Salisbury District Hospital NewApproachFocused Report ... · LetterfromtheChiefInspectorofHospitals...

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Urgent and emergency services Requires improvement –––

Medical care (including older people’s care) Good –––

Surgery Requires improvement –––

Critical care Requires improvement –––

Maternity and gynaecology Good –––

Services for children and young people Requires improvement –––

End of life care Good –––

Outpatients and diagnostic imaging Good –––

Spinal injuries centre Requires improvement –––

Salisbury NHS Foundation Trust

SalisburSalisburyy DistrictDistrict HospitHospitalalQuality Report

Odstock RoadSalisburyWiltshireSP2 8BJTel: 01722 336262Website: www.salisbury.nhs.uk

Date of inspection visit: 1-4 and 13 December 2015Date of publication: 07/04/2016

1 Salisbury District Hospital Quality Report 07/04/2016

Letter from the Chief Inspector of Hospitals

Salisbury NHS Foundation Trust provides care to over 240,000 people across Wiltshire, Dorset and Hampshire. Thisincludes general and acute services at Salisbury District Hospital with specialist services including burns, plastics, cleftlip and palate, genetics and rehabilitation serving over three million people. In addition the Duke of Cornwall SpinalTreatment Centre serves South England’s population of 11 million people.

Salisbury Hospital has 464 beds and is staffed by approximately 4054 members of staff. They provide care to around240,000 people across Wiltshire, Dorset and Hampshire.

CQC uses an intelligent monitoring model to identify priority inspection bands. This model looks at a wide range of data,including patient and staff surveys, hospital performance information and the views of the public and local partnerorganisations. Against this the trust was judged as a low risk, at level six (the lowest level) which it had been at since2013.

We inspected this trust as part of our programme of comprehensive inspections of acute trusts. The inspection teaminspected the standard eight core services as well as an additional service, the spinal service.

Overall, this trust was rated as requiring improvement. We rated it as requiring improvement for safety, being responsiveto patients needs and for being well led and good for providing effective care and being caring.

Our key findings were as follows:

Safety

• Nurse staffing levels in emergency and urgent care, surgical wards, services for children and young people,including the neonatal unit, critical care, maternity and the spinal unit were not always meeting national guidelinesor recommendations.This was a risk to patient safety.

• General infection rates in the Trust were low. There had been no new Methicillin Resistant Staphylococcus Aureus(MRSA) since October 2014. Rates of Clostridium Difficile were below the Trust trajectory as at October 2015.However there were occasions where inspectors found variable compliance with infection control procedures suchas wearing of gloves and aprons. In a minority of areas equipment was found to be dusty and in one area acommode was found to be dirty.

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

• In some areas it was found that resuscitation equipment was not being checked every day as required.

• Patient records were not consistently written and managed appropriately. In particular, in the medical services,there was poor documentation of patient’s weight and the management of intravenous cannulas and catheters.Charts were not kept secure and confidential at all times.

• In the emergency department patients did not always receive an initial clinical assessment by a healthcarepractitioner within 15 minutes of arrival.

• Patients whose condition deteriorated were appropriately monitored with action taken as required.

• There was a strong culture of reporting and learning from incidents. Staff understood their responsibilities to raiseconcerns, record safety incidents and near misses and to report these appropriately. Staff received feedback andlessons were learnt to improve care. There was a culture of being open and the duty of candour was wellunderstood.

Effective

Summary of findings


• In the majority of services, patient needs were assessed and care and treatment delivered in line with legislation,standards and evidence based practice. Performance in national audits was generally the same or better than thenational average.

• Mortality rates were as expected at 107 as measured by the Hospital Standardised Mortality Ratio (July 2015) and107 for the Summary Hospital-level Mortality Indicator (March 2015).

• Themajority of staff and teams worked well together to deliver effective care and treatment. Maternity services andtheatres could do more to improve multidisciplinary working.

• The majority of staff received an annual appraisal. Improvements were needed to ensure the records about whohad received an appraisal were robust.

• Consent and knowledge of the mental capacity act was good however the recording of this needed improvement.

Caring

• Staff provided kind and compassionate care which was delivered in a respectful way.

• The need for emotional support was recognised and provided by a clinical psychology service.

• In the spinal treatment centre some patients felt ignored and isolated, however also in this unit there wereexamples of staff going the extra mile such as arranging a wedding to take place in the unit for one patient.

• The majority of feedback from patients and relatives was extremely positive and although the response rate for thefriends and family tests were below the national average the number of patients who would recommend SalisburyHospital exceeded the national average.

Responsive

• Patient’s individual needs were not consistently met. In spinal services there was disparity between the experiencesof some patients, whist some made good use of the gardens and away days others felt lonely and bored.

• Spinal patients waiting for video-urodynamics and outpatients experienced unacceptable waits for appointmentsand there was little risk assessment of the patients who were waiting.

• The trust did not provide mental health services. Vulnerable patients in the emergency department with mentalhealth needs, particularly children and adolescents who required assessment by a mental health practitioner, didnot always receive a responsive service from the external mental health provider teams.

• The environment for children in the emergency department was not appropriate, with them being cared for in theadult area.

• The trust was not consistently maintaining single sex accommodation.

• Patients living with dementia were generally well supported.

• The investigation of complaints was comprehensive however there were areas that could be improved. Theserelated to working with other organisations to provide a single response when required, the development of actionplanning and learning after the investigation.

• Overall the trust performed well in meeting national targets, including the time patients spent in the emergencydepartment and referral to treatment times.

• The Benson bereavement suite facilities, and sensitive care provided to maternity and gynaecology patients andtheir relatives experiencing loss were outstanding. These services had been developed with the full involvement ofprevious patients and their partners.

Summary of findings


Well led

• The trust had a governance framework which supported the delivery of care although there were some areas ofweakness. The trust had recently undertaken a self- assessment against Monitor’s quality governance frameworkhowever this had not clearly identified weaknesses or areas for improvement. A review had been undertaken tosupport board development. Additionally, an externalreview of the board assurance framework hadbeencompleted inMay 2015 with 'substantial assurance' being attained.

• Risk registers did not consistently identify all risks, mitigating actions or where it did the actions had not alwaysbeen taken or where they had the risk had not been updated.

• One of the strengths of the trust was that staff had a strong sense of respect for each other and communicated well,however we heard of informal conversations between staff that lacked documentation to support an audit trail fordecisions and actions.

• The trust had experienced a deficit for the first time in its history and staff were anxious about the future. A recoveryplan was in place.

• There was an extremely positive culture in the trust, staff felt respected and valued. Many staff had worked in thetrust for a considerable number of years and knew each other well. They frequently referred to themselves as beinglike a family and were very supportive of each other.

• Staff at all levels were very positive about the trust as a place in which to work and this was supported by the staffsurvey results (2014). Staff had contributed to the development of the trust values and lived these in their work.Staff spoke of being proud of working at the trust, were passionate about providing the best care they could.

• The chief executive had a very high profile in the trust and was known by all staff. Staff felt they were listened to andsupported by their managers who were visible in the clinical areas.

• There was a stable executive team with all posts filled on a substantive basis.

• The Governors were fully engaged with the Board, felt supported in their roles and could see their influence whenissues were raised.

• Although in the staff survey there had been some reports of discrimination from staff from black, minority andethnic groups this was not the experience of those spoken with during the inspection who reported feelingsupported.

• Innovation and improvement was encouraged and rewarded. There were award ceremonies at which innovativeand caring practice was shared and recognised, this was well publicised and appreciated by staff who were proudof their colleagues achievements. Participation in research was good and increasing.

We saw several areas of outstanding practice including:

• The surgery wards had identified link roles for staff in varied and numerous relevant subjects. A nurse and ahealthcare assistant had been assigned together to the link role.

• The surgery and musculo-skeletal directorates had regular specialty meetings. A member of the care staff whowould not otherwise attend these meetings joined the meeting each time to provide a ‘sense-check’. They listenedto the content, decided if it made sense and properly described the state of their service.

• There was an outstanding level of support from the consultant surgeons to the junior and trainee doctors and otherstaff including the student nurses.

Summary of findings


• The maternity services strived to learn from investigations in order improve the care, treatment and safety ofpatients. This was evident with the robust, rigorous and deep level of analysis and investigation applied when seriousincidents occurred. For example, the reopening of a coroners case as a consequence of the maternity serviceinvestigations. Further evidence of this was available in meeting minute records. In addition, a wide range of staffdemonstrated that learning from incidents was a goal widely shared and understood.

• The Benson bereavement suite facilities, and sensitive care provided to patients experiencing loss were outstanding.These services had been developed with the full involvement of previous patients and their partners. The facilitieswere comfortable and extensive, enabling patients and their families’ privacy and sensitive personalised care andsupport.

• In the services for children and young people a mobile APP was produced in conjunction with a regional neonatalnetwork to provide information and support for parents taking their babies home.

• Sarum Ward staff worked across the hospital working with a variety of teams to improve services for children andyoung people. Examples were of developing a DVD for pre-operative patients, using child friendly surveys in otherareas of the hospital, supporting any staff with expertise on the needs of children and young people.

• Nurse led pathways were being used. In one example a nurse led pathway was in place for early arthritis, thispathway had been ratified by the Royal College of Nursing. The pathway was evidence based that showed thequicker patients were diagnosed with arthritis, the quicker treatment could be started and the quicker patientscould go into remission. This service came top in a national audit for patients with early arthritis. Staff hadpresented their service at national and international conferences including the Bristol Society of Rheumatologyconference in 2015.

• We observed excellent professionalism from staff in outpatients during an emergency situation. Staff attended tothe patient that needed immediate help and support. Staff also cared for and supported the other patients whohad witnessed the emergency. Patients were moved away from the emergency into another department and keptinformed of what was happening and offered lots of reassurance. When the emergency was over, patients wereshown back into the waiting area with explanations on the subsequent delay to the clinic.

• The outpatients departments monitored how often patients were seen in clinics without their medical records.From January to July 2015 123,548 sets of patients notes were needed for the various clinic appointments acrossthe trust. Out of these, 115 sets of notes could not be located for the appointment. The department identified thatthis was because the notes had been miss-filed, staff had not used the case note tracking properly or the noteswere off site for another appointment. Overall, patients’ medical notes were found for 99.91% of appointments,which was a small increase from the previous two years. This showed that there was an effective system in place formaking sure patients’ medical notes were available for their outpatient’s appointments. Where they were notavailable, a reason was identified to try and reduce the likelihood of the issue happening again.

• In the spinal centre there were examples of care where staff went above and beyond the call of duty. One exampleof this was where a patient got married in the spinal centre. Staff went with the patient’s partner to collect andprepare food and on the wedding day was picked up by a member of staff in their classic car. The couple were thenallowed the use of the discharge accommodation after the wedding.

• The ‘live it’ and ‘discuss it’ sessions were fully integrated into the spinal treatment centre. We observed one sessionwhere patients and relatives were given opportunities to discuss their concerns as a peer group as well as toprofessionals and ex-patients. It was clear that patients and their carers were being supported through a difficulttime and were being educated on important topics preparing mentally and physically them for discharge.

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

Importantly, the trust must:

Summary of findings


• Review nurse staffing levels and skill mix in the areas detailed below and take steps to ensure there are consistentlysufficient numbers of suitably qualified and experienced nurses to deliver safe, effective and responsive care. Thismust include:

• a review of the numbers of staff and competencies required to care for children in the emergency department,

• a review of the arrangements to deploy temporary nursing staff in the emergency department,

• a review of arrangements in the emergency department to ensure that nursing staff receive regular clinicalsupervision, education and professional development.

• a review nursing staff levels at night on Amesbury ward, where the current establishment of one nurse for 16patients, does not meet guidance and is not safe. Other surgery wards with a ratio of one nurse to 12 patients atnight must be reviewed. Pressure on staff on the day-surgery unit, when opened to accommodate overnightpatients, and still running full surgical lists, must be addressed.

• ensuring there are appropriate numbers of, and suitably qualified staff for the number and dependency of thepatients in the critical care unit.

• ensuring there are adequate numbers of suitably qualified, competent and skilled nursing and medical staffdeployed in areas where children are cared for in line with national guidance.

• ensuring there are sufficient numbers of midwifery staff to provide care and treatment to patients in line withnational guidance.

• ensuring one to one care is provided in established labour in order to comply with national safety guidance (RCOG,2007).

• Ensure staff across the trust are up-to-date with mandatory training.

• Ensure that all staff have an annual appraisal and that records are able to accurately evidence this.

• Complete the review of triage arrangements in the emergency department without delay and take appropriatesteps to ensure that all patients who attend the emergency department are promptly clinically assessed by ahealthcare practitioner. This must include taking steps to improve the observation of patients waiting to beassessed so that seriously unwell, anxious or deteriorating patients are identified and seen promptly.

