Royal United Hospital Bath

Updated 27 March 2024

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Royal United Hospital.

We inspected the maternity service at Royal United Hospital NHS Foundation Trust as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The maternity service at the Royal United Hospital provided maternity services to the population of Bath and the surrounding areas. The service worked closely together with the Local Maternity and Neonatal Systems (LMNS). Bath is in the 20% least deprived communities nationally and 7% of women and birthing people attending maternity services were from ethnic minority communities.

The maternity service consisted of one obstetric-led unit with transformation plans in progress for an alongside midwifery-led unit, two standalone Midwifery-Led Units in Frome and Chippenham, two maternity units providing community midwifery antenatal and postnatal services.

There are around 4,500 babies born with the maternity service each year. Maternity services at the Royal Unite Hospital included a maternity assessment unit, Bath Birthing Centre (BBC), delivery suite, two maternity theatres, Mary Ward antenatal and postnatal ward.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital the same. We rated it as Requires Improvement because:

• Our rating of Outstanding for maternity services did not change ratings for the hospital overall. We rated maternity services as Good in safe and Outstanding in well-led during this inspection.

We also inspected 2 other maternity services run by Royal United Hospitals Bath NHS Foundation Trust. Our reports are here:

Chippenham Birth Centre – https://www.cqc.org.uk/location/RD102

Frome Birth Centre - https://www.cqc.org.uk/location/RD121

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited the maternity day assessment unit, the delivery suite (Bath Birth Centre), maternity theatre, antenatal and postnatal wards.

We spoke with 12 midwives, 3 doctors, 3 support workers, 4 women and birthing people. We received 129 responses to our give feedback on care posters which were in place during the inspection.

We reviewed 10 patient care records, 10 ‘observation and escalation’ charts and 4 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 18 October 2023

Updated 26 September 2018

Our rating of this service stayed the same. We rated it it as good because:

• There were clearly defined and embedded systems, processes, and practices, which kept children safe and safeguarded them from abuse. The whole team were engaged in these safeguarding processes, with effective leadership from the named nurse for safeguarding children. Lessons were learnt and themes identified, taking action and changing practice as a result of when things go wrong.
• There was exceptional multidisciplinary team working. Staff, teams and services, both internally and externally, were committed to working collaboratively. They had found efficient ways to deliver joined up care to the babies, children and young people, and their families.
• We observed and heard about exceptional care being provided to babies, children, young people and their families. Feedback from children and parents was overwhelmingly positive. People were truly respected and valued as individuals. They were empowered as partners in their care and kept involved and informed.
• The children and young people’s service was tailored to meet the needs of individuals. The services provided reflected the needs of children, young people and families. They were engaged and involved when improving the design and running of the services.
• The facilities and premises met the needs of people using the service. The Dyson neonatal unit was a purpose-built centre, this was conducive to providing high quality, safe, care and treatment to neonates. The children’s centre was being redesigned to improve access and flow for day surgery.
• There was a proactive approach to understanding the needs and preferences of children and young people. This ensured individual needs were met, promoted equality and enabled accessibility.
• The children’s service demonstrated how they could be accessible, flexible and responsive to meet an increasing demand on the service. The paediatric demand management project had helped to improve patient flow, manage paediatric referrals, and support primary care.
• There were clear responsibilities, roles and systems of accountability to support effective governance and management. The processes for managing risks, issues and performance were effective and well embedded.
• Leaders had the skills, knowledge and experience to lead the service. They had a clear vision for the service which was supported by the strategy. Staff were engaged with this vision and strategy.
• There was a highly positive culture. Staff were proud to work in the children and young people service, and came across as enthusiastic and motivated. They felt their input was valued and they worked as an inclusive team.

