University Hospital Southampton NHS Foundation Trust

University Hospital Southampton NHS Foundation Trust has had foundation trust status since 1 October 2011. It provides services to 1.3 million people living in Southampton and south Hampshire, as well as specialist services to over three million people living in southern England and the Channel Islands. Deprivation in the City of Southampton is higher than average (79 out of 326 local authorities). The surrounding areas of Eastleigh, Fareham, New Forest and Test Valley are less deprived. The trust is also a major centre for teaching and research, in partnership with the University of Southampton, the Medical Research Council and the Wellcome Trust. The NHS trust has approximately 1,372 beds and over 10,000 staff.

The trust includes Southampton General Hospital, the Princess Anne Hospital and Countess Mountbatten House, and also runs outpatient services from the Royal South Hants Hospital.

We carried out this comprehensive inspection as part of our programme of inspecting and rating acute hospitals. The trust had not been flagged as potentially high risk on the Care Quality Commission’s (CQC) Intelligent Monitoring system. We inspected urgent and emergency care, medical care (including older people’s care), surgery, critical care, maternity and gynaecology services, services for children and young people, end of life care, outpatients and diagnostic services.

For specific information about services, please see the reports on Southampton General Hospital, the Princess Anne Hospital and Countess Mountbatten House. Outpatients services at Royal South Hants Hospital are noted in the outpatients and diagnostic imaging section of the Southampton General Hospital report.

Overall, we rated the trust as 'requires improvement'. We rated it ‘good’ for caring, effective and well-led services, but 'requires improvement' for providing safe and responsive care.

We rated A&E, medical care, maternity and gynaecology, and children and young people’s services as ‘good‘ and surgery, critical care, end of life care, and outpatient and diagnostic services, as ‘requires improvement’. Countess Mountbatten House was rated as ‘good’.

Our key findings for the trust were as follows:

Is the trust well-led?

• The trust had a vision and clinical strategy for 2020 that had been written eight years ago. This was being refreshed to take account of its key tenets, and to provide a more up-to-date strategic vision on excellence in healthcare, working in partnership and supporting innovation. Current strategies and plans were dealing with the immediacy of the increasing demand for services, and balancing quality, targets and finance was a serious challenge. The trust was having to take difficult decisions on long-term goals to ensure sustainable services.
• Governance arrangements were well developed at trust, division, care group and ward level. The trust had a comprehensive integrated performance report to benchmark quality, operational and financial information. Clinical quality dashboards were being developed from board to ward, to improve the quality of information, monitoring and reporting. Risks were appropriately managed and escalated to the board overall, although this did not happen in a few areas, and the actions taken on a few risks were not always timely. Safety information was displayed in ward and clinic areas for patients and the public to see.
• The leadership team showed commitment, enthusiasm and passion to develop and continuously improve services. The trust identified a challenging patient improvement framework, and could demonstrate some improvements, if not achievement, in many areas.
• All staff at every level, told us about the visible and inspirational leadership of the chief executive. Staff were positive about working for the trust and the quality of care they provided. The trust was in the top 20% of trusts for staff engagement. There was a focus on improving patient experience, and public engagement was developing to ensure the public had jargon free communication; there was consultation on services, and patients would be told how their feedback was used to improve services.
• The trust had a culture of innovation and research, and staff were encouraged to participate. There were examples of research that were nationally and internationally recognised. Staff were supported to lead innovation projects in their work environment.
• Cost improvement programmes were identified, but savings were not being delivered as planned. The trust was taking further action to reduce the risks of financial deficit but maintain quality.

Our key findings for the trust’s services were as follows:

Are services safe?