• Ensure staff effectively document care delivered in the patient’s healthcare record at the time of assessment ortreatment in line with the hospital’s policy and best practice. This must include effective documentation withregard to intravenous cannulas and urethral catheters and the recording of patients’ weight.

• Strengthen governance arrangements to ensure that all risks to service delivery are outlined in the emergencydepartment’s risk register, that there are clear management plans to mitigate risks, regularly review them andescalate them where appropriate.

• Ensure that all actions are implemented and reviewed to reduce patients being cared for in mixed sexaccommodation.

• Ensure that daily and weekly check of all resuscitation equipment are completed and documented appropriately.

• Ensure there is a hospital policy governing the use and audit of the World Health Organisation surgical safetychecklist. The audit of the checklist must be conducted as soon as an appropriate period of time has passed sinceits reintroduction. Results must be presented to and regularly reviewed at clinical governance.

Summary of findings


• Ensure there is a sustainable resolution to the issue of holes or damage in the drapes wrapping sterile surgicalinstrument sets, and all sets are processed and available for re-use to avoid delays or cancellations to patientoperations.

• Ensure patient charts are kept secure and confidential at all times.

• Must ensure there is effective management of the conflict between meeting trust targets for performing surgery andthe impact this has on patients. Patients must not be discharged home from main theatres unless this cannot beavoided. Surgery must not be undertaken if there is clearly no safe pathway for discharging the patient. Operationsmust take place in the location where staff are best able to care for their recovery.

• Ensure staff consistently adhere to the trust infection control policy and procedures.• Ensure that patients are discharged from the critical care unit in a timely manner and at an appropriate time.• Ensure the process for booking patients an elective beds following surgery is improved and reduce the number of

cancelled operations due to the lack of availability of a post-operative critical care bed.• Ensure that the governance arrangements for critical care operate effectively, specifically that identified issues of risk

are logged and that risk are monitored, mitigated and escalated or removed as appropriate.• Ensure that care and treatmentat the spinal unitis provided in a safe way relating to the numbers of spinal patients

waiting for video uro-dynamics and outpatient appointments and reducing the risk of harm to these patients.• Ensure that risks associated with the spinal service are managed appropriately with the pace of actions greatly

improved. In particular, to the management of the numbers of patients waiting for video uro-dynamics andoutpatient appointments.

• Ensure care and treatment are delivered in a way to ensure that all patients have their needs met which reflects theirpreferences. This includes the training of agency staff, the availability of physiotherapy and occupational therapysessions, and the availability of suitable activities for patients in spinal services.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Requires improvement ––– The emergency department (ED) was notconsistently staffed by sufficient numbers ofappropriately qualified, experienced and skillednursing staff to ensure that people received safecare and treatment at all times. The nursingestablishment did not ensure that an appropriateratio of nursing staff to patients was consistentlyachieved. This was compounded by the fact theservice had a significant numbers of nursing staffvacancies and relied heavily on temporary staff whodid not always have the necessary skills andexperience to provide safe and effective care.Staffing levels at night were of particular concernand there were concerns about the lack of seniorityof medical and nursing staff on duty at night. Wehad concerns that there were insufficient registeredchildren’s nurses employed and there was a lack ofassurance that this risk had been mitigated byensuring that adult trained nurses had receivedspecialist training to care for children. As a result ofthis lack of appropriately skilled staff, the separatechildren’s area was not being used and childreninstead received care and treatment in the adults’department which was not an appropriateenvironment.Staffing issues impacted on the department’s abilityto ensure that patients were consistently promptlyclinically assessed on arrival in the ED. We wereparticularly concerned about the delayed clinicalassessment of self-presenting patients (adults andchildren) who were not adequately observed whilethey waited. We also had concerns that nursingdocumentation was not always completed to therequired standard. Staff shortages may also haveaffected staff’s ability to complete mandatorytraining. Compliance with mandatory training waswell below the trust’s target of 85%. We were notassured that nursing staff had sufficientopportunities for ongoing education anddevelopment or clinical supervision.People’s care and treatment was planned anddelivered in line with current evidence-basedguidance and standards. We saw good levels of

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compliance with recognised care pathways,including those for sepsis and stroke care.Compliance with protocols and standards wasmonitored through participation in national audits.Performance in national audits was generally aboutaverage compared with other English trusts, withthe exception of the Royal College of EmergencyMedicine mental health audit, where performancerequired improvement. There were action plans inplace to make improvements where shortfalls wereidentified. We saw little evidence of local audit.The trust’s un-planned re-attendance rate wasconsistently lower (better than) the Englandaverage. This was an indicator that care andcommunication with patients were effective.Junior doctors felt well supported with regulareducation and supervision. The lack of seniormedical presence in the ED was to some extentmitigated by senior review of all records of patientsseen overnight.The service worked well with other teams andservices so that people received seamless care. Carewas delivered in a coordinated way, with supportfrom specialist teams and services. There wereexcellent working arrangements with the AcuteMedical Unit, which worked closely with the ED aspart of the ‘front door team’. There were clearpolicies agreed with specialty doctors whichformalised their supportive role to ED andreciprocal support was offered by ED consultants tojunior doctors in other specialties.We observed that all staff treated people withcompassion, kindness, dignity and respect. Theyresponded in a caring and compassionate waywhen people experienced pain, discomfort ordistress. Patients and their relatives were involvedas partners in their care. Staff took the time toexplain to patients and their relatives about theircare and treatment. This was done sensitively andin a way that people could understand. Thedepartment had established an outstanding serviceto support bereaved relatives.Feedback we received from patients and visitorswas overwhelmingly positive. We spoke with manypatients and visitors. Unusually, we wereapproached by some patients who were very keento tell us how well they had been looked after. This

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feedback was consistent with results from patientsatisfaction surveys. Friends and family scores wereconsistently high, with over 90% of respondentsindicating that they would recommend the service.Services were not organised and delivered so thatall patients received the right treatment at the righttime.Premises and facilities were largely appropriate forthe services delivered; however children were caredfor in the adults’ department which was not anappropriate environment from them because theywere exposed to sights and noise which may causethem stress. The children’s waiting room, whilstbright and welcoming, was overlooked by andcould be accessed by adult patients and visitors.Patients’ privacy and dignity was sometimescompromised on the short stay emergency unit.The ward was cramped and the layout did notalways allow for single sex accommodation to beprovided.The needs of patients in vulnerable circumstanceswere not always met. Patients with mental healthneeds, particularly children and adolescents, whorequired assessment by a mental healthpractitioner, did not always receive a responsiveservice. This meant that these patients experiencedlong waits which could be detrimental to theirmental health and they were sometimes admittedto hospital unnecessarily.The department had not taken adequate steps tosupport patients in vulnerable circumstances, suchas those living with dementia.The ED was consistently meeting nationalstandards in respect of the time people spent in thedepartment, and the time they waited fortreatment, although this was becoming morechallenging with increasing demand on the service.There were relatively few ambulance handoverdelays but at busy times, some patients queued onambulance trolleys in the department and thisimpacted on their comfort, privacy and dignity.The ED worked well with the patient flow team andthe rest of the hospital to minimise blockages andovercrowding in ED. The trust had invited anexternal review of patient flow by the emergencyintensive support team (ECIST) and had developedan improvement plan based on their

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recommendations and had taken some immediateactions, although some changes required time toembed. Further improvements were planned butrequired time and resource.The service had not developed a clear vision or acohesive strategy. Although the service hadresponded appropriately to recommendationsmade by an external reviewing body and there wereongoing staffing reviews, these were largely reactiveplans and did not form part of an overarchingstrategy. Staff had not been involved or engaged indeveloping a vision or strategy and there waslimited evidence of patient involvement.Risks to service delivery were understood by themanagement team but risk management processeswere not fully effective. The risk register did notcapture the multi-factorial risks to patient safetyand quality and we could not be assured that riskswere appropriately escalated or mitigated.Staff enjoyed working in this service and the culturewas one of mutual respect and teamwork. Staff feltsupported and valued by senior managers whowere both visible and accessible. However, moralewas overshadowed by issues relating to staffing.Staff had little confidence that these issues wouldbe resolved in the short term and there was a riskthat these issues may in the future, impact onrecruitment and retention of staff.

Medical care(includingolderpeople’scare)

Good ––– We rated medical services as good overall. Staffunderstood their responsibilities to raise concerns,to record safety incidents, concerns and nearmisses, and to report them. Learning from incidentswas evident and care and treatment within thehospital protected patients from avoidable harm..Medical cover, nursing levels and skill mix wereappropriate to the needs of the patients on theeight medical wards we visited, which included theacute medical assessment unit, the endoscopysuite and the cardiac catheter laboratories.We did however identify a breach in regulation inrelation to record keeping, and specifically to thedocumentation of cannulas, catheters and patients’weight.Care was effective and was delivered in accordancewith evidenced-based guidelines and current best

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practice. Staff managed patients’ pain well andfeedback from patients reflected this. The trustensured staff were adequately trained andcompetent to carry out their role.Staff provided compassionate care and patientswere treated with kindness, dignity and respect.Patients spoke positively about their experience ofbeing cared for at Salisbury hospital. They feltincluded in their care and were kept informedabout their care and treatment throughout theirstay.The provider planned services and coordinated carewell for patients living with dementia. The layoutand appearance of wards provided a suitableenvironment for these patients. Patients accessedcare and treatment in a timely way.Services were not always responsive to patients’needs and required improvement. The providercould not always assure adequate patient flowwithin the hospital. This meant that mixed-sexaccommodation breaches frequently occurred andpatients were moved during their stay, sometimeslate at night. The hospital could not always providea bed for care and treatment of medical patients ona medical ward. These patients were called medicaloutliers and were admitted to surgical wards.However, staff and patients were always aware ofwhich doctors were providing specialist medicalcare and treatment to them and nursing staff werecompetent to deliver their care.The medical services were well led. Staff wereaware of the hospital’s vision and values spoke ofthe family atmosphere of working in the hospital.The leadership, governance and culture promotedthe delivery of high quality care. There was a clearset of values driven by quality and safety and staffwere familiar with these. The trust engaged itspatients and visitors regularly to obtain feedback inorder to improve the patients’ experience in thehospital. Staff spoke highly of their managers andfelt their views and concerns were listened to andacted upon. The staff survey showed staffrecommended the hospital as a place to work.

Surgery Requires improvement ––– As the hospital recognised, nursing andoperating-department practitioner staffing levelswere not always satisfactory. In some wards the

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established levels of nursing care provided at nightwere not following recommended guidance andunsafe. The workloads from high levels of agencystaff at times were causing some staff stress andanxiety. Patients praised the care but a number feltreluctant to call for support due to a perception ofnurses and nursing assistants being too busy.Safety in operating theatres was good but someimprovements were needed in assurance andculture. Problems with surgical instrument setsneeded resolution. Reviews of deaths in thehospital needed to be improved to show learningand improvement happened. Security of patientcharts needed to be improved as some were notbeing kept confidential. Staff mandatory trainingupdates was not meeting trust targets.The hospital was clean and infection preventionand control protocols followed. Incidents and nearmisses were being well reported and investigated.There was a safe level of cover from the medicalstaff and deteriorating patients were recognisedand responded to.Length of stay in the hospital was mostly betterthan the England average. Patients’ pain, nutritionand hydration were well managed with specialistinput when needed. Staff were skilled andexperienced, although not all had received anannual performance review. There was strongmultidisciplinary input to patient care. Importantservices were provided seven days a week and therewas good access to information. The majority ofaudits showed patients were getting goodoutcomes, but some audit results needed moreattention where they were not being used todemonstrate change, learning or improvement.Feedback from patients and their families had beenalmost entirely positive overall and several patientsdescribed their care to us as outstanding. TheFriends and Family Test produced excellent results.Patients we met in the wards and other units spokehighly of the kindness and caring of all staff,although not without mentioning how busy theywere. Staff ensured patients experiencedcompassionate care, and worked hard to promotetheir dignity and human rights.The hospital had not resolved the conflict betweenmeeting targets for patients to have treatment and

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putting undue pressure on services to perform.There were many aspects of good responsiveness,but pressure for beds was leading to too manypatients being inappropriately discharged from themain theatres or day-surgery unit. As with mostNHS hospitals, this hospital was regularly facedwith a high number of patients who were fit fordischarge, but without transfer of care packages.Patients were complimentary about the food. Therewas a wide-range of leaflets and information forpatients and people with additional needs werebeing looked after. Cancelled operations were low,and the pre-admission, admission and dischargeservices provided good support.The surgery service had an effective governanceprocess, although some areas needed to beimproved to show a consistent approach. There wasgood leadership and local-level support for staff. Allthe staff we met showed commitment to theirpatients, their responsibilities and one another.There was a strong camaraderie within teams. Wewere impressed with the loyalty and attitude of thestaff we met. Staff were recognised by the trust fortheir commitment, professionalism and going theextra mile for the patient.

