Updated 12 October 2022
Overall summary - Trust
The merger of University Hospitals Bristol NHS Foundation Trust and Weston Area Health NHS Trust took place on 1st April 2020. This was the coming together of these organisations to form University Hospitals Bristol and Weston NHS Foundation Trust (UHBW). When a trust acquires or merges with another service or trust in order to improve the quality and safety of care, we will not aggregate ratings from the previously separate services or providers at trust level for up to two years. Therefore, we have rated services at Weston General Hospital as this inspection. However, these ratings do not form part of the Trust’s overall current rating.
The merger of the two organisations and the plan for integration of the hospitals had been significantly impacted by the COVID-19 pandemic. For the periods, 30 January 2020 to 31 July 2020 and 5 November 2020 to 25 March 2021, the NHS was in a level 4 emergency incident. This meant that the Trust was subject to national command and control directives and procedures. Plans were put on hold to allow efforts to be focused on the response to the pandemic and integration had not happened as quickly as planned.
The previous ratings for the former Weston Area Health NHS Trust no longer apply and a new rating for the Weston General Hospital location, under UHBW has been given following this inspection.
On 8 and 9 June 2021, we carried out an unannounced inspection of the trust’s medical care service at both the UHBW Bristol main site and Weston General Hospital. We also carried out an unannounced inspection of the trust’s outpatients service at Weston General Hospital. We spoke with 238 members of staff including members of the senior leadership team, nurses, doctors, managers, allied healthcare professionals, housekeeping and support staff. We also spoke with 51 patients and two visitors and reviewed 59 sets of patient records.
We also inspected the well-led key question for the trust overall. During the well led assessment we undertook a number of staff focus groups including junior doctors, clinicians, divisional directors, nursing sisters and staff representative groups.
At our last comprehensive inspection of University Hospitals Bristol NHS Foundation trust, undertaken in 2019, the trust was rated overall as outstanding.
In February 2021, we carried out a focused inspection of the Bristol Royal Infirmary (part of UHBW Bristol main site) urgent and emergency care service for adults (also known as accident and emergency or A&E) as part of our winter pressures inspection programme. A number of concerns were identified during this inspection. Notably, the service did not have enough medical staff to meet the recommended guidance for the type and size of the department or to be able to expand the service. The trust senior leadership were perceived by some staff as not having been present enough in the department to provide assurance and support, demonstrate recognition and awareness of the risks. Senior leaders were not sufficiently visible and approachable for some staff. There were serious concerns among the staff about the escalation in violence and aggression on staff working in the emergency department and the lack of action to resolve this over many months.
During that inspection and our current well led assessment of the trust, a number of staff contacted us expressing safety concerns caused by insufficient staffing levels. They described some care and treatment which was not of satisfactory quality or safety due to serious concerns around flow, performance, crowding, and timely access to safe care. Although we recognise demand for A&E services was under intense pressure, concerns remain about the trust leadership, management, and ability to support the department through this difficult time.
We undertook an inspection of medical care at Weston General Hospital in March 2021 focusing on the safe and well led key questions. Our inspection resulted in a number of concerns and led to us requesting immediate (same day) assurance about staffing levels for the following weekend.
A Letter of Intent to potentially undertake further enforcement action was also issued. An action plan was provided by the trust to explain how the risks were to be mitigated and managed. For an initial period of three months, beginning in April 2021, we increased the level of engagement with the trust to discuss the actions taken in the medical care service at Weston General Hospital.
During our core services element of this inspection, undertaken on 8 & 9 June 2021 we were significantly concerned about the safe care and treatment of patients receiving medical care at Weston General Hospital and imposed urgent conditions upon the trust’s registration. Within these urgent conditions, the trust was required to take urgent action to protect patients who will or may be exposed to risk of harm. We made this decision for the following reasons:
- The trust had not assured those patients were receiving care and treatment in a ward or department to meet their clinical needs.
- The trust did not have sufficient medical and nursing staff to meet the needs of patients.
- There was no effective clinical leadership to ensure the patients not exposed to the risk of harm.
- Leaders in Weston General Hospital did not demonstrate the capacity to run the service. They understood, but did not manage, the priorities and issues the medicine service faced. They were not always visible or felt to be supportive or approachable in the service for staff.
- The trust senior leadership team were perceived not to be present enough on the wards to understand the issues staff faced.
These were issues raised at previous inspections undertaken by us during the past six months.