However:

• The children and young people’s service recognised a risk around their nursing and medical staffing. There were times when the nursing team were understaffed or there were non-compliant rotas. The medical cover at night and weekends needed improvement.
• Training for advanced paediatric life support required completion or updating to ensure more nursing staff could manage emergencies.
• The processes for cleaning toys did not evidence that children were protected from the risk of infection.
• There were no risk assessments for the environment or young people’s independent use of the adolescent room or quiet room. This posed a safety risk due to the number of ligatures and lack of staff supervision.
• The children’s theatre recovery area was not appropriately separated from the adult recovery area. We identified this as a concern at our previous inspection.
• Although pain was regularly assessed and managed, pain scores were not always clearly documented within patient records.

Updated 26 September 2018

Our rating of this service improved. We rated it it as good because:

• There were clearly defined and embedded systems, processes, and practices, which kept patients safe and safeguarded them from abuse.
• There was a positive and open incident reporting culture.
• Lessons were learned and themes identified. Action was taken and practice changed when things went wrong.
• There was good multidisciplinary team working. Staff on the unit and support services, such as physiotherapy, pharmacy, dietitians, and others were committed to working collaboratively to support patients.
• Patient flow in critical care had improved. There were limited delays for patients being admitted, discharged or moved to a ward at night.
• Leaders had the skills, knowledge, experience and integrity they needed. There was a strong commitment to delivering a safe service and saving lives.
• There were clear priorities for ensuring sustainable, compassionate, inclusive and effective leadership.
• Staff felt supported, respected and valued by senior managers in critical care and the surgical division. Staff we spoke with said there was a good team spirit, and were positive and proud to work for the unit
• The unit did not comply with modern building standards, which included adequate bed spaces and other safety features. This has been assessed and was well managed within the unit. There were plans to redevelop the unit in 2019.
• Not enough nurses had their post-registration qualification in critical care nursing.
• The unit did not offer a follow up clinic for patients admitted to critical care. This meant the unit was not fully compliant with National Institute for Health and Care Excellence (NICE) clinical guideline 83 “Rehabilitation after critical illness in adults”.

Updated 10 August 2016

We have judged end of life care overall to be outstanding because:

• Staff understood their responsibilities to raise and report concerns, incidents and near misses. They were clear about how to report incidents and we saw evidence that learning was shared across the teams.

• The staff in the palliative care team, bereavement and mortuary service were all up-to-date with their mandatory training.

• People’s care and treatment was planned and delivered in line with the latest guidance, standards and legislation. The trust had undertaken a range of service developments over the 18 months prior to our inspection to support the improvement of effective care for patients with end of life care needs. New documentation had been introduced to record a personalised care plan for a dying patient.

• The trust had undertaken a project over the 12 months prior to our inspection called the Conversation Project, whose objective was to improve the identification of the dying patient and their subsequent care.

• Patients were respected and valued as individuals and were empowered as partners in their care. The evidence was universally positive about the way they were treated by staff. Several patients and relatives stated they could not think of how the care could have been improved.

• We found that people’s individual needs and preferences were central to the planning and delivery of end of life care. The trust worked with services in the local community to provide continuity of care where possible and engaged with commissioners and community services to drive improvements. Staff were proactive in their approach to understanding individual patients’ needs and wishes and in their approach to meeting the needs of vulnerable people.

• We found some aspects of leadership, particularly that of the palliative care team to be outstanding. We found that nursing, medical and healthcare staff across the hospital were being engaged and motivated to improve the service they provided in respect of end of life care. There were clear governance structures for end of life care with the objectives of the end of life working group being clearly laid out and monitored. There was positive leadership at board level for end of life care.

• All staff we spoke with were very positive about the trust as a place to work.

Updated 27 March 2024

Updated 10 August 2016

We rated this service as good overall because:

• There were good systems in place for incident reporting and learning from when things went wrong.

• Systems were in place for the safe administration of medicines and for the prevention of infection.

• The departments were clean and tidy and they scored well within cleaning and hand hygiene audits.

• Nursing staffing was good in terms of numbers and skills within outpatients and diagnostic imaging departments,

• Staff were competent in the roles they were being asked to perform. There was good multidisciplinary working both within the trust and with other external organisations such as other health care providers. A comprehensive audit programme was in place across outpatients and diagnostic services.