• National data indicated that the trust was reporting more incidents than the national average. Staff were encouraged and found it easy to report incidents on the electronic system. The greatest proportion of incidents were low and no harm incidents. Slips, trips and falls was the top serious incident requiring investigation (SIRI) and action was being taken to reduce falls across Southampton General Hospital. We found that incidents were investigated and learning shared within services, but learning across services, such as outpatients, could be improved. The reporting of incidents in diagnostic imaging services was not always robust and transparent.
• In most services there was a culture of openness and transparency when things went wrong, and the trust was well placed to meet the new regulations relating to Duty of Candour.
• The NHS Safety Thermometer is a monthly snapshot audit of the prevalence of avoidable harms, including new pressure ulcers, venous thromboembolism (VTE or blood clots), catheter urinary tract infections (C. UTIs) and falls. The information was monitored throughout the trust and the results were displayed for the public to see in clinical areas. Falls were starting to reduce and C. UTIs were consistently low.
• The hospital was working to reduce the prevalence of pressure ulcers incrementally over time. The trust had a target to reduce occurrences by 20% over the year; this had not been fully achieved in 2013-14. Hospital data indicated there was a slightly decreasing trend for avoidable grade 2, 3 and 4 pressure ulcers by the end of 2014.
• The trust had a zero tolerance for hospital infection rates for MRSA. MRSA rates were higher when compared to trusts of similar size and complexity, but there had been no cases since July 2014.. The trust’s infection rates for C. difficile were lower when compared to trusts of similar size and complexity.
• The hospital was visibly clean and patient-led assessments of the care environment (PLACE) scored higher than the national average for cleanliness. Cleaning services were outsourced, but domestic staff were seen to be part of the ward teams.
• During the inspection in December 2014, there was an outbreak of Norovirus and appropriate action was taken to control and contain this, through closure of wards and bays. We observed, however, that not all staff were consistently following trust infection control policies in relation to hand hygiene; this was a concern given the outbreak. We brought this to the attention of senior management and at an unannounced inspection in January 2015 we found improved practice. There were good infection control and hand hygiene practices at the Princess Anne Hospital.
• Safeguarding processes to protect vulnerable adults, children and young people were embedded.
• Staff had access to a range of mandatory training, and attendance was monitored electronically. Mandatory training on end of life care had not yet been implemented.
• Most medicines were managed and stored safely, but some medicines needed better secure storage in theatres. In ophthalmology, a patient specific direction was developed under a patient group direction and healthcare assistants were administering eye drops. This was not in line with the medicines legislation and best practice guidance.
• Some parts of the buildings were constructed before the current building guidelines for health facilities were established, and this, along with the increased activity at the hospitals, resulted in some areas being cramped and outdated, including the emergency department, the Princess Anne Hospital, some children’s wards, and the general intensive care unit (GICU). There were also safety concerns about deficiencies in maintenance, particularly in older parts of the building.
• Most services were well equipped, but there were shortages of some basic equipment across some wards and departments. There were also some delays in the provision of pressure relieving equipment, as the external company who were supplying it were unable to meet demands. Maintenance and checking of equipment was not undertaken regularly in some areas.
• At the Princess Anne Hospital, hoisting equipment was available on Bramshaw Ward. But not all staff were aware of the location or correct use of equipment for the safe evacuation of a woman who may have collapsed in a birthing pool, on either the delivery suite or at the Broadlands Birth Centre. One of the four operating tables could not be lowered adequately and surgeons were required to stand on stools, which increased both the risk of back injuries to the surgeon and also patient risks during surgery. At the time of the inspection there was one bariatric table in use so two theatres were not compliant
• Episodes of interruption to the electrical power on GICU interfered with lighting and with the continuous functioning of some equipment, such as monitors.
• The siting of a gamma camera outside of the confines of the nuclear medicine department created a potential radioactive hazard. Mitigating actions had been put in place, but further action was needed to remove the risks.
• Nursing staffing levels had been reviewed and assessed across the hospital using the Safer Nursing Care Tool. High levels of vacancies were impacting on consistency of staffing to the required levels. Staffing levels were reviewed on a shift-by-shift basis and staff moved across wards to try to mitigate risks; however, this led to concerns about lack of continuity and relevant skills to meet the needs of patients of different specialties. This was accentuated by the high number of, particularly medical, outliers (patients not on medical wards) across the hospital due to high demand and insufficient capacity.
• Funded midwife to birth establishment was 1:28 in line with the Royal College of Obstetricians and Gynaecologists (RCOG) recommendations. However, with sickness and maternity leave the current ratio was 1:31, which was below than the England average of 1:29. There were core midwives who were allocated to different areas. Midwives then followed women to provide their care. As a result, midwives reported frequent moves to different work areas. Most movement occurred in order to provide one-to-one care to women in labour. As a result, midwifery staffing on the ante- and postnatal areas was, at times, below the recommended numbers. This resulted in the care of women in these areas being delayed.
• Low staffing levels in diagnostic imaging services, in particular radiographers, was having an impact on safety.
• Medical staffing was at safe levels in most services and there was an innovative model of 'lead consultant for out-of-hours' (work). However, there was not an interventionist in the neuro intensive care unit (NICU) at night for patients who need critical care treatment, including respiratory support. There was insufficient medical cover, particularly at consultant level, for end of life care services across the hospital.
• The trust reported 98 hours dedicated consultant cover on the delivery suite, which fell below the recommended 168 hours of consultant presence to meet the recommendations of the RCOG Safer Childbirth (2007). There was a separate on-call rota for gynaecology and obstetrics, which meant that medical staff were not required to provide cover to both areas.
• New end of life care plans had been introduced in August 2014 as a pilot on some selected wards. This was in response to the national withdrawal of the Liverpool Care Pathway. Not all wards where the pilot care plan had not been rolled out were aware of the guidance issued. There were concerns that without proper documentation, care provided to patients could be adversely affected.
• The modified early warning score (MEWS) was used effectively to identify deteriorating patients. Some areas, such as the children’s wards, needed to improve their use of the early warning score, and clearer systems were needed for the timely referral of patients, whose clinical condition was deteriorating on the wards, to the outreach team
• Care pathways were being used to standardise care for patients who were acutely ill.