Critical care Requires improvement ––– Critical care services required improvement to besafe and well led. We found the service good forcaring, effective and responsive.Policies and procedures to prevent patients fromthe risk of healthcare associated infections were notconsistently adhered to. The use of personalprotective equipment was inconsistent by bedsidenursing staff during the inspection. A commode wasfound to be dirty and a standard cleaningprocedure for cleaning the commodes was notavailable on the unit.There were occasions when nurse staffing numbersdid not meet recommended staffing ratios. Medicalstaffing was found to be in line with core standardsfor intensive care services.There was sufficient equipment to provide criticalcare and respond to emergencies. However, theresuscitation trolley log was not consistently signed

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to indicate that it had been checked and was readyfor use. The bed spaces did not comply with bestpractice guidelines for critical care facilitiesregarding accessibility and space.Incidents were reported and appropriate actionswere taken to attempt to prevent recurrence.However, mortality and morbidity meetings hadcommenced recently and therefore could notprovide assurance of any improvements or actionstaken.Overall, staff were aware of their responsibilities toreport abuse and how to raise concerns aboutsafety. Some online mandatory training rates fortrained nurses were lower than the trust target of85% and mandatory training compliance data forunit based staff was not supplied, which meantthere was a risk that staff were not up-to-date withcurrent practice.Records and medicines were found to be stored andmanaged securely. However, documentation in thehealthcare records and charts was not alwayscomplete or timely.Patients’ needs were comprehensively assessedand care and treatment regularly reviewed on theunit. Information about care and treatment andpatients outcomes was routinely collected andmonitored. Local and national audits were takingplace and results were being used to improve care,treatment and patients’ outcomes. Staff couldaccess the information they needed in order todeliver effective care. Patients care and treatmentwas planned and delivered in line with currentevidence based guidance, particular focus wasgiven to rehabilitation. However, we found thatthere were some guidance and policies on the unitthat were out of date. In addition, documentationof patients’ pain scores could be improved.There was input into patients care from relevantmembers of the multidisciplinary team in order toprovide effective treatment plans. However, thepharmacist did not attend consultant led wardrounds as recommended in the guidelines for theprovision of intensive care services (GPICS 2015).Staff were qualified and had the skills to carry outroles effectively in critical care. This includedcompetencies in blood transfusion and intravenoustherapy administration. However, half of the

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nursing staff had not received an appraisal in thelast twelve months, order to identify learningneeds. In addition, training in the use of equipmenton the unit required further improvement for bothmedical and nursing staff.Discharge from the unit was planned and includedfollow up services after going home from hospital,to support patients post critical illness.Patients we spoke with were positive about the carethey had received. Many kind and caringinteractions were seen during the inspection. Staffwere seen to maintain a high regard for patient’sdignity and privacy.Relatives expressed that they had been kept up todate with their loved ones progress and supportedby the staff at the bedside. Not all relatives hadreceived timely communication; one family had notbeen updated by medical staff. However, this wasnot a consistent finding amongst all relatives andvisitors, and the majority were very happy with thelevel of emotional care and treatment they andtheir loved ones had received.The support continued following discharge homefrom hospital via the follow up team that supportedpatients after critical illness. The follow up clinicthat the team provided had recently held a reunionevent which had been well attended.Aspects of the refurbishment and design or the unithad been made in collaboration with staff and localpeople. The facilities for relatives had beenimproved with a thoughtful inclusion of securestorage of valuables in the waiting area. However,not all bed spaces were capable of givingreasonable auditory privacy. There were no toilet orshower facilities for patients within the unit.However, patients were able to access thesefacilities in a neighbouring ward without entering ageneral public area.There were delayed patient discharges due to a bedelsewhere in the hospital not being available.Similar to most critical care units in England, in thelast five years between 60% and 70% of alldischarges were delayed by more than four hoursfrom the patient being deemed ready to leave theunit.Urgent surgical operations had been cancelled dueto the lack of an available bed in critical care. This

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was above (worse than) the national average.Figures from NHS England reported 53 cancelledoperations at the hospital between July andDecember 2015. We found that there was no limitper day for how many beds could be booked on theunit for those patients that require critical care afterelective operations.Despite the pressures on bed availability, patientswere admitted to the unit in a timely fashion andthe unit had not transferred patients to other unitsfor non-clinical reasons for over twelve months.Data from the Intensive Care National Audit andResearch Centre (ICNARC) showed that the unittransferred less patients to the wards out of hoursthat the England average (performed better).Arrangements for governance of critical careservices did not always operate effectively. Forexample, the risk register did not include risks thatstaff highlighted during the inspection and the riskshad not been reviewed and updated. Thegovernance structure and processes seemedimmature and not embedded. In addition, it wasnot always clear how the local governance linkedwith formal trust wide processes. This meant thatthere was a risk that issues that required escalationwere not being raised formally.Following the refurbishment and recent changes inleadership of both nursing and consultant leads,the team appeared to be in a period of adjustment.The team culture was strong within the unit.However, opportunities for staff engagement couldbe improved, for example unit meetings had beenabandoned due to poor attendance.

Maternityandgynaecology

Good ––– Care in both the gynaecology and maternity wardsand delivery suite was consultant led. Patients hadrisk assessments completed and reviewed regularly.Incidents were reported and thoroughlyinterrogated for learning and safety improvements.Good safeguarding processes were in place, whichincluded established links with the lead localauthority. Staff demonstrated understanding ofduty of candour regulations and compliance withthis was also evidenced in records.Safety improvements were required to thematernity services. The midwifery staffing levels didnot comply with the Health and Social Care Act

Summaryoffindings

Summary of findings


(2008) Code of Practice on staffing. The midwife topatient ratio exceeded (was worse than)recommended levels and one to one care forwomen in established labour was not evidenced tohave been achieved 100% of the time.The maternity services were responsive to theneeds of local women. Positive feedback wasconsistently provided. This showed the majority ofpatients were highly satisfied with their treatmentand care and would recommend services. We sawrecords documenting patient’s choices andpreferences. The maternity services had achievedfull accreditation with UNICEF UK breast feedingstandards. The gynaecology service had links withother specialists and treatment centres. Thissupported the provision of effective care andtreatment plans for patients. Annual audit planswere in place which enabled clinical standards ofpractice to be checked and improvements made.Policies and procedures were provided in line withnational guidance and policy.There were thorough risk management and qualityand governance structures in place. These linkeddepartmental with trust risk and governancemeetings. This ensured an effective flow ofinformation from ward to board and vice versa.Incidents, audits and other risk and qualitymeasures were scrutinised for serviceimprovements and appropriate actions taken.Systems were in place to effectively shareinformation and learning. Staff were proud of thepatient care they provided and a learning culturewas evident. Leadership was described as good.Junior staff told us they were well supported andsenior managers were visible and approachable.The trust board had approved a capital investmentin the maternity services. This included theprovision of a new midwifery led birth unit.

Services forchildren andyoungpeople

Requires improvement ––– Overall we found the services for children andyoung people to require improvement.Staff were clear they wanted to provide the bestcare they could for children and young people butthere was no clear vision for how the servicewanted to be performing in the coming years.Staffing levels for both medical and nursing staff didnot meet the nationally recommended guidelines

Summaryoffindings

Summary of findings


for the acuity of children cared for in the hospital.Risks to patient safety regarding nurse staffinglevels had been raised as a concern but nopermanent arrangement had been put into place tomaintain safe staffing levels. High dependencypatients were nursed on the ward but there was nofunding available for the extra nursing staff neededto care for these patients.Safeguarding training did not meet nationalguidelines at the time of our visit but we wereshown a plan was in place to provide this trainingand a timeline for meeting the guidelines.There were times when children and young peoplewere cared for in areas used for adults such as someoutpatient appointments, main theatre and daysurgery unit. Some provision had been made toprotect children from adults in these shared areas.We found the screens to protect a child were notalways used.Learning from examples of past practice wasencouraged and medical staff felt well supported bytheir senior colleagues. Staff were able to accesstraining that would add to their skills and themajority of nurses in the neonatal unit were trainedin their specialty. Children and young people’sneeds were cared for and responded to bycompetent staff. Policies and protocols were basedon national guidelines ensuring that best practisewas observed. Audit programmes were contributedto both internally and nationally to demonstratehow well the department performed against othertrusts.All staff worked flexibly to support the needs ofchildren, young people and their families. Staffworked together and shared informationappropriately with community staff to ensure thesafety and wellbeing of children who were beingdischarged home.Staff were compassionate in their treatment ofpatients and their families and privacy and dignitywas respected at all times. Children and youngpeople’s views were listened to and their consentwas always sought in a way they could understand.Facilities were provided and used flexibly forparents to spend time with their children and attimes included the accommodation for the patient’swhole family.

Summaryoffindings

Summary of findings


Staff had developed methods of gaining feedbackfrom children of all ages and had made changes tofacilities in response. Patient and parent feedbackwe saw was positive with comments including“unconditional support and care”, “cheerful, even atthe end of a long shift” and “patience and honesty”.Staff from the children’s unit were supporting thoseareas where adults were also nursed with projectsdesigned to improve a child or young person’sexperience when they visited that area.

End of lifecare

Good ––– We have judged the overall end of life service asbeing good.The trust could organise rapid discharges effectivelybut there were delays due to funding of carepackages in the community. The trust hadnot recently completed an audit of patientsachieving their preferred place of dying.There was an improvement plan in place for end oflife care that was being overseen by a strategysteering group. There had been a number ofchanges put into place in the previous twelvemonths. These were initiated following the resultsof the National Care of the Dying Audit that wascompleted in 2014 and also to respond andimplement national directives such as the NICEQuality Standard on End of Life Care. Theseincluded a new personalised care framework, toreplace the discontinued Liverpool Care Pathway,improved rapid discharge processes and theappointment of two end of life care facilitators toroll out the new documentation and providetraining. Whilst some of the changes were not fullyimbedded the staff were committed and motivatedto provide an improving service and embraced theinitiatives that were being developed by the end oflife steering group.There was evidence of leadership in both thepalliative care team and at board level howeverdespite the work undertaken to deliver theimprovement plan there was no trust wide strategyor policy on end of life care. This was combinedwith limited representation at the strategy steeringgroup from board members.

Summaryoffindings

Summary of findings


Staff understood their responsibilities to raise andreport concerns, incidents and near misses. Theywere clear about how to report incidents and wesaw evidence that learning was shared across theteams.Equipment was readily available and properlymaintained for the use of patients. Anticipatorymedicines were always available and patients beingdischarged home had their medicines providedpromptly.There were processes in place to assess andrespond to patient risk. Staff were able to contactmembers of the palliative care team for adviceabout deteriorating patients and this team wasresponsive and supportive to urgent requests forinput. The palliative care team were staffedsufficiently to provide the advice and support thatwas requested.The trust was providing a seven day service frommembers of the palliative care team but this wasonly currently being funded until the end of March2016.There was a range of training that was provided formembers of the palliative care team and alsotraining that was available to other staff if theycould be released from their duties but there wascurrently no mandatory end of life training for stafftrust wide.Patients received compassionate care and weretreated with respect and dignity by staff. Patientswere communicated with sensitively and keptinformed about their diagnosis and prognosis.Staff worked in a positive and open culture and feltsupported by their colleagues and line managers.Staff felt valued by the trust and were engaged withthe trust objectives.The end of life service rated poorly in the 2014National Care of the Dying survey. New paperworkand processes were being introduced and everymember of staff on every ward was receiving atwo-week training package in end of life care. Therewere no audits to evidence how the service wasachieving rapid discharge or if patients weresupported with their preferred place of care. Theleadership needed to develop a trust wide strategyand policy for end of life care.