The provision of training at Weston General Hospital for trainee doctors has been the subject of some 18 triggered visits by Health Education England (HEE) and the General Medical Council (GMC) since 2012. Much of the focus has been on clinical supervision including that of FY1 trainee doctors (although eight years of this time period related to the former provider of this service).
Following a quality intervention visit undertaken by HEE on 21 January 2021, three immediate mandatory requirements were raised to ensure immediate access to senior, patient facing, clinical supervision for foundation year one (FY1) trainee doctors. This was in response to evidence that these trainees were still not being adequately supervised as they managed patients in the department of medicine. In April 2021, due to continuing concern, HEE made the decision, supported by the GMC, to relocate 10 FY1 trainee doctor posts in medicine out of Weston General Hospital to the Bristol hospitals within the trust.
Following this inspection in June 2021, the ratings for both the core service inspections and the well led assessment deteriorated.
For medical care at University Hospital Bristol and Weston, we rated the main Bristol site as requires improvement for safe, this is a deterioration as this was previously rated as good. We rated the key questions of effective, caring and responsive and well led as good and the overall rating was good
For medical care at Weston General Hospital, we rated the key questions of safe and well led as inadequate. We rated effective and responsive as requires improvement. Caring was rated as good. Overall, the medical care service was rated as inadequate.
For outpatients at Weston General Hospital, we rated safe, caring, effective and well led as good. Responsive was requires improvement and overall, the service was rated as good.
We rated well-led for the trust overall as Good.
We did not inspect a number of core services at both the Bristol and Weston locations. We remain monitoring the progress of improvements to services.
You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.
What we found – Medical Care – UHBW Bristol main site
Our rating of this service stayed the same. We rated it as good because:
- The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
- Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
- Staff treated patients with compassion and kindness, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
- The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff mostly felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and staff were committed to improving services continually.
However:
- The service provided mandatory training in key skills to staff but not all staff had completed it.
- Premises were not always being used for their intended purpose. For example, additional bed spaces added to wards could compromise patient care and privacy.
What we found – Medical Care – Weston General Hospital
We rated it as inadequate because:
- The service did not always have enough nursing and medical staff to care for patients and keep them safe. The service provided mandatory training in key skills but not all staff had completed it. The design, maintenance and use of facilities, premises and equipment did not always keep people safe, the areas used for outlier patients were not suitable for this use. Staff did not always keep people safe by following systems and processes when prescribing, administering, recording and storing medicines. The service did not always learn from incidents and accidents as they did not consistently make changes and improvements when they happened.
- Staff gave patients enough food and drink to meet their needs. This service was not seen to be the same service provision for patients using escalation areas. Access to pharmacy support was not available in all escalation areas. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care but there was not always a clear record of how those capacity decisions had been made.
- The service responded reactively to meet the needs of local people and the communities served, which meant care was sometimes delayed. Forward planning to meet demand was not used. Patients could not always access services when needed and not all received treatment in the right speciality ward or area.
- Leaders had not yet managed the priorities and issues the service faced. The trust vision and strategy were not known by staff. Staff all expressed that they loved working at the hospital but did not feel supported and valued and often felt isolated within the trust. Governance processes were not effective in developing the service. Learning from the performance of the service was not always maintained or used to make positive changes. The management of risks were reactive and not planned which sometimes left patients at risk.
However:
- Staff understood how to protect patients from abuse. The infection risk were controlled well and kept equipment and the premises visibly clean. Staff managed clinical waste well. Staff completed and updated risk assessments for each patient and removed or minimised risks when possible. Staff identified and quickly acted upon patients at risk of deterioration. Staff kept good care records. Staff collected safety information on each ward and used it to improve the service.
- Managers monitored the effectiveness of some aspects of the service. Staff worked well together using a multidisciplinary approach for the benefit of patients. Key services were available seven days a week. The patients were complementary about the meals and availability of food and drinks. Staff ensured patients had enough to eat and drink and gave them pain relief when they needed it.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients, families and carers.
- The service was inclusive and took account of patients’ individual needs and preferences. Staff were focused on the needs of patients receiving care. Staff felt pride in their role and work they undertook. The service promoted equality and diversity in daily work. Engagement was being developed by the trust with staff to improve morale
What we found – Outpatients – Weston
We rated it as good because:
- The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
- Staff provided good care and treatment, gave patients enough to eat and drink when remaining in the departments for lengthy periods, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
- The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
- Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.
However:
People could not access the service when they needed it and had too long waits for treatment.