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University Hospitals Bristol Main Site Scheduled Report

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University Hospitals Bristol Main Site Scheduled Report University Hospitals Bristol NHS Foundation Trust University Hospitals Bristol Main Site Quality Report Upper Maudlin Street Bristol BS2 8HW Date of inspection visit: 10 to 12 and 21 September Tel: 0117 923 0060 2014 Website: www.uhbristol.nhs.uk Date of publication: 02/12/2014 This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this hospital Requires improvement ––– Accident and emergency Good ––– Medical care Requires improvement ––– Surgery Requires improvement ––– Critical care Good ––– Maternity and family planning Good ––– Services for children and young people Good ––– End of life care Good ––– Outpatients Requires improvement ––– 1 University Hospitals Bristol Main Site Quality Report 02/12/2014 Summary of findings Letter from the Chief Inspector of Hospitals University Hospitals Bristol Main Site consists of seven hospitals situated in the centre of Bristol: Bristol Royal Infirmary (BRI); Bristol Royal Hospital for Children; Bristol Heart Institute; Bristol Oncology and Haematology Centre; St Michael’s Hospital; Bristol Eye Hospital and The University of Bristol Dental Hospital. This report relates to findings across the University Hospitals Bristol Main Site and will refer directly to individual hospitals within the narrative as necessary. It provides acute services to a population of approximately 300,000 in central and south Bristol. In addition, it provides specialist tertiary care in cardiac surgery, children’s services, haematology, oncology and bone marrow transplants to a population of approximately six million across the whole of the South West of England and South Wales. University Hospitals Bristol NHS Foundation Trust has a staff of 8,442, the majority of whom work on the main site. We carried out this comprehensive inspection as part of our in-depth inspection programme.. The trust moved up two bands in our ‘intelligent monitoring’ system from a low risk to a medium risk between March 2014 and July 2014. Our inspection was carried out in two parts: the announced visit, which took place on 10, 11 and 12 September 2014; and the unannounced visit, which took place on 21 September 2014. Overall, this hospital was rated as requiring improvement. We rated it good for being caring and as requiring improvement in safety, effectiveness, being responsive to patients’ needs and being well led. Our key findings were as follows: Safety • Safety required improvement within surgery, medical and outpatient services. • Risks to patients were understood and there were systems in place to report, investigate and learn from incidents across the main site. However, there were concerns with regards to the management of medicines within medical and surgery services. These related to both the safe and secure storage of medicines and also the principles of safe medicines’ administration. Within medical services, not all resuscitation trolleys were fit for purpose. • In a number of services within the main site, for example within maternity services, there were innovative solutions in place to ensure safe staffing levels. However, within medical and surgical services there were shortfalls in staffing. Within theatres, staffing fell below recognised guidelines and wards were not always fully staffed to their rostered numbers and skill mix as bank and agency staff could not be recruited. There was frequent use of temporary staff within the urgent and emergency services and occasions when these services were forced to manage without a full complement of nursing staff. • Despite the ongoing building work on the site, the environment was generally clean and well maintained. However, within the outpatient services there were issues with the maintenance of equipment and the environment within the fracture clinic was not safe. We were told that a risk assessment had been completed for the building work which was ongoing but staff were unable to locate this. • Records were generally found to be well kept. However, in outpatient services there were issues with missing patient notes and records were not stored appropriately in order to maintain confidentiality. Effective • Services were found to be effective in all but surgery. Patient outcomes were below the England average for hip fractures. Fewer patients than the England average received surgery within 48 hours or were seen by an orthogeriatrician. The standardised relative risk of readmission rate was significantly higher for both elective and non-elective cases in upper gastrointestinal surgery. The processes in place for managing the patient pathway were not always consistent for these patients. 2 University Hospitals Bristol Main Site Quality Report 02/12/2014 Summary of findings • There were effective pain management processes in place. A variety of tools for monitoring a patient’s level of pain were in place, in order to meet the patient’s needs. For example, specific tools were in place for use with children and patients with cognitive impairment. Audits of pain management were carried out in all areas. Although we found that patients had received adequate pain assessments and pain relief had been recorded, audits showed room for improvement in documentation. • There was effective multidisciplinary working throughout the trust. This was notable within the children’s hospital where the recent centralisation of all children’s services had improved the multidisciplinary working on emergency trauma cases. Staff spoke of good working relationships and easy access to other specialist advice where required. • Services were working towards seven-day working across the hospitals. There was access to imaging services out of hours and at weekends. There was one theatre manned 24 hours a day, seven days a week in the Hey Grove suite. Allied healthcare professionals provided some cover over weekends. There was on-call specialist end of life care support out of hours. However, cancer clinical nurse specialists and the diabetes specialist nurses provided a service from Monday to Friday, 9am to 5pm, and there were no plans for seven-day working. Caring • Throughout the hospitals, in all services we observed caring staff providing kind and compassionate care and treatment. We witnessed positive interactions between patients and staff. • Friends and Family Tests for all the hospitals were positive, with the majority of patients saying that they would recommend the hospital. • Patients and relatives with whom we spoke were complimentary about the care that was received. Patients had a good understanding of the care they were receiving. Patients and relatives told us that they felt involved in the care and were treated with dignity and respect. • A range of services to support the emotional needs of patients and relatives was available throughout the trust. This included multi-faith spiritual spaces in a number of hospitals. Responsive • Services on the main site required improvements in order to be responsive to patients’ needs. There were significant issues with access and flow in the hospitals. This had a particular impact on urgent and emergency services; surgery; medical; critical care; and outpatient services. There were high levels of bed occupancy and poor patient flow. We found patients who were fit for discharge awaiting social care packages or social service assessment. • While there were significant challenges within the health economy regarding the availability of social care support for patients leaving hospital, these were not the sole reason for the access and flow issues. Processes for ensuring a timely discharge from hospital for patients requiring social care support were not always effective. There were also issues with the management of emergency theatre lists which meant that surgery was often cancelled or patients’ access to theatres was delayed. • The percentage of patients whose operation was cancelled and who were not treated within 28 days was consistently higher than the England average. Patients often went to theatre without an allocated bed having been identified. At times, patients were required to remain in the recovery area overnight. This included critical care patients. • There were delays in transferring patients out of critical care units, which meant that patients could not be admitted. Patients were discharged home from the recovery area and from critical care units rather than from a ward. • Some surgical patients were moved at night. This disturbed their sleep, and that of others in the areas they were moved from and to. There was an increased risk of falls and other patient safety incidents as a result of disorientation and confusion. • The trust was not consistently meeting all five of the core accident and emergency (A&E) access targets. Although patients were mostly being assessed promptly on arrival, some patients arriving by ambulance were forced to queue in the corridor outside A&E because the department had no capacity. This compromised patient experience and put them at increased risk. 3 University Hospitals Bristol Main Site Quality Report 02/12/2014 Summary of findings • Outpatient services were struggling to meet the demands on their capacity and were not meeting the 18-week referral-to-treatment targets. There were long waiting times for people in clinics, with inconsistency in the information
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