North Bristol NHS Trust

We carried out this focused inspection of the North Bristol NHS Trust to follow up on the areas that were rated as inadequate and requires improvement in our inspection in November 2014. Because we rated children’s services as good in November 2014 we did not inspect them. All services had been rated as good for caring in November 2014 so we did not re-inspect this area, although we observed how people were cared for during the inspection.

The announced part of the inspection was carried out on 8, 9 and 10 December 2015 and the unannounced part of the inspection was carried out on 16 December 2015.

Overall we saw improvements had been made at this hospital, although the rating remained requires improvement.

Our key findings were as follows:

Safety:

• Although we rated safety as requires improvement in the trust, improvements had been made.

• There were significant improvements within safety in urgent and emergency care services, with patients now receiving timely assessment on arrival.

• Systems for investigating incidents were embedded in most areas. However, improvements were required in end of life care .

• Nurse staffing levels were meeting national guidelines. A review of nurse staffing had been undertaken across the trust since our inspection in November 2014 and action taken as a result.

• Although infection control procedures were followed across the trust, there were higher rates of infection for Clostridium difficile and methicillin resistant Staphylococcus aureus (MRSA) than the target for the trust for the year.There had also been an outbreak of Pseudomonas aeruginosa in the critical care unit. These had been investigated and improvements in cleaning were identified and actioned as a result.

• In the community CAMHS service, young people had access to the staff kitchen at Monks Park House, which contained knives and hazardous cleaning products. The therapy rooms and waiting room were not clean.

• Therapy rooms at Monks Park House had no alarm system and staff did not follow lone working procedures.

• The trust was not meeting its target of 85% for the percentage of staff receiving mandatory training.

• A new electronic records system had been implemented in the month prior to our inspection. Although training and support had been put in place for staff, some were hesitant and found the system difficult to navigate.

• Staff within community CAMHS services had not consistently documented that they had assessed the risk to young people.

• In most areas of the trust, paper records were stored securely. However, in the theatre department and outpatients areas, some were stored in rooms which were not secured.

Effective:

• We rated the overall effectiveness of services in the hospital as requires improvement. However, improvements had been made in urgent and emergency care services, which we rated as good.

• Across the trust there was involvement in audit and benchmarking both internally and externally. There were clear links to improvement in care within most areas.

• Mortality rates were significantly lower than expected when compared with other hospital trusts, as measured by the Hospital Standardised Mortality Ratio and the Summary Hospital-level Mortality Indicator.  However, improvement was required in patient outcomes as they were below the England average in many areas.

• Improvements had been made in supporting staff within their roles, through the appointment of nurse education practitioners and education programmes in the emergency department and in critical care. Further support was required in the theatre department for newer staff.

• Staff appraisals were undertaken across the hospital, but improvements were required within medical and community CAMHS services.

• Staff, teams and services worked well together to deliver effective care and treatment. We observed collaborative working from all staff contributing to patient care.

• Consent was obtained for any procedures undertaken by the staff. This included both written and verbal consent. In most areas documentation relating to a patient’s capacity to consent and those relating to the mental capacity act were completed appropriately. However, in some areas there were was not clear evidence that account had been take of a patient’s ability or lack of ability to make specific decisions and there were omissions in the assessment and documentation of capacity.

Responsive:

• Although there was a trust wide focus on patient flow within the hospital and improvements had been made this still required improvement. Bed occupancy within the hospital was consistently high at 96% and within critical care was above 80%. Research has shown that bed occupancy of both 85% (and above 70% within critical care services) could start to affect the quality of care provided to patients.

• The four hour target, within the emergency department, to admit or discharge patients to the hospital had been achieved for a three month period between June and August 2015. However this had deteriorated from September 2015 and in November 2015 only 82% of patients met this standard.

• There was a high level of delayed transfers of care which was frequently above 100 patients per day and at the time of the inspection was 114.However, there had been significant work undertaken since the inspection in November 2014 to facilitate patient discharges. This included the implementation of an integrated discharge lounge in October 2015.There was a focus on embedding discharge pathways and gaining pace in discharge activity.

• Within surgical services there was not timely access for patients to treatment and operations. There were long waiting times, delays and cancellations ongoing. Action to address this was not always timely or effective and had resulted in a high number of complaints. The trust performed worse than the England average for most national targets, this included the Admitted Adjusted Referral to Treatment time (where the time from referral to treatment should be less than 18 weeks). The trust was also not meeting standards for referral to treatment pathways within outpatient services.

• The number of cancelled operations was worse (higher) than the England average and the percentage of patient not treated within 28 days of a cancelled operation was above (worse than) the England average.

• This had an impact on the critical care unit which had a high number of delayed discharges from the unit and the length of stay for patients was higher than the NHS national average. This was not optimal for patient social and psychological wellbeing.

• Within maternity services, ‘flow midwives’ had been introduced to provide an overarching approach to flow within the service. This enabled midwives to focus on providing direct patient care. Although bed occupancy remained high within maternity services (excluding the central delivery suite) this had improved flow within the service.

• The needs of patients with complex needs were well understood within all areas of the hospital. Patients with dementia received care and treatment that was sympathetic and knowledgeable. The work undertaken by the dementia care team within medical services was seen as outstanding. There were 100 dementia champions within the trust (including the director of facilities) and a focus on environmental changes to support patients.

