14 January 2020 to 29 January 2020
During a routine inspection
Our rating of the trust stayed the same. We rated it as good because:
At core services level, effective, responsive and well-led were rated as good overall. Caring was rated as outstanding. The rating of well-led for the trust management was good as was the trust’s use of resources. This led to a combined overall rating for the trust of good.
At core services level, safe remained as requires improvement overall following our last inspection published in late 2017, and more work was required in this area. The questions of effective, responsive and well-led remained as good. Although responsive was good overall, not enough patients were being treated in accordance with NHS constitutional referral to treatment standards. Caring retained its rating of outstanding. This outstanding rating came from caring in medical care and critical care services.
We rated well-led at the trust management level as good. The leadership had the capacity and capability and commitment to deliver high quality, sustainable care. There was a clear vision and credible strategy for the future, which involved and centred on the imminent merger with Somerset Partnership NHS Foundation Trust. There was a strong culture of high-quality, safe and sustainable care throughout the staff. However, some of the systems and processes to ensure harm to patients was avoided did not have sufficient oversight or monitoring.
There were clear responsibilities, roles and systems of accountability to support good governance and management. Information was accurate and effectively processed. There was good engagement with patients staff, and stakeholders. There were systems to support learning, and significant strength in innovation and quality improvement which were highly encouraged.
However, there was some work needed, as recognised by the trust, to tackle wellbeing and the pressure upon staff. More staff, particularly those from a black, Asian and minority ethnic background, needed to feel safe and valued and to feel confident to report abuse from members of the public, including patients and families.
The mortality investigations, encompassing the National Quality Board learning from death requirements, were not consistent, structured, or always of high quality. Learning from death and reporting did not fully meet trust policy. It was not always reported on at the trust board, and there was little evidence of learning in those reports, even though it was clearly undertaken well in the wider trust. Families or those who cared for the patient were not involved in investigations into the death where there were failings in care.
The operational performance at the trust was meeting few of the national targets or standards for treating patients. It was performing worse than the England average in some measures, particularly referral to treatment times (patients waiting to start treatment). The trust was fully aware of performance and this was responded to with recovery plans and actions which key staff were taking with sufficient seriousness.
Medical care (including older people’s care) was rated as good overall. The overall rating stayed the same, and due to improvements made, safe moved up from requires improvement to good. The trust had addressed the areas needing improvement from our last inspection, although not entirely in relation to checking emergency equipment. Responsive was rated as good, but not enough patients were being referred for treatment in a timely way and in line with NHS constitutional standards. The other key questions were rated as good and caring remained rated as outstanding.
In safe, the service had enough well-trained staff to keep patients safe and protected from abuse. There was a good safety culture. Staff had training in key skills, understood how to protect patients from abuse, and mostly managed safety well. Staff assessed risks to patients, acted on them and kept good care records most of the time.
However, the four-bed high dependency respiratory unit was not staffed in line with trust policy. Some individual risk assessments were not always completed when patients with mental health needs moved areas. Records of patients with a deteriorating condition were not always completed by medical staff after nursing staff informed them of the increasing risk. Some emergency equipment was not consistently checked on a daily basis.
Effective was good with care and treatment following evidence-based practice and outcomes for patients were good. Staff were capable and competent and their performance reviewed. Patients were able to make informed decisions. However, mental capacity documentation was inconsistent and endoscopy services had not reached accreditation.
In caring, patients were treated compassionately and to minimise any distress. The care delivered was outstanding. Patients were given time to make decisions and treated as individuals. Responsive was good and services planned to support patients and treat them in accordance with their needs. However, not all patients were treated in the time required by NHS standards. Patients and families were able to easily give feedback and this was listened to and acted on.
Well-led was good with leaders having the skills, capacity and experience to lead the service. Staff were respected and valued. Governance was effective and most risks were recognised and managed. There was a strong commitment to innovation, learning and improvement.
Critical care was rated as good overall. Effective, responsive and well-led were rated as good. Caring was again rated as outstanding. However, as previously, safe was rated as requires improvement.