Summaryoffindings

Summary of findings


Outpatientsanddiagnosticimaging

Good ––– Salisbury NHS Foundation Trust outpatient anddiagnostic services were overall rated as good.There were good systems in place for incidentreporting and learning from when things did not goas planned. Systems were in place for the safeadministration of medicines and for the preventionof infection. The outpatient and medical recordsdepartment achieved a high standard in makingsure medical notes were available for 99.91% ofappointments. Staff were knowledgeable aboutsafeguarding and their responsibilities tovulnerable adults and children. During ourinspection we observed an emergency situation inthe outpatients department. The way in which thiswas handled showed staff were aware of the healthof their patients and responded quickly andappropriately to any deterioration in a patient’shealth.Staff were very competent in the roles they werebeing asked to perform. There were someoutstanding areas of practice including the nurseled pathways within the rheumatology outpatientsclinics and one stop clinics within urologyoutpatients. There was good multidisciplinaryworking both within the trust and with otherexternal organisation such as other health careproviders and the Ministry of Defence.Staff communicated in a professional but friendlymanner with patients and their families. Commentsfrom patients and relatives were very positiveabout the staff and how they provided their careand treatment. Patients were involved in their careand treatment and always put them first.The departments provided a good service to makesure people were not waiting long periods of timefor either outpatients or diagnostic services. Thetrust was working with other local hospitals andlooking at capacity demand in order to make surewaiting lists did not increase. We saw that the trustwas achieving 92.94% for its cancer two weekwaiting time against a standard of 93%. Outpatientsdepartments operated a ‘patient initiatedfollow-up’ appointment which meant for a threemonth period patients could arrange a follow-upappointment if they felt they needed it. We saw

Summaryoffindings

Summary of findings


evidence that complaints were discussed atdepartmental meetings and changes were madewhere necessary to help prevent furthercomplaints.Staff were supported at all levels from theirimmediate manager through to the trust executiveteam including the chief executive. Goodgovernance systems were in place acrossoutpatients and diagnostics. Whilst some staffdescribed the culture as a ‘them and us’ we did notsee this view shared by the majority of staff. Themajority of staff we spoke with felt the culture wasopen and that staff strived to make sure theexperience for patients was outstanding in line withthe trust vision.

Spinalinjuriescentre

Requires improvement –––

Summaryoffindings

Summary of findings


SalisburSalisburyy DistrictDistrict HospitHospitalalDetailed findings

Services we looked atUrgent and emergency services; Medical care (including older people's care); Surgery; Critical care;Maternity and gynaecology; Services for children and young people; End of life care; Outpatients anddiagnostic imaging; Spinal injuries centre


Contents

PageDetailed findings from this inspectionBackground to Salisbury District Hospital 25

Our inspection team 25

How we carried out this inspection 26

Facts and data about Salisbury District Hospital 26

Our ratings for this hospital 27

Findings by main service 28

Action we have told the provider to take 233

Background to Salisbury District Hospital

Salisbury NHS Foundation Trust provides care to over240,000 people across Wiltshire, Dorset and Hampshire.This includes general and acute services at SalisburyDistrict Hospital with specialist services including burns,plastics, cleft lip and palate, genetics and rehabilitationserving over three million people. In addition the Duke ofCornwall Spinal Treatment Centre serves South England'spopulation of 11 million people.

We inspected this trust as part of our programme ofcomprehensive inspections of acute trusts. Theinspection team inspected eight core services as well asan additional service, the spinal service:

• Urgent and emergency services

• Medical care (including older people’s care)

• Critical care

• Maternity and gynaecology

• Services for children’s and young people

• End of life care

• Outpatients and diagnostic imaging

• Spinal services

Our inspection team

Our inspection team was led by:

Chair: Julie Blumgart; former Clinical Quality Director,South region.

Head of Hospital Inspections: Mary Cridge, Care QualityCommission

The team included CQC inspectors and a variety ofspecialists: two directors of nursing, lead for safeguardingadults and children, registrar in emergency medicine,senior sister in emergency medicine, matron in trauma

and orthopaedics, consultant anaesthetist, critical carenurse, consultant in paediatric palliative medicine, wardsister, deputy medical director - consultant obstetricianand gynaecologist, head of midwifery, consultantphysician, clinical nurse specialist, consultant radiologist,nurse, consultant neonatologist, senior manager forpaediatrics and child health, consultant general surgeonand medical director, surgical nurse, specialist registrar,ST3 in immunology. The team also included two expertsby experience, analysts and an inspection planner.

Detailed findings


How we carried out this inspection

Before visiting, we reviewed a range of information weheld and asked other organisations to share what theyknew about Salisbury Hospital. These included the localcommissioning groups, Monitor, the local council,Wiltshire Healthwatch, the General Medical Council, theNursing and Midwifery Council and the Royal Colleges.

We held two listening events in Salisbury on the 3 and 19November 2015. More than 59 people attended theevents. People who were unable to attend the eventshared their experiences by email and telephone and onour website.

We carried out an announced inspection on 1, 2, 3 and 4December 2015 and an unannounced inspection on 13

December 2015. We held focus groups and drop-insessions with a range of staff in Salisbury Hospital,including nurses, junior doctors, consultants, studentnurses, administrative and clerical staff, physiotherapists,occupational therapists, pharmacists, domestic staff,porters and maintenance staff. We also spoke with staffindividually as requested.

We talked with patients and staff from across most of thetrust. We observed how people were being cared for,talked with carers and family members, and reviewedpatients’ records of their care and treatment.

Facts and data about Salisbury District Hospital

Salisbury Hospital has 464 beds and is staffed byapproximately 4054 members of staff. They provide careto around 240,000 people across Wiltshire, Dorset andHampshire.

In 2014/15, the trust had 6,405 elective inpatientadmissions and 28,494 emergency admissions. Therewere 183,732 outpatient attendances, along with 43,998attendances at accident and emergency. It had revenueof £355,014k, the full cost was £355,593k therefore therewas a financial deficit of £579,000. This was the first yearin its history Salisbury NHS Foundation Trust hadreported a deficit.

Overall the bed occupancy at the trust has been belowthe national average (85.9%) apart from in the fourthquarters of both 2013/14 and 2014/15. It is generallyaccepted that bed occupancy over 85% is the level atwhich it can start to affect the quality of care provided topatients and the orderly running of the hospital.

Salisbury NHS Foundation Trust has fairly stableexecutive and non-executive team. The chairman hasbeen in post for one year supported by a board ofnon-executive directors with a range of skills andexpertise, two of whom have been in post for seven years.The chief executive has been in post for two years havingworked in the trust since 1986. The director of nursing

and chief operating officer are the newest recruits to theboard at one year and six months respectively, with othermembers of the executive team having been in post threeto five years, except for the director of finance andprocurement who had been in post for 29 years.

CQC Inspection History

Salisbury District Hospital has had three inspections since2011. The first inspection carried out in May 2011 foundthat Salisbury District Hospital was meeting all theessential standards of quality and safety, but to maintainthis we suggested that some improvements were made inreducing the incidences of pressure ulcers, appropriateuse of bed rails, timely support for patients, recordkeeping and cleanliness of some public areas.

Another inspection was carried out in February 2013 andstandards were not met in staffing and the keeping ofrecords. Concerns were raised that staff did not havesufficient qualifications, skill or expertise to meet thepeople’s needs effectively at all times. Concerns were alsoraised that paper-based confidential patient informationwas not being protected effectively on certain wards. Afurther inspection was carried out in October 2013 toreview whether improvements had been made foundthat sufficient improvement had been made by the trustin these areas.

Detailed findings


Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices

Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Medical care Good Good Good Requiresimprovement Good Good

Surgery Requiresimprovement Good Good Requires

improvement Good Requiresimprovement

Critical care Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Maternity andgynaecology

Requiresimprovement Good Good Good Good Good

Services for childrenand young people

Requiresimprovement Good Good Good Requires

improvementRequires

improvement

End of life care Good Good Good Good Requiresimprovement Good

Outpatients anddiagnostic imaging Good Not rated Good Good Good Good

Spinal injuries centre Requiresimprovement

Requiresimprovement Good Inadequate Requires

improvementRequires

improvement

Overall Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Notes

1. We are currently not confident that we are collectingsufficient evidence to rate effectiveness forOutpatients & Diagnostic Imaging.

Detailed findings


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceUrgent and emergency care and treatment is provided atSalisbury District Hospital (SDH) by the medical directorate.The emergency department (ED), otherwise known as theaccident and emergency department, operates 24 hours aday, seven days a week. The ED saw approximately 44,400patients in 2014/15 of whom around 20% were children.Some expected patients referred by their GPs are admittedvia the ED. However the ED is not the only point of urgentaccess to the hospital, with some expected urgent casesbeing admitted directly to the acute medical assessmentunit (AMAU), the surgical assessment unit (SAU) and thechildren’s ward, Sarum.

Adult ED patients receive care and treatment in two mainareas; minors and majors. Self-presenting patients withminor injuries are assessed and treated in the minors area.This area is open from 8am until midnight. Some patientsare streamed to see the co-located out-of-hours GP.Patients with serious injuries or illnesses who arrive byambulance are seen and treated in the majors area, whichincludes a three-bay resuscitation room. The majors area isaccessed by a dedicated ambulance entrance.

There is a separate children’s unit; however this was not inuse at the time of our visit because it could not beadequately staffed. Although the dedicated children’swaiting room was in use, children were assessed andtreated in the adults’ department.

The ED is designated a trauma unit and provides care for allbut the most severely injured trauma patients. Severelyinjured trauma patients are usually taken by ambulance to

a major trauma centre if their condition allows them totravel directly. They are otherwise stabilised at SDH andeither treated or transferred as their condition dictates.There is a helipad located close toon the hospital site fromwhich patients are transferred to the ED by roadambulance.

There is a short stay emergency unit (SSEU) locatedadjacent to the ED and staffed and managed by the ED.This is an eight-bed observation ward that allows forfurther assessment of patients who are likely to remain inthe unit for between four and 24 hours, or in the case of ahead injury, 48 hours, but are not likely to requireadmission. The unit is also used to accommodate patientswho require admission to a specialty bed but none areavailable.

We visited the ED over two and a half weekdays and we didan unannounced inspection at the weekend. We spokewith approximately 30 patients/relatives. We spoke withstaff, including nurses, doctors, managers, therapists,support staff and ambulance staff. We observed care andtreatment and looked at care records. We receivedinformation from our listening events and from people whocontacted us to tell us about their experiences. Prior to andfollowing our inspection, we reviewed performanceinformation about the trust and information from the trust.

Urgentandemergencyservices

Urgent and emergency services


Summary of findingsThe emergency department (ED) was not consistentlystaffed by sufficient numbers of appropriately qualified,experienced and skilled nursing staff to ensure thatpeople received safe care and treatment at all times.The nursing establishment did not ensure that anappropriate ratio of nursing staff to patients wasconsistently achieved. This was compounded by the factthe service had a significant numbers of nursing staffvacancies and relied heavily on temporary staff who didnot always have the necessary skills and experience toprovide safe and effective care.

Staffing levels at night were of particular concern andthere were concerns about the lack of seniority ofmedical and nursing staff on duty at night. We hadconcerns that there were insufficient registeredchildren’s nurses employed and there was a lack ofassurance that this risk had been mitigated by ensuringthat adult trained nurses had received specialist trainingto care for children. As a result of this lack ofappropriately skilled staff, Tthe separate children’s areawas not being used because it could not be adequatelystaffed. and cChildren instead received care andtreatment in the adults’ department which was not anappropriate environment.

Staffing issues impacted on the department’s ability toensure that patients were consistently promptlyclinically assessed on arrival in the ED. We wereparticularly concerned about the delayed clinicalassessment of self-presenting patients (adults andchildren) who were not adequately observed while theywaited. We also had concerns that nursingdocumentation was not always completed to therequired standard. Staff shortages may also haveaffected staff’s ability to complete mandatory training.Compliance with mandatory training was well below thetrust’s target of 85%. We were not assured that nursingstaff had sufficient opportunities for ongoing educationand development or clinical supervision.

People’s care and treatment was planned and deliveredin line with current evidence-based guidance andstandards. We saw good levels of compliance withrecognised care pathways, including those for sepsisand stroke care. Compliance with protocols and

standards was monitored through participation innational and local audits. Performance in nationalaudits was generally about average compared withother English trusts, with the exception of the RoyalCollege of Emergency Medicine mental health audit,where performance required improvement. There wereaction plans in place to make improvements whereshortfalls were identified. We saw little evidence of localaudit.

The trust’s un-planned re-attendance rate wasconsistently lower (better than) the England average.This was an indicator that care and communication withpatients were effective.

Junior doctors felt well supported with regulareducation and supervision. The lack of senior medicalpresence in the ED was to some extent mitigated bysenior review of all records of patients seen overnight.

The service worked well with other teams and servicesso that people received seamless care. Care wasdelivered in a coordinated way, with support fromspecialist teams and services. There were excellentworking arrangements with the Acute Medical Unit,which worked closely with the ED as part of the ‘frontdoor team’. There were clear policies agreed withspecialty doctors which formalised their supportive roleto ED and reciprocal support was offered by EDconsultants to junior doctors in other specialties.

We observed that all staff treated people withcompassion, kindness, dignity and respect. Theyresponded in a caring and compassionate way whenpeople experienced pain, discomfort or distress.Patients and their relatives were involved as partners intheir care. Staff took the time to explain to patients andtheir relatives about their care and treatment. This wasdone sensitively and in a way that people couldunderstand. The department had established anoutstanding service to support bereaved relatives.

Feedback we received from patients and visitors wasoverwhelmingly positive. We spoke with many patientsand visitors. Unusually, we were approached by somepatients who were very keen to tell us how well they hadbeen looked after. This feedback was consistent with




results from patient satisfaction surveys. Friends andfamily scores were consistently high, with over 90% ofrespondents indicating that they would recommend theservice.