Are services effective?

• In most services care and treatment was provided in line with national best practice guideline, and outcomes for patients were often better than average. The hospital was developing end of life care in line with national guidance. The results of the 2013/14 National Care of the Dying Audit of Hospitals (NCDAH) highlighted a number of areas for improvement. The hospital had since made some progress on the implementation of the action plan.
• The trust had a hospital standardised mortality rate which was higher than expected during April 2013–March 2014. This trust was regularly reviewing hospital deaths within specialities to identify and improve on areas where there might have been suboptimal care. Investigation demonstrated low numbers of potential avoidable deaths. Over a rolling 12 month period (August 2013 to July 2014) the latest data was demonstrating that mortality indicators were within the expected range, although the data required verification. There were, however, some diagnosis groups (acute and unspecific renal failure, pneumonia, cancer of the oesophagus, and cancer of the rectum and anus) that were mortality outliers. The trust was reviewing standards of care for these patients.
• A new initiative of Interim Medical Examiner Group (IMEG) meetings had been introduced to rapidly review all deaths in the trust. The group included representation from bereavement care, pathology, the patient safety team, patient support services and senior clinicians. It was led by the associate medical director for safety. This has improved the quality of information on death certificates and the speed of death certification, information to the Coroner, the communication with families regarding concerns, and the recognition and improvement of patient safety issues, as well as the need to raise awareness about reporting incidents.
• Seven-day services had been developed in medical and surgical services, and most critical care units, but improvement was needed in out of hours consultant cover for the neuro intensive care unit.
• Staff were supported to access training, and there was evidence of appraisal and supervision.
• Staff received relevant training and had the necessary skills and competence to look after patients in their speciality area. However, the need to move nurses to other wards to cover staff shortages, plus the high number of outliers on some wards, meant there was a risk that nursing staff may not have the specific skills and competencies to meet the needs of patients at all times.

• There was effective multidisciplinary working across the hospital.

• There were a high number of delayed transfers, both internal and external. Discharge planning commenced on admission, but timeliness of discharge needed improvement in some areas.