• Staff treated patients as individuals, and showed them respect and treated them with dignity. Patients told us how professional, kind and caring staff were towards them and how they provided emotional support for their patients. The family and friends test showed very positive results. This was reiterated in the positive comments of the 40 patients we spoke with during our inspection.

• Good governance systems were in place across outpatients and diagnostic imaging. Staff told us how their immediate line managers and divisional managers were always available and felt their view were listened to and respected. Managers also told us how proud they were of their teams and the care they provided to patients. Staff put patients at the centre of everything they did and the trust supported them to do that with an open and honest culture. Staff and patients had opportunities to give their feedback on services and they felt listened to.

However:

• Staffing was more problematic with the medical staffing numbers. This was mainly because of senior doctors retiring and subsequent problems in recruiting suitably experienced and qualified staff.

• Within some specialties patients were waiting long periods of time for their appointments. The trust was working to resolve the waiting times and acknowledged they still had improvements to make. We saw evidence that complaints were discussed at departmental meetings and changes were made where necessary to help prevent further complaints. We observed good practice for patients with dementia and learning difficulties.

Updated 10 August 2016

We rated surgery services as good because:

• The trust encouraged openness and transparency about incident reporting and incidents were viewed as a learning opportunity. Staff felt confident in raising concerns and reporting incidents. However, not all staff reported receiving feedback following the reporting of an incident.

• The trust encouraged an open culture. Staff were aware of the principles of Duty of Candour and apologised to patients when things went wrong.

• Risks to patients were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health and medical emergencies.

• Reporting on the Safety Thermometer between December 2014 and December 2015 indicated the number of reported harms to patients were low.

• The majority of feedback we received from patients and their relatives about their treatment by staff was positive. Patients gave us individual examples of where they felt staff ‘went the extra mile’ and exceeded expectations with the care they gave. Patients felt staff maintained their privacy and dignity at all times and provided them with compassionate care.

• Consent to care and treatment was obtained in line with legislation and guidance. Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded. However, we did find one incident where part of the care and treatment of a patient who lacked capacity to make a decision was not recorded on the consent form.

• Staff supported people living with a learning disability and those living with dementia to have a better experience of being in hospital. Staff were kind and patient with people living with dementia and a learning disability. We observed one-to-one care taking place and activities planned on their assessed needs. A specialist team of staff in the hospital provided support to patients living with a learning disability or dementia and for staff caring for them.

• Patients care was coordinated when a number of different staff was involved in their care and treatment, for example physiotherapists and occupational therapists. All relevant staff were involved in the assessing, planning and delivery of patient care and treatment. Staff worked collaboratively to meet patients’ needs.

• The hospital performed better than the England average in some national audits, for example, the national hip fracture audit 2015.

• The trust monitored the number of bed moves after 10pm on the surgical wards. The numbers had reduced in November 2015 compared to October 2015. However, two patients told us they had been moved very late at night and found it very disruptive.

• The service leadership was good and a cohesive clinical governance structure showed learning, change and improvement took place. Managers regularly reviewed the approach to risk management in the departments. A number of specialty meetings fed into the overall clinical governance and provided board assurance.

However:

• Patient records were not being stored securely on the admissions suite, so there was a potential risk of access by unauthorised people.

• The trust-wide Admitted Adjusted Referral to Treatment (NHS England consultant-led referral to treatment 18 week standard) performance was worse than the England average for all but one of the six months to May 2015, when the target was abolished. By November 2015 performance had deteriorated to under 60%. Over the entire period, all specialties performed below 90%.

• The hospital performed worse than the England average in some national audits, including the Patient Reported Outcome Measures (PROMs) for April 2014 to March 2015, which is based on patients reporting to the hospital on their outcome following surgery for groin hernias, hip replacements, knee replacements, and varicose veins. In relation to groin hernias for both indicators and a mixed response in the varicose veins.

• There were periods of understaffing on the surgical wards where the trust’s safer staffing numbers of qualified nurses were not met. Additional non-qualified staff were used at times to cover any gaps in the rota.

Updated 10 March 2021