Services were not always responsive to people'sneeds.organised and delivered so that all patientsreceived the right treatment at the right time.Childrendid not always receive care and treatment in anappropriate environment and patients with mentalhealth needs, including children and adolescents,sometimes waited too long to be assessed by a mentalhealth practitioner. At busy times patients queued ontrolleys in the emergency department corridor and thisimpacted on their comfort, privacy and dignity.

Premises and facilities were largely appropriate for theservices delivered; however children were cared for inthe adults’ department which was not an appropriateenvironment from them because they were exposed tosights and noise which may cause them stress. Thechildren’s waiting room, whilst bright and welcoming,was overlooked by and could be accessed by adultpatients and visitors. Patients’ privacy and dignity wassometimes compromised on the short stay emergencyunit. The ward was cramped and the layout did notalways allow for single sex accommodation to beprovided.

The needs of patients in vulnerable circumstances werenot always met. Patients with mental health needs,particularly children and adolescents, who requiredassessment by a mental health practitioner, did notalways receive a responsive service. This meant thatthese patients experienced long waits which could bedetrimental to their mental health and they weresometimes admitted to hospital unnecessarily.

The department had not taken adequate steps tosupport patients in vulnerable circumstances, such asthose living with dementia.

The ED was consistently meeting national standards inrespect of the time people spent in the department, andthe time they waited for treatment, although this wasbecoming more challenging with increasing demand on

the service. There were relatively few ambulancehandover delays but at busy times, some patientsqueued on ambulance trolleys in the department andthis impacted on their comfort, privacy and dignity.

The ED worked well with the patient flow team and therest of the hospital to minimise blockages andovercrowding in ED. The trust had invited an externalreview of patient flow by the emergency intensivesupport team (ECIST) and had developed animprovement plan based on their recommendationsand had taken some immediate actions, although somechanges required time to embed. Further improvementswere planned but required time and resource.

The service had not developed a clear vision or a set ofvalues which staff were engaged with. There wasstrategy which set out a five year plan in respect ofstaffing. cohesive strategy. Although the service hadresponded appropriately to recommendations made byan external reviewing body and there were ongoingstaffing reviews, these were largely reactive plans anddid not form part of an overarching strategy. Staff hadnot been involved or engaged in developing a vision orstrategy and tThere was limited evidence of patientinvolvement.

Risks to service delivery were understood by themanagement team but risk management processeswere not fully effective. The risk register did not capturethe multi-factorial risks to patient safety and quality andwe could not be assured that risks were appropriatelyescalated or mitigated.

Staff enjoyed working in this service and the culture wasone of mutual respect and teamwork. Staff feltsupported and valued by senior managers who wereboth visible and accessible. However, morale wasovershadowed by issues relating to staffing. Staff hadlittle confidence that these issues would be resolved inthe short term and there was a risk that these issuesmay in the future, impact on recruitment and retentionof staff.




Are urgent and emergency services safe?


The emergency department (ED) was not consistentlystaffed with appropriate numbers of suitably skilled andexperienced staff to ensure that patients received safe careand treatment at all times.

The nursing establishment fell short of the nurse to patientratio recommended by the National Institute for Health andCare Excellence (NICE) and this was overwhelmingly thebiggest area of concern raised by nurses and doctorsduring our visit. Notwithstanding the nursingestablishment, the ED had a significant number of nursestaff vacancies and absences which meant the departmentrelied heavily on temporary staff. We could not be assuredthat temporary staff were appropriately skilled andexperienced to provide safe care in ED.

Staffing levels at night were of particular concern, with thenurse to patient ratio sometimes as low as one nurse to tenpatients in majors. Staff regularly missed their breaks, andwere at risk of fatigue. Medical staffing at night was also aconcern, with only junior medical staff on duty frommidnight onwards, albeit with a well established supportsystem from the wider hospital medical staff and EDconsultants, who were resident when on call.

There were insufficient numbers of registered children’snurses employed to ensure that there was always achildren’s nurse on duty and the trust could not assure usthat they had adequately mitigated this risk through stafftraining.

We judged that staffing levels and the frequent use oftemporary staff may have impacted on other areas ofpractice, resulting in unsafe or potentially unsafe practice.Patients did not consistently receive prompt initial clinicalassessment to ensure that those patients with serious andlife threatening conditions could be prioritised. Waitingpatients, including children, were not adequately observed.

Nursing documentation, particularly on the short stayemergency unit (SSEU), was generally poor.

A significant proportion of staff were not up-to-date withmandatory training. This meant we could not be assured oftheir knowledge of safe systems, processes and practices.

Despite these areas of concern, the department had a goodtrack record on safety, with no recent serious incidentsreported. Staff were encouraged to report incidents andthey received feedback when they raised concerns.

Incidents

• There were no serious incidents reported in theemergency department (ED) between August 2014 andAugust 2015.

• Staff told us they were encouraged to report incidentsand they received feedback when they did so. Importantinformation following incidents was disseminated athandover meetings, via a communication book or byemail.

• There were quarterly mortality and morbidity meetingswhere the care of patients who had complications orunexpected outcomes was reviewed so that learningcould be identified and shared.

• Staff were familiar with their responsibilities under theDuty of Candour regulation. However, we were notprovided with any examples of disclosure so we couldnot be assured that the regulations were complied with.

• Safety thermometer data (data collected on a single dayin each month and used to record patient harms) for theperiod August 2014 to July 2015 showed:

▪ There were threeno pressure ulcers reported

▪ There were noseven falls reported

▪ There wereas oneno catheter acquired urinary tractinfections reported

Cleanliness, infection control and hygiene

• In CQC’s 2014 A&E survey the trust scored nine out of 10in response to the question which asked patientswhether the ED was clean.

• The department was tidy and mostly visibly clean.However, we found items of equipment in theresuscitation area which were dusty. A patientcommented to us that the heart monitor used in theircare was dusty.

• Cleaning staff were not available overnight. Nursing stafftold us that if an area became contaminated and a




specialist or deep clean was required during the nightthey would have to undertake this themselves (althoughthey were not trained to do so) or take the affected areaout of use until the following day.

• There were monthly audits of hand hygiene andcompliance with the uniform policy including the barebelow the elbow policy. Hand hygiene audits inSeptember and October 2015 showed some room forimprovement.

• There were sufficient appropriately sited hand washbasins and hand gel dispensers. We saw that most staffregularly washed their hands and observed standardinfection control precautions. However we saw onenurse did not wash their hands or use hand gel inbetween patients. StaffMost staff observed the ‘barebelow the elbow’ policy.y, although on occasions wesaw staff (particularly night staff) wearing long sleevedsweatshirts. We observed a nurse being reminded to tietheir hair back at a morning handover meeting. Thesenior nurse told us that compliance with hygienestandards was checked at every handover meeting.

• Staff wore appropriate protective clothing (gloves andaprons). However, we saw a nurse enter the sluice todispose of waste and they were still wearing theirprotective gloves when they came out of this areaThisincreased the risk of cross contamination.

• There were two private assessment/treatment rooms inED majors where infectious patients could be isolated.

Environment and equipment

• The design, maintenance and use of the ED were mostlyappropriate to keep protect people from avoidableharm.

• A patient-led assessment of the care environment(PLACE) was undertaken ED in September 2015. Theassessment looked at the safety, suitability andcleanliness of the environment. No major issues wereidentified.

• In terms of layout the ED was being used well. Thecentrally located work station in ED allowed medicaland nursing staff to observe patients in the department.

• There was a separate waiting room for children, whichwas adjacent to the adults’ waiting area. This wasoverlooked by, and could be accessed by adults in the

main waiting area. There were restricted lines of sight tothe children’s waiting area. The area could only bepartially viewed by receptionists. The Royal College ofEmergency Medicine (RCEM) recommends in its TriagePosition Statement 2011 that in the triage environment,consideration should be given to visualisation of thewaiting environment. Health Building Note (HBN) 15-01states “the (ED) waiting area should be provided tomaintain observation by staff but not allow patients orvisitors within the adult area to view the waiting area.”

• The department was well equipped. However, someequipment was not appropriately stored. In theentrance to the ED there were a number of wheelchairsstored. On one day of our inspection these were storedtwo deep in an untidy fashion and there was a risk thatpatients and visitors may knock their legs on these andsustain an injury.

• Consumable items were in plentiful supply and wereappropriately stored. However, we found chlorinegranules (a hazardous substance) stored in an unlockedcupboard in the sluice.

• We checked a range of equipment, includingresuscitation equipment. It was accessible, mostly cleanand well maintained. Regular equipment checks tookplace; however, on the SSEU there were no recordsavailable to show that the crash trolley had beenchecked on 1 and 2 December 2015. In the resuscitationarea we found a syringe pump which was overdue forservice.

Medicines (includes medical gases and contrastmedia)

• Medicines were appropriately stored in lockedcupboards or fridges. Fridge temperatures regularlychecked and they were they correct at the time of ourvisit.

• Controlled drugs were appropriately stored and suitablerecords were kept. Controlled drugs are medicineswhich require extra checks and special storagearrangements because of their potential for misuse.

• We found a box of mixed intravenous fluids stored in theresuscitation area. This increased the risk that staff maynot identify the correct fluid in an emergency situation.

• In CQC’s 2014 A&E survey the trust scored 9.2 out of 10 inresponse to the question which asked patients whether




that the purpose of new medicines was explainedbefore they left A&E. However, the trust scored only 5.3out of 10 in response to the question that asked patientswhether they were told about possible side effects ofmedicines for those prescribed new medicines while inA&E.

• Some Emergency Nurse Practitioners (ENPS) weretrained as non-medical prescribers so that they couldsupply and administer certain medicines. There werealso Patient Group Directions (PGDs) in place. PGDs areagreements which allow some registered nurses tosupply or administer certain medicines to a pre-definedgroup of patients without them having to see a doctor.We saw evidence that PGDs were up-to date oridentified as being under review.

Records

• Patients’ records were accessible. In ED the need foraccessibility outweighed the need for security but wewere satisfied that patients’ records were not easilyaccessible to people who were not authorised to viewthem. In the SSEU patients’ records were stored on thetop of the nurses’ station which made them easilyaccessible to unauthorised people.

• We looked at a sample of patient records. Nursingdocumentation was generally poor. Although regularobservations were consistently recorded, other nursingcare was not well documented and entries werefrequently not dated and timed.

• We found documentation on the SSEU to be particularlypoor. In one patient record we found scanned notesrelating to two other patients. The nursing assessmentdocumentation did not have addressograph labelsaffixed to every page, which meant there was a risk thatpatients’ records may be mixed up. Two sets of recordswere maintained for each patient. One set related totheir attendance in ED and the other to their admissionto SSEU. Entries by nursing staff to document the caregiven to patients whilst on the SSEU were brief andinfrequent, and were sometimes recorded in the wrongset of notes, making it difficult for continuity of care tobe assured. A nurse told us that agency staff werefrequently employed on this unit and may be unfamiliarwith the paperwork.

• The ED participated in an annual records audit, the lastone of which took place in late 2014 and showed goodlevels of compliance with record keeping standards.

Safeguarding

• Staff understood their responsibilities in respect ofsafeguarding vulnerable adults and children and wereaware of safeguarding policies and procedures. Twoconsultants and two nurses were identified assafeguarding leads., although there was no lead nursefor safeguarding.

• All ED staff were required to complete level 2safeguarding training as a minimum. This is one of thesafeguarding children’s standards set by the RoyalCollege of Emergency Medicine (RCEM). Training recordsshowed that only 64% of staff had completed thistraining. The RCEM also recommends that all senioremergency medicine doctors (ST4 or equivalent andabove) should have level 3 child protection training. Thetrust confirmed that this standard was not met,although training had started in 2015 and was plannedto continue in the forthcoming year.

• The ED patient record prompted staff to considersafeguarding in their assessment of each patient. Wesaw that safeguarding assessments were consistentlycompleted.

• There were processes in place for the identification andmanagement of children at risk of abuse:

▪ The patient record system identified previous childattendances in the last 12 months so that staff wouldbe alerted to possible safeguarding issues.

▪ Frequent attenders were discussed with thepaediatric team.

▪ There was access to a senior paediatric opinion 24hours a day for child welfare issues.

▪ All skull or long bone fractures in children under oneyear were discussed with a senior paediatric or EDdoctor during their ED attendance.

▪ There was a safety net system in place whereby thetrust safeguarding lead reviewed all children’s EDrecords and all health visitor referral forms. However,records were only collected weekly; therefore afailure to make a safeguarding referral would not beidentified promptly. We identified that a child at risk




was not identified when they attended the ED in earlyNovember 2015. This had not been picked up by thesafety net system. We drew this to the attention ofthe ED senior staff and the trust safeguarding leadand asked them to investigate the system failure.This was still under investigation.