• Useful information was provided to patients and visitors and communication aids including interpreters were readily available.

• Complaints were dealt with in line with trust policy. It was easy for people to complain or raise a concern and they were taken seriously when they did so. Improvements were made to the quality of care as a result of complaints and concerns.

Well Led:

• The leadership, governance and culture of the trust promoted the delivery of high quality patient centred care.

• The vision and values within the trust were clearly articulated by staff and board members alike. There was alignment between service and trust plans. Significant work was being undertaken on the trust strategy which was being led by the medical director. This work was to be completed in early 2016.

• The board had developed significantly since our last inspection. A development plan had been initiated and coaching was ongoing. This was being cascaded to directorate leadership.

• Relationships with commissioners had improved and matured. The trust saw the development of external relationships as an area for further development.

• Governance systems had developed since our last inspection. The board and other levels of governance within the organisation functioned effectively and interacted with each other appropriately.

• The quality and safety of patient care received sufficient coverage within board meetings and other associated meetings within the trust. There was clear visibility of risks at board level.

• The leadership of the trust was knowledgeable about quality issues and priorities, understood the challenges are and took action to address them.

• Financial pressures were managed so that they did not compromise the quality of care.

We saw several areas of outstanding practice including:

• As the major trauma unit for the Severn region the department was required to report all treatment results of major trauma patients to the national trauma audit and research network (TARN). Results for 2015 showed that the emergency department at Southmead Hospital had the best survival rate of any trauma unit in England and Wales.

• Frontline staff and managers were passionate about providing a high quality service for patients with a continual drive to improve the delivery of care.

• Managers were strong and committed to the patients and also to their staff and each other.

• There was an outstanding example of responsiveness with the work of the dementia care team and the availability of 100 dementia champions in the trust including the Head of Facilities who was focussing on environmental changes.

• In the pre-admission clinic they had a pharmacist working full time who reviewed elective patients. They made sure their VTE assessment was completed. They reviewed patients’ medications, wrote them up on the medication chart and gave advice to patients about their medication (what needed to be stopped prior to admission). The purpose for this was to reduce the amount of operations cancelled due to medication issues.

• The bereavement midwife visited women in the CDS and also followed women up at home at any time, even beyond the normal time limit for postnatal midwifery care. Family support was also offered for subsequent pregnancies

• The trust had developed some good training for staff in caring for patients living with dementia. Staff explained how they were able to offer extra time to this group of patients to ensure they were well cared for and made to feel relaxed and calm in an unfamiliar environment. Staff in the pre-operative assessment clinic were able to assess patient’s cognition and report back to GPs if it was below expected levels.

• The specialist palliative care team had worked with the acute medical unit with complex end of life patients to improve patient outcomes.

• CCHP started the central intake team (CIT) to manage the risk of service users new to the service and subject to urgent referrals. This team managed new referrals for young people up to the age of 13 who were at risk of self-harm or were in need of urgent help to stabilise their mental state. Staff then referred the young person to their local team for on-going work once the crisis had passed. The young person and their carer received contact information for the C.I.T. team and the Samaritans should they enter crisis again before their follow up appointment.

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

Importantly, the trust must:

• Improve patient flow within the hospital and ensure that there is a robust hospital-wide system of bed management so as to: significantly reduce delays in patient flow through the emergency department; reduce occupancy to recommended levels within medical services; and, ensure that there is capacity within the hospital so that patients can be admitted to and discharged from critical care at the optimal time for their health and well-being.

• Records must be fully completed and provide detailed information for staff regarding the care and treatment needs of patients.

• Take action to improve the safe storage of medical notes

• Ensure patient information remains confidential through appropriate storage of records in the outpatient clinics and theatre departments to prevent unauthorised people from having access to them.

• Ensure that risk assessments in care records are consistently completed for all of the young people who use the community CAMHS service

• Ensure that the environment at Monks Park is safe for the people who use the service and staff.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated North Bristol NHS trust specialist community mental health services for children and young people as requires improvement because:

• Staff did not consistently complete risk assessments. The trust partially met the previous requirement notice

• The environment at Monk Park House was not clean and young people had access to hazardous cleaning products and knives.

• Staff did not consistently use safe lone working practices.

• The rate of completion of staff appraisals was inconsistent between teams.

• The systems in place to monitor the completion of mandatory training were not effective.

• Staff morale was variable between teams.

• There were breaches of regulations 12 and 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations. As the trust has not provided the service since 1 April 2016 these issues will be followed up with the new providers.

However:

• The trust had met the previous requirement notice regarding staffing by reviewing the staffing levels and skill balance in the CAMHS teams. The trust had employed additional staff and the service was in the process of agreeing more funding for staff posts. Existing staff had moved teams to help meet the needs of children and young people.

• The trust had governance structures to monitor the effectiveness of changes in the service design. These included monitoring the waiting list for the newly established central intake team fortnightly. Staff also had monthly meetings to feedback on the service.

• The trust had introduced new roles to improve communication between senior management and staff. This included a new integrated CAMHS lead and local teams had nominated lead roles within themselves.