workload within the histopathology service. At the time of our inspection there was further work going on in this area and we will continue to monitor this with the trust.

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.

We carried out this review to follow up on the compliance action for outcome 5 "meeting nutritional needs" which we served on the trust following the Dignity and Nutrition review carried out in May 2011.

We reviewed five wards across University Hospitals Bristol NHS Foundation Trust Main Site, including two children's wards and three adult wards. These wards provided surgical and medical care and included an acute ward for patients who had suffered a stroke.

We spoke with 18 people who were using the service (and their parents on the children's wards), 23 members of staff, observed the care on the wards during the lunchtime period and reviewed the care records of 17 people who use the service.

People on the adult wards told us staff within the trust supported them with their nutritional needs. One person, who had some paralysis in their left side and was unable to cut meat or butter toast, said staff always help with cutting food or opening packages of marmalade. They also said staff make sure they have the help they need at mealtimes.

People told us they had enough to eat and drink. One person said "actually they give you too much, I waste an awful lot". Another person said "I'm a very small eater and they want me to put on weight". She said that staff make sure she has a meal which is at a size she will eat rather than being overwhelmed by. We saw that this person was given a snack in the middle of the morning in addition to their main meals. A third person said "staff are caring and ask if I've had enough. They also ask my opinion about the food".

One of the people we spoke with missed meals over four consecutive days whilst they were waiting to have their surgery. This was in preparation for their surgery. On each day when it became apparent that the surgery was not going to take place the person was offered a choice of sandwiches to eat. They told us they were not offered a hot meal but they were happy with sandwiches. None of the other people we spoke with had missed a meal.

People who used the service told us they could ask for additional food if they were hungry.

We spoke with five young people and their parents on the children's wards. They told us that staff checked whether they had enough to eat and drink, although this may be through observation rather than directly asking. Four out of six of the young people we spoke with said that they had been asked about their food preferences on admission. We found that four of the young people had missed a mealtime whilst in hospital. Three of them were offered a meal on their return to the ward and were given a choice. One young person was told there was no other food available and had to wait until teatime for their next meal. Their parents told us they were not happy about this because the young person was hungry.

We observed people on both adult and children's wards were supported and encouraged to eat in a positive and respectful manner. For example, one young person did not fancy their meal when it arrived and staff asked them what they would like. Staff prepared cheese on toast as requested by the young person.

We found that care plans were not always fully completed and gave limited information to support staff in meeting people’s nutritional needs. However, staff that we spoke with had good knowledge of the needs of the people for whom they were caring. We also saw staff were meeting people's nutritional needs by supporting and encouraging them in their eating.

Most patients and their relatives told us that they were satisfied with the care and treatment they received at University Hospitals Bristol Main Site. They said they had been treated with courtesy and respect and that their privacy and dignity had been protected.

People told us that all staff explain and ask if it is alright before they help or provide any care. One patient said “Yes they do. They are respectful of our privacy. Yes they do always draw the curtains”. People told us that care is given in a respectful way but that they sometimes feel that some staff don’t like giving care or are shy.

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

Most people told us that they had received information about the care and treatment options available to them although some didn’t feel that they had received enough information. People told us that they had not received information about the facilities available within the hospital or about what will happen when they leave the hospital. People told us that they understood the information that was given to them and that staff take time to ensure that you understand. One person said “the staff don’t really have much time to talk to you unless you need a lot of care.”

People told us that staff respond to their needs quickly enough during the day time but that at night they feel that they are short staffed and that it takes longer for somebody to come and help them.

Most people told us that they were asked what they liked to be called but that in some cases staff did not use this name to address them. One person told us that they had not been asked what they liked to be called but that it didn’t matter.

We inspected University Hospitals Bristol Main Site as part of our comprehensive inspections programme of all NHS acute trusts.

The inspection was announced and took place between 22 and 24 November 2016. We also inspected the hospital on an unannounced basis on 1 December 2016.

We rated the hospital as outstanding overall. The effective and well led key questions were rated as outstanding; safety and caring was rated as good; and the responsiveness of the hospital was rated as requires improvement.

Our key findings were as follows:

Safe:

• We rated safety in the hospital as good, and found safety was good in all the services we inspected.