▪ All child attendances were notified to GPs and tohealth visitors and school nurses.

▪ Some staff were familiar with the policy whichoutlined responsibilities in relation to safeguardingwomen or children with, or at risk of, female genitalmutilation (FGM). Other staff knew where to locatethe guidance on the trust’s intranet. One nurse wespoke with had no knowledge of any policy orguidance in relation to this.

Mandatory training

• A significant proportion of staff were not up-to-date withmandatory training. This meant we could not beassured of their knowledge of safe systems, processesand practices. Training records showed mandatorytraining compliance was well below the trust target of85% as follows:

▪ Equality and diversity: 73%

▪ Fire safety: 51%

▪ Hand hygiene assessment: 56%

▪ Health and safety overview: 71%

▪ Infection prevention and control: 64%

▪ Information governance: 51%

▪ Moving and handling: 52%

▪ Safeguarding adults: 78%

▪ Safeguarding children level 2: 64%

Assessing and responding to patient risk

• Patients did not always receive an initial clinicalassessment by a healthcare practitioner within 15minutes of arrival in ED. Guidance issued by the Collegeof Emergency Medicine (Triage Position Statement, April2011) states that a rapid assessment should be made toidentify or rule out life/limb threatening conditions toensure patient safety. This should be a face-to-faceencounter which should occur within 15 minutes of

arrival or registration and assessment should be carriedout by a trained clinician. This ensures that patients arestreamed or directed to the appropriate part of thedepartment and the appropriate clinician. It alsoensures that serious or life threatening conditions areidentified or ruled out so that the appropriate carepathway is selected.

• Information displayed on a notice board in the EDstated that during the month of October 2015 theaverage time patients waited to see an assessmentnurse was 23 minutes. During our unannounced visit ona Sunday we observed patients were frequently waitingin excess of 30 minutes, with some self-presentingpatients waiting up to an hour.

• The trust used a recognised triage tool (Manchestertriage tool), although this and the triage policy wereunder review at the time of our visit. A streamingprotocol had recently been introduced for patients whoself-presented at reception. Receptionists had a list ofpatient conditions/complaints, which were categorisedas red, requiring assessment in majors or blue, requiringassessment in minors. Patients who were categorisedred would be called through to majors to wait in acubicle if there was on available. However during ourunannounced visit, when the department was busy,they could not be accommodated in majors andcontinued to wait in the waiting room. We wereconcerned that there were undifferentiated unwellpatients sitting in the waiting room who were notobserved by healthcare practitioners. When we raisedthis concern with a senior nurse they acknowledged thatthis was a concern. They told us that the triage nursewas responsible for overseeing the waiting room.However, we observed that the triage nurse rarelyentered the waiting room and called patients from thedoor of the assessment cubicle. Receptionists were ableto describe serious and life threatening conditionswhich would prompt them to call for immediate supportfrom a healthcare practitioner. There was a visual alerton the electronic patient record system where receptionstaff documented concerns, along with the name of themember of staff they had escalated their concerns to.

• A checklist had been developed to help staff prepare forthe arrival of a seriously ill/injured patient for which theyhad received an alert from the ambulance service. This




ensured that they obtained vital information from theambulance service and informed the relevant clinicians,for example the stroke team or the trauma team, so thatthey were on standby.

• We observed a failure to appropriately escalate andrequest a medical review of a patient who presentedwith palpitations. The patient was triaged within 15minutes of arrival and placed on a heart monitor.However, monitor readings indicated the need for anurgent doctor review which should have been requestedimmediately. This was not requested for a further 40minutes, at which point the patient was reviewed by adoctor immediately.

• Patients presenting in ED with mental health issueswere assessed using a recognised mental health riskassessment. This graded the risk of self-harm or harm toothers as red, amber or green. We noted that the riskassessment documentation was not consistently used.Four out of ten patient records we reviewed for patientspresenting with mental health issues between 20October and 3 November 2015 had not had a mentalhealth risk assessment completed. Two of these 10patients had been assessed as medium to high risk butwere discharged without referral to the mental healthliaison team. We discussed our concerns with the EDconsultant lead for mental health. They acknowledgedthat there had been a problem regardingdocumentation of psychiatric referrals. A new proformahad recently been introduced to document discussionswith the mental health team and guidance had beenissued to junior doctors.

• Staff told us that patients who were assessed as highrisk would be cared for in majors so that they could beclosely observed, while awaiting an assessment by themental health team. We saw a documented example ofthis.

• There was an enhanced nursing risk assessment toolused to assess the need for additional nursing supportfor patient, including those who had some form orcognitive impairment, learning difficulties or mentalhealth concerns. There was also an intentional roundingtool used to monitor patients who had been identifiedas being at high risk of falls. We saw this in use for apatient who was living with dementia who was admittedto the SSEU overnight.

• The ED and SSEU used a recognised early warning scoretools to assess patients’ risk and their need for physicalobservations. Documentation clearly set out triggers forfrequent observations and when to seek senior help.There was similar documentation for infants, pre-schoolchildren and children of school age.

• We looked at a sample of observation charts in the EDand the SSEU. They were mostly consistentlycompleted, showing that observations were takingplace with the required frequency. However, on theSSEU we noted for one patient that the frequency ofobservations required was not recorded. The patientwas receiving four hourly observations but there was nodocumented reason to explain why the frequency hadreduced from the two hourly observations that hadtaken place when they were in the ED. When we queriedthis with the nurse on duty, they told us that theinformation had been passed on verbally but notrecorded.

• Monthly audits of observation charts took place onSSEU. The most recent audit data provided (June 2015)showed that charts were appropriately completed,although one out of five charts reviewed did not havefrequency recorded.

Nursing staffing

• The ED was not consistently staffed with appropriatenumbers of suitably skilled and experienced nursingstaff to ensure that people received safe care andtreatment at all times. Nurse staffing levels wasoverwhelmingly the biggest area of concern voiced to usby both nursing and medical staff.

• Staffing levels had recently been increased. A review ofnurse staffing levels in ED was undertaken by the EDsenior nurse in June 2015. Prior to this, there had beenno formal review of ED nurse staffing levels for 11 years.The review was undertaken in the context of increasingdemand and a department which was described in thereview as “struggling to consistently deliver safe,responsive and effective care…” The review took intoaccount the draft ‘Safe Levels of Nurse Staffing in theEmergency Department’ published in January 2015 bythe National Institute for Health and Care Excellence(NICE) and the more recent ECIST review in February2015. ECIST recommended that there should be a




review of the seniority and skills mix of nursing staff andwith particular attention to the out-of-hours andovernight levels. “There were two recommendationswhich were considered to be urgent:

▪ The deployment of a senior nurse to manage eachshift. The trust had acted on this recommendationand had employed additional band 6 nurses tomanage each shift, although we were told thatoccasionally a more junior nurse (band 5) may bedeployed. Despite this action, a number ofconsultants expressed the view that some nursesdeployed to manage shifts were not sufficientlysenior or experienced and there remained a lack ofsenior decision makers at night. Draft NICE guidancerecommends that the senior nurse in charge shouldbe a band 7 nurse. The trust had not followed thisguidance because of financial and recruitmentconstraints.

▪ An increase in the nurse to patient ratio in theresuscitation area. The trust had acted on thisrecommendation and increased the staff to patientratio from 1:3 to 2:3.

• Notwithstanding the above increases in staffing, thecurrent established levels still fell short of staff to patientratios as recommended by the draft NICE guidelines andcontinued to cause concern to nursing and medicalstaff.

• The current nurse staff establishment provided a staff topatient ratio of one registered nurse to five patients inmajors, supported by a healthcare assistant. At nightthis ratio reduced to one to 10. NICE recommends thatthe minimum staff to patient ratio in majors should beone registered nurse to four patients. This could only beachieved by utilising the second nurse from theresuscitation area or by using the senior nurse who wascoordinating the shift and triaging ambulance bornepatients, to provide patient care.

• During our visits we saw that the senior nurse wasfrequently diverted from their coordination role toprovide patient care. On one occasion we saw the seniornurse serving breakfast to a patient. This resulted in thephone not being answered. On another occasion thesenior nurse was providing care to a patient, resulting in

a patient handover from the ambulance crew beingdelayed. Staff in the resuscitation area and in triagewere also used flexibly to support the majors area whereactivity allowed.

• Staffing levels at night were particularly a concern. Onthe first day of our visit, staff who had just completedthe night shift told us they had experienced a busy and“difficult” shift. The shift had been fully staffed, althoughtwo of the nurses on duty were temporary staff. Twoseriously injured/ill patients had arrived in ED at thesame time and assistance was required from outsidethe department to manage these emergencies andother patients in the department. Support was providedby nurses from the hospital at night team, the clinicalsite manager and the critical care outreach team.Although their support was welcome one staff membercommented that these staff were not familiar with EDand therefore they were not as effective as regular staffmembers. One nurse described to us the pressure theywere under at night with just one nurse caring for 10patients in majors. They told us that the critical careoutreach team was frequently called upon to supportstaff in the resuscitation area in order “to stop majorsgrinding to a halt”. They told us told us “I havesometimes gone home and cried.”

• Despite the fact that an additional ‘floating’ nurse shifthad been established in the middle of the day,specifically to cover breaks, many nurses told us theywere regularly unable to take their breaks. Some staffhad reported this via the incident reporting system butmost staff told us that after a busy shift with no breakthey did not have the energy to do this. There was afeeling of resignation and a belief that nothing could bedone to resolve this concern.

• On the day of our unannounced visit the floating nurseshift had not been filled and the nurse in charge told usit was difficult to allocate staff all staff their breaks. Inthe early afternoon we asked the triage nurse if they hadbeen able to take a break. They told us they had taken ashort tea break at 10.30am. They were working a 12 hourshift (8.30am to 8.30pm). They told us it was unlikelythey would get a further break because they and thenurse in charge were the only two staff on duty whowere trained to perform triage. We were concerned that




this staff member was required to undertake thisintensive role for a prolonged period without sufficientbreaks. There was a risk that they would becomefatigued and less effective in their role.

• The staffing situation described above wascompounded by the fact that The ED had a significantnumber of nurse staff vacancies (1.11 WTE band 6, 3.3WTE band 5 and 3.3 WTE band 2). There were also asignificant number (6.6 WTE) of staff on long termabsence. The trust monitored actual staffing levelsagainst planned levels shift by shift. Data showed thatthe ED was consistently filling shifts. However, thedepartment relied heavily on bank and agency staff whowere regularly deployed in addition to existing staff whoworked extra shifts to cover shortfalls in the rota. Welooked at the nurse staff rosters between 16 Novemberand December 2015. The percentage of temporary staffdeployed each day ranged from 26% to 66%, with theaverage being around about 40%.

• Nursing staff told us that some temporary staff did nothave adequate skills or experience to performcompetently and safely in ED. The deputy lead nurse forED told us that they had developed a range of essentialand desirable competencies for temporary staff so thatthey could be assured that temporary staff wereappropriately experienced and skilled. However, theywere unable to provide these competencies and wewere advised to contact the bank office to obtain them.When we contacted the bank office, the staff memberwe spoke with was not familiar with these competenciesand told us that as long as a nurse had a PIN number,indicating they were registered with the Nursing andMidwifery Council, they would be permitted to work inED. During our unannounced visit an agency nurse wasdeployed in the SSEU in the afternoon, swapping withthe substantive nurse who had been on duty in themorning. The nurse in charge explained that the agencynurse did not have the required competencies to beeffective in the ED.

• Temporary staff were required to complete a wardorientation form at the beginning of their first shift in theemergency department. Temporary staff working duringour visit confirmed that they had completed thisorientation. There was a system in place which allowedsenior staff to feed back on the performance oftemporary staff.

• There was not a dedicated paediatric trained workforcein ED. The Royal College of Paediatrics and Child Health(RCPCH) Standards for Children and Young People inEmergency Care Settings (2012) identifies that thereshould always be registered children’s nurses in ED ortrusts should be working towards this. There were 4.69whole time equivalent (WTE) registered nursesemployed in ED, who were dual-trained to care foradults and children. There was an additional one WTEwho had completed external training to achievecompetencies to care for children. The ED was unable toensure there was always an appropriately qualifiednurse on duty. We were told by the management teamthat support could be obtained for the children’s ward.However, this relied on goodwill and a nurse told us thatthey did not consistently receive support, which they feltwas dependant on who was on duty.

• The department had taken some steps to mitigate thisrisk.

▪ There was a paediatric best practice group led by asenior nurse who was dual-trained. This group was asource of information and advice to the wider adultnurse team.