• Staff had appropriate knowledge of the Mental Capacity Act 2005 to ensure that patients’ best interests were protected. There was guidance for staff to follow on the action they should take if they considered that a person lacked mental capacity. However, staff awareness of the requirements of Deprivation of Liberty Safeguards varied. The trust was developing policies to ensure the latest national guidance was being used correctly in all areas, including the emergency department.

Are services caring?

• Staff were caring and compassionate, and treated patients with dignity and respect. The chaplaincy team were involved in undertaking a specific listening exercise on what compassionate care meant for staff working at the trust. The 10 key recommendations from this report were now being implemented across the organisation.

• We observed outstanding care and compassion in children and young people’s services. Staff were person-centred and supportive, and worked to ensure that patients and their relatives were actively involved in their care. We also observed examples of outstanding care, such as from reception staff in the emergency department who, although busy and working under tremendous pressures, made considerable efforts to reassure, inform and direct people presenting to them. Also, the emotional support for patients and relatives in critical care, and the patience and understanding of staff on the older people’s wards.
• Patients and their relatives described the care and treatment at Countess Mountbatten House as “excellent”. There was a strong commitment to, and support for, the patients and their relatives, both before and after death. Patients were treated with compassion and care. They were put at the centre of their care through ongoing consultation and the involvement of their relatives.
• Patients told us their experiences of care were good. The average response rate of the trust for the NHS Family and Friends Test (FFT) was above the England average. Between April 2013 and March 2014, 73.6% of patients were ‘extremely likely’ to recommend the trust to family and friends.

Are services responsive?

• Bed occupancy at the trust was 92% (January 2013-March 2014), consistently above both the England average of 88%, and the 85% level at which it is generally accepted that bed occupancy can start to affect the quality of care provided to patients, and the orderly running of the hospital. The trust had been operating at near 100% occupancy (measured at midday) in the months leading up to and during the inspection. Adult critical care was at 89.36% bed occupancy – above the England average of 83.24%. In the months leading up to and during the inspection, bed occupancy in the units was between 90% and 100%.

• Despite the best efforts of staff at all levels of the trust to monitor and maximise use of available capacity, high demand was having an impact on access and flow throughout the trust; for example, patients admitted for elective surgery, who required planned critical care beds, were remaining in theatre recovery areas for lengthy periods of time until critical care beds became available, resulting in admissions to the units during night hours.

• There were two fully staffed obstetric theatres from 8am-1pm every weekday. At all other times one theatre was available for emergencies and a second team available to be called upon if needed. There were some delays for non-emergency procedures, such as the repair of third and fourth degree perineal tears, these had reduced since the opening of a second theatre in the mornings. 

• The trust was meeting the national target for 92% of patients to be waiting 18 weeks or less, from referral to treatment (incomplete pathway). There was, however, a backlog of patients waiting for surgery, and the trust was not meeting the national target for 90% of patients to actually be treated within 18 weeks (admitted pathway). The trust could demonstrate that it was focusing on the longest waiting patients, and those with complex and urgent cases for surgery. Performance against this target was improving; for example, increased theatre use had improved waiting lists in trauma and orthopaedics.

• Emergency admissions impacted on capacity, and were adding pressure to services. The lack of available beds was resulting in cancelled operations and patients spending longer periods in the theatre recovery areas while waiting for a bed. The trust had improved performance over the year on reducing cancelled operations, and for patients with cancelled operations being treated within 28 days, but was still not meeting national targets.

• The number of non-clinical cancellations increased at the end of the year, when Southampton General Hospital was experiencing extreme capacity issues and was on ‘black alert’. For example, there were 27 non-clinical cancellations for the week ending 10 August 2014; this increased to 55 for the week ending 7 December 2014. Systems were put in place to prioritise operations that should go ahead each day and to give patients as much notice as possible of any cancellations.

• The trust was now meeting the two week cancer waiting time target for referral from a GP to see a specialist. The trust was also meeting the 31 day target from diagnosis to definitive treatment, although this was below the England average for cancer waiting times. The trust was not meeting the target for people to be waiting less than 62 days from referral to start of treatment. There was a detailed cancer recovery plan, which included seeking specialist external advice from the NHS Interim Management and Support Team.