• Openness and transparency about safety was embedded in the services we inspected. There was a positive safety culture with good staff involvement. Learning opportunities were identified and shared with staff within their own area and across the trust to support improved safety, and led to changes in practice
• When things went wrong patients were provided with a timely apology and support. The majority of staff understood their responsibilities under the Duty of Candour requirement and could provide examples when they had been used.
• Innovation was encouraged, such as SHINE in the emergency department, which provided staff with a simple checklist to ensure patient-safety based actions were completed. Since its introduction there had been no incidents of a deteriorating patient not being identified and then managed.
• Wards and departments appeared visibly clean. A thorough cleaning programme was in place across the hospital and staff were observed using personal protective equipment to prevent infection. Staff were seen to use hand sanitising gel prior to providing care and treatment to patients.
• Medicines managed safely and effectively in the services we inspected. Learning was evidenced from incidents relating to medicines, and medicines administration records were fully completed.
• Nurse and medical staffing levels met national and local guidelines and planned to ensure safe care, and agency staff were only used when required to cover increased demand and vacancies. There were effective handovers and shift changes, to ensure staff can manage risks to patients who use services.
• Consultant cover in the emergency department did not meet the 16-hours on-site standard and was reduced significantly at weekends. However, junior doctors felt well supported and both the local management team and trust executives were aware of this concern and had actions ongoing to improve the levels of cover.
• Staff understood their safeguarding responsibilities. Staff were aware of local procedures and knew what to do if they had a concern. In surgery we found examples were staff had taken steps to prevent abuse from occurring and responding to signs of abuse by working with the safeguarding team and local authority to ensure patients were protected. There was lack of clarity around the correct processes to safeguard children between the ages of 16 and 18 years in the surgical trauma assessment unit. There were concerns in this unit around the levels of safeguarding training provided to staff working overnight.
• Staff carried out comprehensive risk assessments for patients and developed management plans to ensure risks to patients’ safety were monitored and maintained. The World Health Organisation surgical safety checklist was utilised effectively to keep patients safe. However, the environment for patients on the oncology ward presented a potential risk to the safety of patients who may be confused or could not maintain their own safety.
• Systems to ensure patients’ information was kept safe were not always implemented. Records were found to not be stored securely which could cause a potential breach of patients’ confidentiality in the emergency department, outpatients departments and on medical wards.
• Mandatory training compliance for nursing and medical staff across the services we inspected were below the hospitals target, including fire, resuscitation and safeguarding training for medical staff. Receptionists in the emergency department had not received any training or guidance to help them identify potentially seriously unwell patients.

Effective:

• We rated the effectiveness of services within the hospital as outstanding. Urgent and emergency services were rated as outstanding, and medical care and surgery were rated as good. We do not currently rate the effectiveness of outpatients and diagnostic imaging.

• Patients had comprehensive assessments of their needs, which include consideration of clinical needs, including both mental and physical health and wellbeing, nutrition and hydration needs.
• We found there was good multidisciplinary working and people received care from a range of different staff, teams or services, in a coordinated way. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.
• Patients’ care and treatment was planned in line with current evidence based guidance. Clinical care pathways were developed in accordance with national guidelines. Trust policies included reference to NICE guidance and other national strategies. However, the diagnostic imaging service did not always ensure it met best practice clinical guidance for report turnaround time for medical staff requesting diagnostic imaging to be carried out.
• Patients received care from different teams who worked together to coordinate care. We observed board rounds taking place on wards, which demonstrated effective multi-disciplinary working. For some wards complex discharges were daily occurrences. A multidisciplinary audit programme was in place and actively used by staff to encourage and monitor improved outcomes. There were links with GPs and community providers to ensure safe patient discharge.
• The hospital achieved good patient outcomes and delivered effective care in the emergency department and medical wards. A programme of local and national audits was used to monitor care and treatment. Some areas showed improvements, including the national stroke audit. In outpatient departments clinics were benchmarked against each other and actions put in place to improve outcomes. Outcomes for people who used the surgical services were mixed. The trust performed well in the bowel cancer audit and the oesophago-gastric cancer national audit and had an improving picture for the national emergency laparotomy audit. However, results were not always in line with the national scores. For example, the trust was performing worse than the national average in some elements of the hip fracture audit, although, the service provided at this trust was relatively small compared to other trusts.  Despite this, mortality rates were better than the England average in all audits we reviewed.
• Innovative approaches were used to deliver care. This included simple solutions such as a touchscreen guideline system in the emergency department resuscitation area, and the close working relationships with external partners to deliver alternative care pathways and admission avoidance programmes. The SHINE patient safety assessment tool had driven significant improvements and clearly demonstrated improved outcomes.
• Patients’ consent to care and treatment was sought in line with legislation and guidance. Staff had a clear understanding of the Mental Capacity Act 2005, Deprivation of Liberty Safeguards and patient consent.
• Not all staff had received an appraisal in the last year, with particular low compliance in the ancillary staff group. Without an appraisal, learning needs may not be identified and a plan put in place to support staff to develop their practice.