▪ There was a business case to employ an additionalregistered nurse in the minors department. It wasproposed that with structural changes to thedepartment (which had been agreed), this nursewould then be able to support the care of children.Discussions were ongoing with regard to thenecessary staff education and training required tosupport this. This included joint working with thechildren’s ward, rotations and secondments;however a detailed plan and timescale for thisdevelopment had not been developed.

▪ We were told that all nursing staff were trained inpaediatric life support (PLS), as recommended by theRCHP. Data provided showed that six staff had notcompleted this training but were scheduled toreceive training later in the month of our inspection.All nursing staff and healthcare assistants wererequired to acquire and be assessed against a rangeof paediatric competencies within 12 months ofstarting work in ED. However, the trust was unable toconfirm how many staff had acquired thesecompetencies.




• Medical staffing• There was consultant presence 15.5 hours a day (8.30am

to midnight) and senior medical cover was provided oncall outside of these hours. Concerns were recorded onthe department’s risk register with regard to the lack ofsenior medical cover in the department at night.Following their visit in February 2015 the EmergencyCare Intensive Support Team (ECIST) raised concernsthat there was no middle grade or consultant coverovernight. This, they noted, combined with the lack ofseniority of nursing staff at night, meant that there wereno senior decision makers on duty. They recommendedthat this be reviewed as a matter of urgency. The trust’saction plan which was developed in response to ECIST’srecommendations stated that a paper outlining a rangeof options to address this situation had been submittedto the medicine division’s management team.

• The lead ED consultant acknowledged that there were“huge pressures on the consultant body” and thatdemands on ED consultants were greater than thenorm. Consultants reported that they sometimesworked beyond midnight, until 1am or 2am to providesupport to junior doctors. They told us they wereconcerned that this situation could not be sustainedlong term, in the context of increasing demand on theservice and the age profile of the consultant body.

• The lead consultant described the steps the departmenthad taken to mitigate the identified risk:

▪ Consultants on call were able to respond quickly tocalls for support. They told us that consultants wholived more than 150 minutes away were residentwhen on call. The on call room was located withinfive10 minutes’ walk of the ED.

▪ Consultants attended for all trauma patients.

▪ There was support available from doctors and seniornurses in the wider hospital. There was a hospital atnight team led by a medical registrar and supportedby a clinical site coordinator, anaesthetists, juniordoctors in medicine and surgery and paediatrics, anda critical care outreach team. The hospital at nighthandbook described the responsibilities of this teamto support junior doctors in ED overnight and referralpathways were outlined.

▪ Consultants reviewed the records of all patientsdischarged from ED overnight. This provided an

effective safety net. We saw an example of a patientwho was discharged from ED at night afterappropriate tests. Although the management of thepatient had been appropriate, the consultant calledthe patient back for further tests the followingmorning after reviewing their records.

• Junior medical staff were generally happy with the levelof consultant and senior medical staff cover at nightbecause there was support from elsewhere in thehospital. It was acknowledged by both junior and seniormedical staff that the effectiveness of this arrangementrelied on goodwill. There was also concern expressed byone junior doctor that support from elsewhere in thehospital may sometimes be provided by a similarlyjunior doctor.

• Locum medical staff were rarely employed and wereusually bank staff, rather than externally employeddoctors.

• There was an induction package for locum staff and alllocums were reviewed by a substantive consultant toensure their competence.

• There were two consultants with a special interest in thecare of children. Medical staff had received appropriatelevels of life support training for children.

• Other Staffing

• A portering service was provided by a trust-wide team.Staff reported that response times were variable andthey were encouraged to report any significant delays.During our visits we observed nurses frequentlyundertook portering duties such as taking patients tox-ray.

• Major incident awareness and training

• There was a draft trust-wide major incident policy inplace which had been widely communicated across theorganisation. There was an emergency departmentbusiness continuity plan and impact assessmentavailable in the emergency department and held on thetrust's emergency planning shared drive. and a lack ofwritten guidance for staff in relation to disastercontingency planning. This was identified on the ED riskregister but had been highlighted as a risk since 2001and it was unclear from this document how this risk wasbeing managed. A senior nurse told us that theoreticaltraining to raise staff awareness in major incident




management was provided at annual mandatorytraining updates but practical training had not beenprovided for a number of years. The trust told us that atrust-wide multi-agency major incident exercise washeld in April 2015. I addition, three staff had beentrained as trainers, including a consultant, charge nurseand senior nurse. There was a supply of laminatedaction cards attached to lanyards, which were kept inthe majors department and which outlinedresponsibilities for each staff role in the event of a majorincident. There was also a resource board which wouldprovide a central point of information to assist oversightand coordination of an incident.

• There was an Emergency Department Chemical IncidentPlan March 2013, which was currently under review. AnED consultant and a senior nurse had recently attendeda ‘train the trainer’ course on arrangements to deal witha chemical, nuclear, radiological and nuclear (CBRN)incident. A cohort of eleven staff had also recentlyattended theoretical CBRN training.

• There was a permanent, fully equippeddecontamination unit adjacent to the ED.

• There were security staff employed in the hospital whocould be called upon to support staff in the ED. We weretold that they were responsive to calls for assistance.Staff were trained in control and restraint.

• In CQC’s 2014 A&E survey the trust scored 9.7 out of 10 inresponse to the question which asked patients if theyfelt safe in the ED.

Are urgent and emergency serviceseffective?(for example, treatment is effective)

Good –––

Patient’s care and treatment was planned and delivered inline with current evidence-based guidance and standards.There was a comprehensive emergency departmenthandbook which contained clinical guidance andprotocols. We saw good levels of compliance withrecognised care pathways, including those for sepsis andstroke care.

Compliance with protocols and standards was monitoredthrough participation in national audits. Performance innational audits was generally about average comparedwith other English trusts, with the exception of the RoyalCollege of Emergency Medicine (RCEM) mental health auditwhere performance required improvement. There wereaction plans in place to make improvements whereshortfalls were identified. A range of local audits had alsobeen undertaken.We saw little evidence of local audit.

The trust’s un-planned re-attendance rate was consistentlylower (better than) the England average. This is an indicatorthat care and communication with patients was effective.

Junior doctors felt well supported with regular educationand supervision. Consultants reviewed the records of allpatients discharged overnight and junior doctors were ableto invite patients back for consultant review.

Nursing staff did not benefit from the same level ofstructured education and supervision. The trust wasunable to provide us with information which assured usthat nurses were able to access regular education orinformal and formal supervision.

The service worked well with other teams and services sothat people received seamless care. Care was delivered in acoordinated way, with support from specialist teams andservices. There were excellent working arrangements withthe Acute Medical Unit, which worked closely with the EDas part of the ‘front door team’. There were clear policiesagreed with specialty doctors which formalised theirsupportive role to ED and reciprocal support was offered byED consultants to junior doctors in other specialties.

Evidence-based care and treatment

• Care and treatment was delivered using recognisedclinical guidelines, for example, National Institute forHealth and Care Excellence (NICE) guidelines and theRoyal College of Emergency Medicine’s ClinicalStandards for Emergency Departments. There was acomprehensive ED handbook which contained clinicalguidance and protocols, internal procedures andprocesses.

• We saw evidence that guidance and protocols werefollowed. We reviewed a sample of records for patientswho had presented to the ED with chest pain. Recordswere well documented and showed appropriate




management and senior review. The ED had developeda set of non-standard risk factors to stratify cardiac riskfor a fast troponin test. (this is a test. This had reducedlength of stay in the department significantly.

• There was good awareness of and engagement with thesepsis protocol. This was demonstrated by speakingwith staff and by reviewing a sample of records.

• There were clear pathways for patients who presentedwith stroke symptoms and we saw good joint workingwith the stroke team.

• There was an effective ‘see and treat’ service providedby emergency nurse practitioners (ENPs). Five of theseven ENPs were trained as non-medical prescribers.This meant that they could supply and administer arange of medicines without referral to medical staff.

Pain relief

• Patients we spoke with told us they had receivedadequate and prompt pain relief. Records we examineddemonstrated that pain was mostly assessed promptlyand reassessed at appropriate intervals and pain reliefwas offered as appropriate. However at busy timeswhen there were delays in the triage process there was arisk that pain relief was not offered promptly.

• We reviewed the record of a patient who arrived in theED at 2am on 3 December 2015. A pain score of eight outof ten (high) was recorded but no pain relief wasadministered during the six hours they were in thedepartment.

• In the CQC 2014 A&E survey the trust scored eight out of10 in response to the question which asked patients ifstaff did everything they could to control their pain,although the score was only 6.9 out of 10 in response tothe question in relation to waiting too long to receivepain relief if requested.

Nutrition and hydration

• There were no set drinks rounds undertaken in ED,although we observed staff providing drinks from timeto time. Patients we spoke with confirmed that hadbeen offered and/or provided with food and drink.Nursing documentation in ED and SSEU did notconsistently record when patients were offered food anddrink so we could not be assured that this occurredregularly.

• In the CQC 2014 A&E survey the trust scored 7.13 out of10 in response to the question which asked patientswhether they were able to get suitable food or drinkswhen they were in the A&E department. This was aboutthe same as other English trusts.

Patient outcomes

• Information about patient outcomes was routinelycollected and monitored. The trust participated innational Royal College of Emergency Medicine (RCEM)audits so they could benchmark their practice andperformance against best practice against other EDs.Action plans had been developed to improveperformance where shortfalls were identified.

• In the RCEM 2013-14 audit of severe sepsis and septicshock there was variable performance. The trust scoredin the average quartile for seven indicators, in the upperquartile for three indicators and in the lower quartile fortwo indicators. The trust was required to meet astandard set and monitored by its commissioners(commissioning for quality and innovation standard -CQUIN) in relation to the treatment of sepsis. Thisrequired that patients were screened for sepsis and thatfor those patients where sepsis was suspected, thatintravenous antibiotics were administered within onehour of arrival in ED. In October 2015 the ED reportedthat 100% of appropriate patients had been screenedand antibiotic treatment had been initiated within thehour for 80% of cases.

• We observed that a sepsis screening tool wasconsistently used for all patients who had an earlywarning score of three or more.

• In the 2014/15 RCEM audit of initial management of thefitting child the trust performed in middle quartile for allindicators, compared with other English trusts.

• In the 2013/14 asthma in children audit the trust’sperformance was mostly in the middle quartilenationally.

• In the 2014/15 mental health in the ED audit the trustperformed poorly and was in the in the lower quartilefor five of the nine indicators, two of which wereclassified by the RCEM as fundamental standards whichall providers should meet. These standards related tothe completion of a risk assessment and the provision ofa dedicated assessment room for mental health




patients.We saw that the emergency department had adedicated assessment room for mental health patientswho require an assessment by a mental healthpractitioner. The audit showed that 93% of patientswere assessed by a mental health practitioner in adedicated assessment room.

• In the 2013/14 paracetamol overdose audit the trustperformed in middle quartile compared with otherEnglish trusts.

• In the 2014/15 audit: assessing for cognitive impairmentin older people the trust’s scores were in the upperquartile for three indicators, in the middle quartile fortwo indicators and in the lower quartile for oneindicator. The trust failed to meet the fundamentalstandard which requires that an early warning score isdocumented, although it scored above the nationalaverage. .

• The unplanned ED re-attendance rate within 7 days wasconsistently better than the national standard of 5%.Year-to-date performance reported in August 2015 was2.5%.

• There was an effective system to reconcile all radiologydiagnosed fractures with patients’ notes. A review tookplace every day by a consultant. There was aconsultant-led ED review clinic where junior doctorscould refer patients who had attended overnight whenthey needed a senior review. Consultants also reviewedthe records of all patients who had absconded from thedepartment and children who had had not presentedfor a review.

Competent staff

• We could not be assured that nursing staff had the rightqualifications, skills, knowledge and experience to dotheir job. There was no identified education lead fornursing staff and no department-wide overview oroversight of nurse staff competencies. We did nottherefore have assurance that all staff had appropriateand up-to-date competencies.

• The deputy lead nurse had responsibility forcoordinating and rostering training. They told us thatthe department held dedicated team (training) days,which included mandatory updates, competencyassessments, safeguarding supervision, as well as butmainly focused on those areassubjects identified by

staff. where they would like further education. The teamdays were attended by the ED lead and deputy lead whoprovided updates on quality and operational issuessuch as complaints and performance.

• The trust told us that they had developed a range ofcompetencies for band 5 and band 2 staff and thesewere to be released shortly, followed by band 6 staff.This would enable staff to develop and progress withintheir roles.