In safe, the ageing facilities were complex to manage and maintain. Not all areas were fit for purpose and some equipment stores were not secure. During our inspection we found the unit had unrestricted public access, with the main entry doors being unlocked. This was resolved by the trust shortly after our inspection. The checking of the resuscitation equipment was not carried out consistently, as was the case on our previous inspection. There were not enough specialist doctors trained in advanced airway skills on duty at all times and insufficient pharmacist cover to meet guidelines – although the pharmacist cover was addressed shortly after our inspection. There were not enough allied health professional staff to provide optimal care at all times in line with recommended practice.
However, patients were protected from abuse. Staff had good infection prevention and control processes. There were enough nursing staff to provide safe care and treatment. Patients’ records were well completed and clear, and medicines were safely managed.
In effective, which was good, care was delivered on evidence-based practice. There was good pain, nutrition and hydration management. Staff were competent for their roles and worked in a strong multidisciplinary approach to patient care. However, not all staff were having annual performance reviews on time, and there was insufficient input from therapy staff at times.
Caring was outstanding with staff treating patients with compassion and kindness. There was outstanding emotional support to patients and to their families and carers. The service received overwhelmingly positive feedback about the quality of care. Responsive was good with care planned to meet the needs of patients who were treated as individuals.
In well-led, which was good, there was strong leadership with support for staff. Staff felt respected and valued. There was good governance and engagement with patients and staff. Staff were committed to service improvement. However, there was insufficient review of audits, and there were no minutes kept for mortality and morbidity reviews.
Maternity was rated as good overall although safe required improvement. We do not compare the ratings this time with our previous ratings as in the previous report they included a review of gynaecology services. Despite a challenging environment, infection risks were well managed. Midwife staffing levels were safe and regularly reviewed. Records for patients were mostly good and complete. Incidents were investigated and families were provided with honest information when things went wrong. However, staff were not compliant with the target for updating some mandatory training modules. There were issues with the safe management of medicines. Records did not always have the right information about a patient’s mental health needs. There was a lack of clarity around the cleaning for birthing pools.
Care and treatment were effective and based on national guidance. Pain, nutrition and hydration were well-managed. Staff were competent, capable and able to develop. They cared for patients and their families with kindness and insight. The service met the needs of women and included those in need of extra support. However, due to the lack of full cover from anaesthetists at all times, there were risks to the timeliness or procedures, including administration of epidurals and delays in induction of labour. Complaints were not always responded to in good time.
There was good leadership and staff felt supported and valued. There were mostly effective governance and assurance processes including management of risk. Innovation and improvement were encouraged.
Services for children and young people was rated as good overall. Safe improved from requires improvement to good, with other key questions remaining rated as good. The areas in safe we asked the trust to address had been improved. Staff knew how to protect children and young people from abuse. Staffing levels were good, and staff had the right skills and experience to provide safe care. Records were well maintained for patients, and medicines were safely managed. However, the ageing environment was not easy to manage. The ward was located some distance from other services. The unit was often too hot in the warmer months, and due to wear and tear, not easy to maintain and keep clean. Not all patient records were stored securely.
The service provided effective care based on national guidelines. Pain, nutrition and hydration were managed well. Staff had reviews of their performance and they were all involved in decisions around care and treatment for their patients. Children, young people and their families were treated with kindness and supported to make decisions.
There was good access to all the services children and young people needed, including for their mental health. However, the need to provide care and treatment to patients with mental health illnesses had an impact at times on others on the ward especially in the context of the older building and the layout of the unit.
There was strong and committed leadership. Staff promoted a strong and cohesive culture and felt supported and valued. There was good governance and assurance and staff engaged with children and young people, their families and others to help improve the services they delivered.
Other services and ratings
On this inspection we did not inspect urgent and emergency care (A&E), surgery, end of life care, or outpatients. The ratings we gave to these services on the previous inspection published in 2017 are part of the overall rating awarded to the trust this time.
Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.
Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RBA/reports