• The trust was not meeting the national referral to treatment target time for 95% of patients to be referred and treated within 18 weeks for outpatient services. In some outpatient services clinic hours were being extended to evenings, and also run on a Saturday, to improve access. Waiting times for patients upon arrival in the outpatient clinics varied. Some patients could wait for several hours to be seen in some clinics, and were warned in advance of this possibility.

• Bed pressures were compounded by high numbers of delayed transfers of care. Delayed transfer of care is when patients are in hospital, fit to be discharged, but are unable to leave the hospital due to external factors. During our inspection, 200 (16%) medical patients and 54 (6%) surgical patients had a delayed transfer of care. The main cause of delay was the provision of community services, especially care home places, to meet patients’ ongoing needs, and timely social care assessments. The trust was engaged with partner organisations in managing these delays to minimise the impact on individual patients and on the service overall.

• The trust was not meeting its own internal targets to review and discharge patients, who were medically fit and could go home, at set times during the day. Patients were positive about the discharge lounge and this was working well, but this was only used for medical patients.

• The trust steering group was set up to improve discharge arrangements. This included plans to commence discharge on admission, and for patients to have an estimated date of discharge and a best interest assessment within 48 hours. Patients would be allocated for fast track, simple or complex discharge as soon as possible, and assessment and management would be supported by the trust's integrated discharge bureau working in partnership with commissioners, the local authorities, and the local community and mental health trusts.

• The hospital had a rapid discharge service for end of life patients to a preferred place of care. A recent trust audit (2014) had shown that 47% of patients with cancer, who were known to the specialist palliative care team, were dying at home.

• We observed mixed sex accommodation breaches on AMU 1, and on the cardiac short stay ward; this compromised privacy and dignity. The staff were reporting when patients needed to be cared for in a mixed sex bay on AMU 1, and we noted this was in line with agreements with local commissioners. But the staff on the cardiac short stay ward did not recognise these breaches. There was also a risk of mixed sex breaches in critical care services, when there were delays to level 1 patient transfers to wards.
• Staff across the hospital demonstrated a good understanding of how to make reasonable adjustments for patients living with dementia or those who have a learning disability. We found examples of adjustments made for patients with a learning disability in outpatients and diagnostic imaging, and in surgical services.

• The hospital had implemented an interpreter service. They also encouraged staff with existing foreign language skills to participate in a training programme, enabling them to qualify as an interpreter.

• There were various printed information leaflets available to patients and their relatives across the trust. All information for patients was only available in English. Patients could request information to be made available in another language, but that request leaflet was also only published in English, making it highly unlikely that a patient who spoke another language could access the information in their own language. We did not see any information in an easy-to-read format.

• Departments across the hospital reviewed and acted on complaints and feedback, to improve services.

Are services well-led?

• Staff were committed to the values of putting the patient at the centre of their work and were inspired by the CEO’s focus on this. They were aware of the trust’s vision and had started to be involved in discussions about updating the trust strategy.
• In most services the departmental strategy and vision was recognised by staff. Staff in some departments were not aware or confident that there were clear plans and strategies to address some significant concerns in a timely way.
• There were governance systems in place to identify risks and for quality monitoring. But in some services there was a disconnect between the risks and issues described by staff and those reported to and understood by senior management and the board. These included pressures on service capacity, staffing levels, and the safety of outdated and cramped clinical environments. The trust had taken mitigation actions around the environmental risks.
• Across services, staff reported a strong supportive leadership from matrons, senior sisters and lead clinicians. They told us the CEO and senior management team communicated effectively with staff at all levels.

• Staff were positive about working at the hospital and would recommend it as a place to work despite the challenges. Across the hospital, there was an ethos of openness and transparency, and collaborative multidisciplinary working.
• There was a strong commitment to research in a clinical environment supported by research nurses.

• Innovative practices were encouraged.