Caring:

• Overall, caring within the hospital was rated as good. Surgery was rated as outstanding for caring and all other services inspected were rated as good.

• People we spoke with praised the staff for their kindness and compassion. Patients told us they had been treated with dignity and respect at all times by staff who were respectful and caring.
• Staff often went out of their way to meet the emotional and physical needs of patients. It was clear they had taken the time to get to know and understand their patients. Staff took the time to ensure patients were comfortable, responding compassionately to patients in pain or distress and giving reassurance and support.
• We observed doctors and nurses introducing themselves when they met patients and their families for the first time. Patients in the emergency department were addressed by their preferred name. Patients and those close to them were treated as partners in their care and supported to make informed decisions about their care and treatment. We saw examples where relatives and carers were included as part of the care provided for both physical and emotional wellbeing. In outpatient departments staff talked about patients compassionately with knowledge of their circumstances and those of their families. Relatives were encouraged to be involved in care as much as they wanted to be, while patients were encouraged to be as independent as possible.
• We saw staff from all groups assisting patients and others who were confused or lost in the emergency department in a helpful and supportive manner. One doctor was seen helping a patient to the toilet.
• Staff in the emergency department had received lots of positive feedback about the compassionate care provided in the form of cards and letters, and these were displayed in the staff room.
• Patients’ privacy and dignity was respected and staff sought permission before carrying out care and treatment in all the services we inspected. In the emergency department staff used curtains around the bed spaces to provide privacy when assessing and treating patients, and ensured patients’ dignity was maintained when curtains were opened. Patients in the corridor, however, did not have the same provision to ensure their privacy. Staff did their best to ensure confidentiality and privacy in the corridor by keeping conversations as quiet as possible, but because of the close proximity of other patients and relatives conversations could still be overheard.

Responsive:

• Overall, improvements were required to ensure that services within the hospital were responsive to patients’ needs. We rated the responsiveness of services within the hospital as requires improvement. Urgent and emergency services were rated as requires improvement. However, surgical services, medical care and outpatients and diagnostic imaging were rated as good.

• Access and flow was an issue within the hospital. The hospital was consistently failing to meet the national standard which requires 95% of patients to be discharged, admitted or transferred within four hours of their arrival at the emergency department. The emergency department suffered from regular crowding, and this was cited as the department’s greatest risk. Patients spent longer in the emergency department compared to the England average.
• The emergency department and the trust were working closely with commissioners and partners to address system-wide flow issues and introduce innovative methods to improve patient flow.
• Waiting times, delays and cancellations were minimal and managed.
• Referral to treatment times for different specialties within the medicine division were not all within the England standards. Within surgery referral to treatment standards were being met 92% of the time. Where there had been a slip in performance there were clear actions to address these which had been proven to be effective. In the outpatients departments the overall referral to treatment standard on average was slightly worse than the national average.
• Processes to ensure patients who were medically fit to leave the hospital were not always timely. However, in the majority of cases, reasons for discharge delays were not attributable to the hospital.

• We found that medical and surgical services were planned and delivered in a way that met the needs of local patients. The hospital offered choice and flexibility to patients and provided continuity of care. New clinics, services and virtual facilities were implemented, to ensure services met patients’ needs. However, sometimes incurred delays due to issues elsewhere.

• The medical wards were creative to ensure patient flow through the hospital was maintained and was responsive to the ever-changing demand. There was a constant oversight by senior staff, of how different departments were managing flow, to ensure staff across all areas of the hospital prioritised patient safety, whilst maintaining the flow of patients through the hospital.
• The flow of patients through the medical division was monitored and actions taken to minimise the numbers of patients being cared for on wards other than those related to their medical condition/specialty. These patients were known as medical outliers. The hospital ensured outlying patients received the care and input from nursing and medical staff, relevant to their medical condition/specialty.
• The radiology department was slightly below the national standard of 90% of patients referred by the cancer referral process to be seen within two weeks. However; the diagnostic and imaging department was above the national average for the percentage of patients seen within six weeks.
• Patients were not always able to locate the outpatients and diagnostic imaging departments because they were not clearly signposted. A wide selection of information leaflets were available to patients; however, they were not available in other languages.
• The parking facilities did not always meet the demand leaving patients unable to find a space in a timely manner.
• There was good support for patients living with dementia or learning difficulties, and translation services were available for patients whose first language was not English. Reasonable adjustments were made for people living with dementia or with learning difficulties including use of the ‘this is me’ document and access to activities for stimulation. There were access to dedicated teams for dementia, learning disabilities and psychology which were always available.
• In response to the last inspection and feedback from patients, each outpatient department had introduced waiting time boards which displayed the waiting times for each clinic for that day.

