Royal United Hospitals Bath NHS Foundation Trust Royal United Hospital Bath Quality Report

Royal United Hospitals Bath NHS Foundation Trust Royal United Hospital Bath Quality Report Combe Park Bath Somerset BA1 3NG Tel: 01225428331 Date of inspection visit: 15-18 and 29 March 2016 Website:www.ruh.nhs.uk Date of publication: 10/08/2016 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 ––– Urgent and emergency services Requires improvement ––– Medical care (including older people’s care) Requires improvement ––– Surgery Good ––– Critical care Requires improvement ––– Maternity and gynaecology Good ––– Services for children and young people Good ––– End of life care Outstanding – Outpatients and diagnostic imaging Good ––– 1 Royal United Hospital Bath Quality Report 10/08/2016 Summary of findings Letter from the Chief Inspector of Hospitals We inspected the Royal United Hospitals Bath NHS Foundation Trust as part of our comprehensive inspections programme of all NHS acute trusts. The inspection was announced and took place between 15 and 18 March 2016. We also inspected the hospital on an unannounced basis on 29 March 2016. We rated the hospital as requires improvement overall. The effective, and well led key questions were rated as good, caring was rated as outstanding and the safety and responsiveness of the hospital was rated as requires improvement. End of life care within the hospital was rated as outstanding, but critical care services were rated as requires improvement. Our key findings were as follows: Safe: • We rated safety in the hospital as requires improvement. Urgent and emergency care, critical care and maternity and gynaecology were rated as requires improvement. All other services were rated as good. • There were periods where staffing and skill mix were not as planned by the trust. This was mitigated by higher numbers of healthcare assistants and in some cases supervisory ward sisters acting in a clinical capacity. Nurse staffing and skill mix was assessed and reviewed twice a year using recognised tools to determine staffing levels, in places wards had not been fully engaged with this in the review in August 2015, but were in February 2016. Although there was awareness and systems in place to flex nurse staffing across wards, these were not clear and relied upon the judgement of senior staff rather than being grounded in clear processes. There was, however, a process in place for the authorisation of the use of agency staff and a staffing escalation policy in place. Recruitment was ongoing for nursing vacancies across the trust and the trust was training assistant nurse practitioners in order to provide additional support. • The trust commissioned a fire safety review in November 2015.Actions were being taken to mitigate the concerns raised. However, these were ongoing and would not be complete until quarter three of the 2016/17 financial year. The trust told us about the actions they were taking and provided an action plan but this action plan did not clearly show the progress and interim mitigating actions. • The records maintained regarding the servicing, repair and cleaning of equipment was not always clear and did not provide assurance that all equipment was being regularly maintained. Within maternity services, there were not sufficient numbers of key equipment available, for example epidural pumps. • In some areas of the hospital, for example in critical care and maternity services, cleaning required improvement. There had also been a higher rate of infections with Clostridium difficile than the hospital target, and also a case of legionella colonisation on one of the wards. • Openness and transparency about safety was encouraged and embedded across the hospital. Systems were in place for the recording, investigation and learning from incidents. Staff understood their responsibilities to raise and report concerns, incidents and near misses. There was evidence that learning was widely shared across the hospital. However, within critical care not all incidents were reported and had become ‘every day events’. • When something went wrong, patients received a sincere and timely apology.They were told about any actions taken to improve processes to prevent the same happening again. The majority of staff understood their responsibilities under the Duty of Candour requirement and could provide examples when they had been used. 2 Royal United Hospital Bath Quality Report 10/08/2016 Summary of findings • Performance showed a good track records and steady improvements in safety.The morality risk was similar at weekends to that during the week within the hospital and the trust scored within the expected range.Rates of new pressure ulcers, falls and catheter acquired urinary tract infections were monitored with no discernible trends. There were techniques in place to help patients avoid harm. These included: the discrete identification of risks on the patient board, for example, their risk of falls and vulnerable pressure areas; and, comfort rounds carried out by staff. • Medicines were managed effectively throughout the hospital, with secure storage and effective recording where appropriate. • Records throughout the hospital were stored securely. However, there were some instances where confidential information was not secure if left unattended. • The completion of records was variable within the hospital. In most areas records were completed and there were clear plans of care and treatment for patients. However, within the emergency department, records were not always completed in order to ensure that it was easy to identify if a patient’s condition was deteriorating. • In most areas of the hospital there was a proactive approach to anticipating and managing risks to patients. These were embedded and were recognised as being the responsibility of staff. However, in the emergency department, the time taken to triage and assess patients who self-presented at the department (not admitted by ambulance) was not consistently recorded and accurate performance data was not available. This meant we could not be assured that patients were quickly assessed to identify or rule out life or limb threatening conditions to ensure patient safety. We saw examples of patients waiting over an hour for initial assessment. • There were clearly defined and embedded systems, processes and standard operating procedures to keep patients safeguarded from abuse. Staff understood the processes and there was evidence of reporting occurring as necessary. Effective: • We rated the effectiveness of services within the hospital as good .All services that we rate for effectiveness were good with the exception of medical care which requires improvement. • Patients care and treatment was planned and delivered in line with current evidence-based guidance and standards. We saw good levels of compliance with recognised care pathways, including those for sepsis and stroke care within the emergency department. • Compliance with protocols and standards was monitored through both internal and national audit. Performance with national audits was mostly in-line with or better than other trusts. For example, the trust was rated C in the Sentinal Stroke National Audit Programme, which placed them in the top 44% of trusts offering stroke care. There was evidence that audit was used to improve performance and practice, for example in the treatment of sepsis in the emergency department. However, improvement was required in the National Diabetes Inpatient Audit from 2015 and the Myocardial Ischaemia National Audit Programme form 2013/2014. Improvements were also required in the audit of compliance with guidance on the termination of pregnancy and the monitoring of rated of infection post caesarean section for learning. • Patient outcomes were generally good, although patient reported outcome measures (PROMs) for patients receiving surgical treatment for groin hernias and varicose veins were worse than the England average. 3 Royal United Hospital Bath Quality Report 10/08/2016 Summary of findings • In most areas of the hospital, staff were provided with the training and support they needed to do their job. In the emergency department nursing and medical staff received regular teaching and supervision. They were encouraged and supported to develop areas of interest in order to develop professionally and progress in their careers. However in medical services, there was not a reliable system for staff supervision, and appraisal performance in services for children and young people required improvement. • Care was delivered in a coordinated way with support from specialist teams and services. There was close, collaborative working across the hospital, for example between the emergency department, stroke team, discharge assessment team, medical nurse practitioner (older person's unit), mental health liaison service and the alcohol liaison service. • Staff had a good understanding of the Mental Capacity Act 2005. However, for Deprivation of Liberty Safeguards, the trust policy was not in line with the code of practice and stated that for the majority of patients, their stay in hospital would be less than 72 hours so the wider Mental Capacity Act should be applied. For those remaining in hospital for longer than 72 hours the ‘acid test’ for deprivation should be applied.The

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