• The hospice (Countess Mountbatten House) had a dedicated staff team, with clear visions and values. Staff commented “we work as a team and all pull together”, in order to achieve best outcomes for the patients. There was strong clinical leadership at the hospice. There was a clear governance structure from unit level to the trust board. Members of the board made quarterly visits to both the hospice and community services. The friends and family test (FFT) was embedded but other processes for seeking the views of patients and their relatives was not fully developed. Further work with partners was needed to develop bereavement services, and a ‘hospice at home' service.

We saw several areas of outstanding practice including:

• The emergency department used a coloured name band scheme for patients, as a direct result of learning from investigating falls in the department. Staff would know, at a glance, which patients had specific requirements, such as a high risk of falls, because of the coloured, highly visible name bands.
• We observed outstanding care and compassion in critical care, and in children and young people’s services. Staff were person-centred and supportive, and worked to ensure that patients and their relatives were actively involved in their care. We also observed examples of outstanding care, such as from reception staff in the emergency department, who, although busy and working under tremendous pressures, made considerable efforts to reassure, inform and direct people presenting to them.
• A vulnerable adults support team (VAST) was based in the emergency department, and worked across the inpatient and community areas to support and safeguard vulnerable adults from abuse and harm.
• The hospital had developed a specific post for ‘lead consultant for out-of-hours’ (work). This had led to more effective management of medical patients outside the working hours.
• Consultants involved with elderly patients worked on a locality-based model, and there were named consultants for patients belonging to each GP locality. This had helped to improve continuity of inpatient care, and communication with patients and families, and other healthcare services in the community. Patients found it beneficial because they saw the same consultant every time, and found it was easier to approach consultants should they need any advice.
• A new initiative of Interim Medical Examiner Group (IMEG) meetings had been introduced to rapidly review all deaths in the trust. The group included representation from bereavement care, pathology, the patient safety team, patient support services and senior clinicians. It was led by the associate medical director for safety. This has improved the quality of information on death certificates and the speed of death certification, information to the Coroner, the communication with families regarding concerns, and the recognition and improvement of patient safety issues, as well as the need to raise awareness about reporting incidents.
• The trust used an automated text system to alert staff about vacant shifts that needed to be filled urgently.
• There is a strong ethos of quality improvement and innovation within the neurosurgical department, which includes the development of the first day case intracranial tumour surgery programme within the UK, which has since been adopted by other units nationally.
• The general intensive care unit (GICU) had introduced early mobilisation for ventilated patients and this had resulted in reducing length of stay.
• Guidance and a training package had been developed to support the managing of patients with challenging behaviour in the critical care setting.
• The 'Uncertainty, Safety or Stop' cultural initiative in the neuro intensive care unit (NICU) was credited with giving all staff permission to say 'I do not know how to do this, and I need help’. This had helped to improve patient safety.
• Consultants in the cardiac intensive care unit (CICU) arranged weekend meetings for bereaved families. Families were invited back to the unit to discuss their relative’s treatment and death, in order for them to better understand the patient’s journey and the reason why they did not survive.
• Patient profiles were obtained in the NICU to give staff insight into a patient’s likes, dislikes and interests. This enabled staff to talk with the patient about subjects that would interest them, whether they were conscious or not.
• The paediatric day care unit included a nurse-led service where nurses had extended roles. These included prescribing medicines and discharging patients.
• To ensure children’s voices were heard and acted upon, the day care unit had developed the 'Pants & Tops' initiative. Through this initiative, children were invited to write down on templates what had been 'tops' or 'pants' about their hospital stay. Children who were very young, and were unable to write, could still provide feedback.
• The children and young people's service used play leaders and youth support workers as advocates for children and young people. The service had an ethos of compassionate care and peer support, and social events were actively encouraged for children and for the parents of children with cancer, and long-term or chronic diseases.
• The trust had implemented a 'Ready, Steady, Go' initiative to support young people through the transition from children's to adult services. Young people were involved in deciding when they were transferred.
• The chaplaincy team held a listening exercise with staff to help identify what compassionate care meant for staff working at the trust. The 10 key recommendations from this report were now being implemented across the organisation.
• The bereavement support team were involved in the co-ordination of tissue transplantation. They explained how families could get involved, and supported families through the tissue transplant process. As a result of this service, tissue transplant donation had increased by 300% (from 20 tissue donations in 2011, to 60 donations in 2013/14).
• The Allergy Clinic within the outpatients department, had received a World Health Organization (WHO) award for excellence.
• Midwives who held a caseload (caseload midwives) worked in areas of greatest deprivation and with the largest number of teenage pregnancies. These midwives had smaller caseloads and provided greater continuity of care, and often followed the women into the maternity unit to deliver.
• There was a ‘birth afterthoughts’ service, which enabled women to have a debrief with a midwife following their delivery. Themes from this service were identified and fed into the governance process. Over 400 women had accessed the service during 2014.
• Women with hyperemesis could be cared for as day case patients and receive intravenous fluid rehydration. This meant they could remain at home and helped to prevent admission.
• A telephone triage service had been agreed with a neighbouring trust and was about to be implemented. This initiative would direct women to the appropriate place for care.