Well led:

• We rated the well led domain as outstanding. Urgent and emergency services and surgery were rated as outstanding; and medical care and outpatients and diagnostic imaging were rated as good.

• The leadership, governance and culture promoted the delivery of high-quality person centred care. There was a clear statement of vision and values within the trust which was driven by quality and safety. We found clear statements of vision and values for medical care, surgery, and outpatients and diagnostic imaging, which were driven by safety and quality. The strategies and supporting objectives were stretching, challenging and innovative whilst remaining achievable. The emergency department strategy had not yet been drafted and agreed, although there were programmes of work underway which showed progress towards achieving the department’s vision.
• Staff understood the vision and strategy and their role in in delivering it. They were proud to work for the hospital and patient focused. Staff demonstrated a kind culture, both to patients and relatives, and to each other.
• Governance structures were complex to follow. However, the board and other levels of governance within the hospital functioned effectively and interacted well. Staff told us their responsibilities were clear and quality, performance and risks were understood and managed. Risks were escalated when needed and the information communicated to the hospital board flowed well. Processes were in place to monitor, address and manage current and future risk. Performance issues and concerns were escalated to the relevant committees and board. There was a continued focus and drive to improve safety and quality through excellent governance and leadership.
• Comprehensive and successful leadership strategies were in place to ensure delivery and to develop the desired culture and to motivate staff to succeed. Leaders understood the challenges to good quality care within and outside the organisation, and there were collaborative relationships with stakeholders.
• Staff felt leadership was good and divisional lead staff were accessible. Staff told us they felt supported and heard, and there was a collective culture of openness to drive quality and improvement. Leaders and staff demonstrated the participation and involvement of patients who used the service was important to them.
• Staff were proud of the organisation as a place to work and spoke highly of the culture. There were high levels of constructive engagement with staff. Where there had been a poor culture identified innovative and effective actions were put into place to resolve them.
• Innovative approaches were encouraged and supported, and these had a clear focus on patient safety, quality and performance, from staff led forums to improve the efficiency of work streams to research in pioneering research techniques. Changes were monitored effectively to evidence the improvements to patient care the changes had.
• Leaders demonstrated a drive for continuous learning and improvement through the ongoing evaluation and monitoring of the service and by delivering projects and innovative developments aligned to this.
• The management and governance of current performance of staff mandatory training did not ensure all staff were fully training. For medical staff, this included fire, safeguarding and resuscitation training.
• The medical division had recognised a risk in the acute oncology service at night, concerning both staffing levels and a lack of suitably skilled triage staff. However, sufficient action was required to minimise the risk to patients in both the service provision and staffing provision.

We saw several areas of outstanding practice including:

• In times of crowding the emergency department was able to call upon pre-identified nursing staff from the wards to work in the department. This enabled nurses to be released to safely manage patients queueing in the corridor.
• The audit programme in the emergency department was comprehensive, all-inclusive and had a clear patient safety and quality focus.
• New starters in the emergency department received a comprehensive, structured induction and orientation programme, overseen by a clinical nurse educator and practice development nurse. This provided new staff with an exceptionally good understanding of their role in the department and ensured they were able to perform their role safely and effectively.
• In the emergency department the commitment from all staff to cleaning equipment was commendable.
• The comprehensive register of equipment in the emergency department and associated competencies were exceptional.
• Staff in the teenagers and young adult cancer service continually developed the service, and sought funding and support from charities and organisations, in order to make demonstrable improvements to the quality of the service and to the lives of patients diagnosed with cancer. They had worked collaboratively on a number of initiatives. One such project spanned a five year period ending May 2015 for which some of the initiatives were ongoing. The project involved input from patients, their families and social networks, and healthcare professionals involved in their care. It focused on key areas which included: psychological support, physical wellbeing, work/employment, and the needs of those in a patients’ network.
• The use of technology and engagement techniques to have a positive influence on the culture of an area within the hospital. There were clear defined improvements in the last 12 months in Hey Groves Theatres.
• The governance processes within the division to ensure risks and performance were managed.
• The challenging objectives in the strategy and how they are used to proactively develop the quality and the safety of the service.
• The use of innovation and research to improve patient outcomes and reduce length of stay. The use of a discrete flagging system to highlight those patients who had additional needs. In particular those patients who were diabetic or required transport to ensure they were offered food and drink.
• The introduction of IMAS modelling in radiology to assess and meet future demand and capacity.
• The use of in-house staff to maintain and repair radiology equipment to reduce equipment down time and expenses.
• The introduction of a drop in chest pain clinic to improve patient attendance.

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

• Ensure all medicines are stored correctly in medical wards, particularly those which were observed in dirty utility rooms.
• Ensure records in the medical wards and in outpatient departments are stored securely to prevent unauthorised access and to protect patient confidentiality.
• Ensure all staff are up to date with mandatory training.
• Ensure non-ionising radiation premises in particular Magnetic Resonance Imaging (MRI) scanners restrict access.

In addition the trust should:

• Ensure chemicals are stored securely at all times in the emergency department and on medical wards.
• Ensure checks of the equipment in the emergency department’s resuscitation area are recorded consistently.
• Ensure patients in the emergency department have access to call bells at all times.
• Ensure reception staff are able to recognise patients who attend the emergency department with serious conditions and need urgent referral to the triage nurse and provide a formalised process for summoning help.
• Continue working towards providing 16-hours on-site consultant cover in the emergency department, and increase consultant cover at the weekend.
• Ensure the emergency department is accessible to wheelchair users and the layout of the reception desk allows staff to interact with wheelchair users whilst sat at the desk.
• Ensure the emergency department develops and formalises its vision and strategy.
• Ensure staff in the emergency department are up-to-date with their mandatory training, including safeguarding adults and children.
• Work with commissioners and the local mental health service provider to ensure mental health patients arriving at the emergency department receive the care they require in a timely manner.
• Ensure all staff working in the emergency department and medical staff receive an annual appraisal.
• Ensure clear signage and equipment is in place for staff, patients and visitors to wash their hands when entering a medical ward area.
• Ensure the environment in the oncology department and ward keeps patients safe and comfortable, especially for patients who may be confused or cannot maintain their own safety.
• Ensure access to the staff room on the medical assessment does not allow access to unauthorised people.
• Take remedial maintenance action to ensure the heating system on ward D703 maintains a suitable and safe temperature for staff and patients.
• Ensure staff have a greater understanding and awareness of the intercom system on the Hepatology ward, to ensure safe and prompt access to the ward and confidentiality of patient information.
• Ensure medical doctors’ inductions are undertaken in scheduled blocks and planned so doctors do not start work on the wards without an induction.
• Ensure clear signage and equipment is in place on medical wards to advise staff, patients and visitors to wash their hands when entering a ward area.
• Ensure delays in the provision of take home medicines do not delay patients.
• Ensure medical records are legibly and fully completed. This includes patient risk assessments.
• Audit records in the cardiac catheter laboratory to ensure they are fully complaint with the World Health Organisation surgical safety checklist for all surgical procedures.
• Address the risk in the acute oncology service where patients may be placed at risk by reduced staffing levels at night due to admissions of emergency oncology patients. There should be suitably skilled staff in place at night to ensure safe triage advice is given to patients accessing the emergency oncology service. Whilst the trust recognised these risks, sufficient action should be taken to minimise the risk to patients in both the service provision and staffing provision.
• Ensure pain audits are established to monitor if pain was managed effectively for patients with an ability to express their pain.
• Continue to monitor staff’s use of the Abbey Pain Scale to ensure patients with cognitive impairment in the specialised services division have an effective tool to assess their pain needs.
• Continue to ensure all efforts be made to maintain flow through the hospital and patients be nursed on the correct wards to meet their needs.
• Reduce the risk on the hepatology ward in relation to lone working practices, when accompanying patients off the ward at night to smoke.
• Improve the level of safeguarding training for staff working overnight in the surgical trauma assessment unit.
• Improve compliance for mandatory training in surgical areas.
• Improve patient outcomes to bring them in line with the national average for the hip fracture audit and improve the National Emergency Laparotomy Audit.
• Ensure patients within all of the diagnostic imaging waiting rooms can be monitored by staff.
• Monitor the World Health Organisation (WHO) Surgical Safety Checklist is always used in the appropriate area as a checklist when carrying out non-surgical interventional radiology.
• Provide leaflets within outpatient departments are available in different languages
• Check local and national diagnostic reference levels (DRLs) are on display as stated in Regulation 4(3)(c) of IR(ME)R 2000 and IR(ME) amendment regulations 2006 and 2011.

• Make improvements on the follow up backlog waiting list to meet people’s needs and minimise risk and harm caused to patients through excessive waits on follow up of outpatient appointments and  the reporting of images.

Professor Sir Mike Richards

Chief Inspector of Hospitals