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

Importantly, the trust must ensure:

• Nurse staffing is consistently at safe levels, to meet the needs of patients at the time and support safe care.

• Equipment is regularly tested and maintained, and a record of these checks is kept.

• There are suitable environments to promote the safety, privacy and dignity of patients in the cardiac short stay ward, G8 ward, and all critical care areas with level 1 patients.

• There is sufficient basic equipment in all departments and timely provision of pressure relieving equipment, beds and cots.

• The access and flow of patients across the Southampton General Hospital is improved. Discharge is effectively planned and organised, and actions are taken to improve delayed transfer of care discharges.

• All wards have the required skill mix to ensure patients are adequately supported with competent staff.

• No risks are posed to patient safety in the event of electrical failures in critical care areas.

• All risks associated with the cramped environment in critical care areas are clearly identified, and timely action is taken to address those risks.

• Overhead hoists in critical care units are correctly positioned and in working order, so they can be used, as intended, for patient care.

• There is an effective process embedded into practice for alerting medical staff or the outreach nursing team in the event of patients deteriorating on the general wards.

• There is appropriate management of identified risks in the general intensive care unit.

• There is a definite plan to develop critical care services to meet the local and regional population's health needs; this plan is to include the provision of appropriate follow-up services.

• The specialist palliative care team reviews the level of medical consultant support.

• There are safe staffing levels in diagnostic imaging teams to prevent untoward safety incidents occurring.

• Incidents are reported by radiographers, and there is learning from all IR(ME)R and diagnostic imaging incidents, and processes for Duty of Candour are appropriately followed.

• All maternity staff are aware of the location or correct use of equipment for the safe evacuation of women from the birthing pools.

• The operating tables in maternity theatres can be lowered adequately, so surgeons are not required to stand on stools, which would otherwise increase the risk of back injuries to the surgeon and patient risks during surgery.

As a provider, the trust should ensure:

• Continue to improve complaints handling procedures, in particular to ensure that complaint responses address all identified concerns, lessons are learnt and overdue complaints are reviewed.
• Its clinical strategy is updated and implemented.
• Transformation and strategic plans are well developed, and formal processes with commissioners and partners are used effectively.
• Clinical quality dashboards are further developed at division, care group and ward level, and there is the ability to monitor the patient improvement framework at these levels.
• Risk registers are up to date, with appropriate mitigation and controls.
• The board assurance framework is developed and reviewed, to assurance around actual, anticipated and potential strategic and operational risks.
• Director’s portfolios are clear and understood by staff.
• There is better leadership in services where this is of concern, including critical care and diagnostic imaging.
• Divisions continue to work together to improve patient pathways across the trust
• The trust completes the cultural safety survey.
• The equality and diversity strategy is integrated within the trust.
• The Fit and Proper Persons Requirement (FPPR) is implemented appropriately.

Please refer to the location reports for details of where the trust SHOULD also make improvements

Professor Sir Mike Richards

Chief Inspector of Hospitals