• There was a system in place to provide informal andformal supervision of nursing staff. The trust told us thatsenior nursing staff had been trained to undertake staffsupervision. The deputy lead nurse in ED told us that allnursing staff were assigned to a mentor group led by asenior (band 6) nurse. There were five mentor groupsand an ENP was linked to each group. The senior nurseswere allocated one day per month to undertake theirsupervisory role. We were told that this included one toone supervision of the staff in their mentor group. Thedeputy lead nurse was unable to provide any evidencethat this was taking place consistently or regularly. Theytold us that one senior nurse had been absent for sixmonths and another had been absent since September2015 so there was “some catching up to do”. Staff wererostered to work night shifts with their mentor so thatthey had opportunities to work together, allowing aform of informal supervision. We were told that eachstaff member should attend one mentor training dayand one mandatory training day per year andbut limitedevidence was provided to support this.

• The deputy lead nurse did not know how many staff hadreceived their annual performance appraisal, althoughthey told us that they thought they were “doing ok”. Datasubsequently provided by the trust showed that only72% of nursing staff and 38% of Emergency NursePractitioners had had received a performance appraisalin the last 14 months.

• Nursing staff were encouraged to research and developareas of interest and act a source of advice and trainingfor the team. There were link nurses identified in areassuch as dementia care, alcohol misuse, andbereavement. However, due to staffing pressures in thedepartment, dissemination of information and learningtook place in an ad-hoc and unstructured way.




• There was protected time for medical staff teaching.Junior medical staff felt well supported. A consultanttold us that two of the recent cohort of trainee doctorshad decided to pursue a career in emergency medicinefollowing their placement in Salisbury ED. Medical staffhad received regular performance appraisal.

Multidisciplinary working

• Care was delivered in a coordinated way with supportfrom specialist teams and services. There were excellentworking arrangements with the Acute Medical Unit,which worked closely with the ED as part of the “fontdoor team”. There were clear policies agreed withspecialty doctors which formalised their supportive roleto ED and reciprocal support was offered by EDconsultants to junior doctors in other specialities. Forexample, an orthopaedic specialist registrar wouldattend ED with an anaesthetist to perform a jointreduction (dislocation) if this had not been possibleusing gas and air.

• We saw examples of excellent multidisciplinary working.

▪ Radiology services were reported by ED staff to beaccessible and responsive, with a good range ofservices available until 8pm and a more limitedrange available out of ours. Staff told us thatradiology reporting was very prompt, with themajority of CT scans being reported on within onehour. Radiology systems were linked with centres inSouthampton,Bournemouth, Portsmouth ole andBasingstokeSouthampton so that images could beviewed in these tertiary centres in real time.

▪ ED staff reported that the pathology service wasreliable and responsive.

Seven-day services

• There was senior medical staff presence in the ED sevendays a week. Other services, including radiology, mentalhealth liaison and therapy services were also available.

Access to information

• There was a paper-based patient record which waspre-populated electronically with patients’demographic details. Care and treatment was recordedmanually and completed records were scanned byreception staff on to the electronic system.

• There was an electronic information system whichallowed staff to view activity in the department as awhole. This was an effective tool to help staff managepatient flow, although there were problems reported bystaff who were not able to see attachments (identifiedby a paperclip icon) which may contain importantpatient information. This information had to berequested from, and printed by, reception staff.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff demonstrated a knowledge and understanding oftheir responsibilities in relation to the Mental CapacityAct 2005 and consent.

• There was little reference to patients’ consent recordedin their records. notes. However, we observed doctorsand nurses asking patients’ permission before theyundertook examinations or provided care or treatment.They also explained the reasons for undertaking tests.

• There was an information sheet and consent form usedto explain procedure and record written consent for thedisposal of early pregnancy tissue. This sensitivelyexplained options.

Are urgent and emergency servicescaring?

Good –––

We observed that all staff treated people with compassion,kindness, dignity and respect. Staff introduced themselvesand spoke with people in a friendly and polite manner.They responded in a caring and compassionate way whenpeople experienced pain, discomfort or distress.

Patients and their relatives were involved as partners intheir care. Staff took the time to explain to patients andtheir relatives about their care and treatment. This wasdone sensitively and in a way that people couldunderstand.

The department had established an outstanding service tosupport bereaved relatives.

Feedback we received from patients and visitors wasconsistently positive. We spoke with many patients andvisitors. Unusually, we were approached by some patients




who were very keen to tell us how well they had beenlooked after. This feedback was consistent with results frompatient satisfaction surveys. Friends and family scores wereconsistently high, with over 90% of respondents indicatingthat they would recommend the service.

The ED scored better than other trusts in the CQC 2014 A&Esurvey, with a score of 8.4 out of 10 in response to thequestion which asked patients if they would rate theirexperience overall as ‘good’.

Compassionate care

• The trust used the friends and family test to capturepatient feedback. Results for the ED were consistentlygood, with the majority of respondents indicating theywould recommend the service to friends and family.One patient, who was one of many who providedpositive feedback about their experience in ED duringthe week prior to our visit, commented: “Greeted by x ina very friendly and professional manner, treated byconsultant y who immediately put me at my ease anddealt with me superbly. Well looked after by z. Well doneand thanks to all.”

• We also received almost universally positive feedbackfrom patients and visitors during our visits. Patients toldus that all staff, including receptionists, nurses anddoctors, were polite and friendly. One patient describedthe care they had received as “brilliant”. They said theyhad received constant reassurance and had beentreated as if they were the only patient in thedepartment.

• We observed an example of outstanding compassionatecare provided to a distressed patient in the resuscitationarea. They showed great empathy through their verbaland non-verbal responses.

• Patients’ privacy and dignity were mostly respected. InCQC’s 2014 A&E survey, the trust scored 9.2 out of 10 inresponse to the question which asked patients whetherthey thought that overall, they were treated with dignityand respect while they were in the ED. We saw stafftaking care to maintain people’s privacy and dignity,drawing curtains where appropriate. We observed atriage nurse check with a patient that they were happyfor their colleague, who had attended with them, to be

present during their assessment. However, on the shortstay emergency unit we saw on a several occasionspatients were not appropriately covered to protect theirdignity.

• Patients received respectful and considerate care. InCQC’s A&E survey the trust scored 9.1 out of 10 inresponse to the question which asked patients if staffdid not talk in front of them as if they weren’t there. Apatient told us they had appreciated the time that staffhad taken to explain their condition clearly and, eventhough the department was very busy, they didn’t feeltheir care had been rushed.

• We observed that staff were friendly and courteous.They introduced themselves by name and role andspoke with people politely and respectfully.

Understanding and involvement of patients and thoseclose to them

• Patients and those close to them were involved aspartners in their care. In CQC’s 2014 A&E survey:

▪ 8.3 out of 10 in response to the question which askedpatients whether they were as involved as much asthey wanted to be in decisions about their care andtreatment.

▪ The trust scored 8.6 out of 10 in response to thequestion which asked patients whether they felt thedoctor or nurse explained their condition andtreatment in a way they could understand.

▪ The trust scored 9 out of 10 patients in response tothe question which asked patients if they felt thedoctor or nurse listened to what they had to say.

▪ The trust scored 8.2 out of 10 in response to thequestion which asked patients whether their familyor someone else had enough opportunity to talk to adoctor if they wanted to.

• Patients and relatives told us they were kept informedabout what was happening and what would happennext.

• We observed a doctor speaking over the telephone witha relative of a patient who had just arrived in ED. Theyexplained clearly and sensitively what was happening tothe patient and what tests they were going to carry out.They then took the phone to the patient so that theycould speak directly with their relative.




• We observed that all young children who attended EDwere given a teddy bear. We saw also that children weregiven a copy of their x-ray to take home. Parents told usthey were impressed that staff spoke to their children,rather than just addressing the parents and thateverything was explained to them in a way that theycould understand.

• Emotional support

• In CQC’s 2014 A&E survey the trust scored 6.7 out of 10 inresponse to the question which asked patients if theyfelt reassured by staff if they were distressed while inA&E. The trust scored 7.8out of 10 in response to thequestion which asked if they had any anxieties and fearsabout their condition or treatment, a doctor or nursediscussed these with them.

• There was a bereavement service in the ED/SSEU.Details of the service were sent with sympathy cards tobereaved relatives. A dedicated nurse worked in the EDthree hoursone day a week providing support tobereaved relatives in person or by telephone.

• There was understanding and sensitive care provided topatients who had miscarried in early pregnancy.Patients were transferred to the Benson Suite, abereavement suite in the maternity departmentdedicated to caring for families who had lost their baby.

• We saw feedback received from a patient who hadrecently attended the ED with suspected Ebola. Theywrote: “I have received outstanding care, attention andthoughtfulness over the past 60 hours…I was soimpressed by the way the nurses were called off wardsand the chaplain sat with me outside the isolation unitfor hours on end. In the short stay I saw again the vastarray of what your staff deal with. Thank you so much.”

Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)


Services were not always responsiveorganised anddelivered so that all patients received the right treatment atthe right time.to people's needs.

Premises and facilities were largely appropriate for theservices delivered; however children were cared for in theadults’ department which was not an appropriateenvironment from them because they were exposed tosights and noise which may cause them stress. Thechildren’s waiting room, whilst bright and welcoming, wasoverlooked by and could be accessed by adult patients andvisitors. Patients’ privacy and dignity was sometimescompromised on the short stay emergency unit. The wardwas cramped and the layout did not always allow for singlesex accommodation to be provided.

The needs of patients in vulnerable circumstances were notalways met. Patients with mental health needs, particularlychildren and adolescents, who required assessment by amental health practitioner, did not always receive aresponsive service. This meant that these patientsexperienced long waits which could be detrimental to theirmental health and they were sometimes admitted tohospital unnecessarily.

The department had not taken adequate steps to supportpatients living with dementia or those with a learningdisability.

The ED was consistently meeting national standards inrespect of the time people spent in the department, andthe time they waited for treatment, although this wasbecoming more challenging with increasing demand onthe service. There were relatively few ambulance handoverdelays but at busy times, some patients queued onambulance trolleys in the department and this impactedon their comfort, privacy and dignity.

The ED worked well with the patient flow team and the restof the hospital to minimise blockages and overcrowding inED. The trust had invited an external review of patient flowby the emergency intensive support team (ECIST) and haddeveloped an improvement plan based on theirrecommendations and had taken some immediate actions,although some changes required time to embed. Furtherimprovements were planned but required time andresource.

Service planning and delivery to meet the needs oflocal people

• The emergency department (ED) was well sign posted,both within the hospital building and within the hospitalgrounds. There was a drop off zone and parking wasavailable close to the department. A staff member




arrived twenty minutes late for their shift during the dayof our visit because they had experienced difficultyfinding a parking space. Staff reported that this was aregular problem for staff and visitors.

• Steps had been taken to ensure patients’ privacy anddignity. There were side rooms in majors, which allowedprivate discussions or examinations to take place. At thereception desk, the floor had been painted to create astanding area, designed to prevent queuing patientsoverhearing others’ private conversations. In CQC’s 2014A&E survey the trust scored 7.6 out of 10 in response tothe question which asked patients if they had enoughprivacy when discussing their health problem with thereceptionist.

• The trust scored 9.1 out of 10 in response to thequestion which asked patients whether they were givenenough privacy during examinations and treatment.However, the triage area was not private, with only acurtain to screen one entrance to it. This meant thatconversations could be overheard by patients waiting tosee the out-of-hours doctor.

• The short stay emergency unit did not consistentlyprovide single sex accommodation.

• Waiting rooms provided adequate seating toaccommodate patients and visitors during our visit.However, staff told us that at busy times there wassometimes insufficient seating and patients and visitorshad to sit on the floor.

• Patients had access to vending machines where theycould purchase hot and cold drinks and a range ofhealthy snacks.

• There were toilets suitable for adults and children andnappy changing facilities were available. A sign atreception advised that a suitable area could beidentified on request for breast feeding mothers.

• There was a dedicated children’s department within theED; however, due to a shortage of nursing staff withpaediatric competencies, the department was not beingutilised because it could not be adequately staffed. Thismeant that children were assessed and treated in theadults’ department, although there was one designatedchildren’s cubicle which had been decorated andequipped for children.

• Patients were given information so that they knew whatto expect during their visit to ED. Waiting times weredisplayed in the ED waiting room. In CQC’s 2014 A&Esurvey the trust scored about the same as other trusts inquestions relating to waiting times, although theyscored particularly poorly in relation to not being toldhow long they would have to wait before beingexamined by a doctor. Patients who self-presented atthe ED reception were given written information aboutpathway they were likely to follow while in thedepartment. This helped them to understand the flow ofthe department, what to expect and how long they mayspend in the department.

Meeting people’s individual needs

• Services were not planned or delivered to take accountof people with complex needs, for example those livingwith dementia or those with a learning disability. Weasked the trust to tell us how they supported this groupof patients. They told us that staff had not receivedspecialist training to support people living withdementia or people with a learning disability but theyhad designated link nurses who acted as a source ofadvice and support to staff. We spoke with thedesignated dementia care link nurse. They were unableto describe any particular steps taken to support thisgroup of patients, other than trying to locate them incubicles where they could be easily observed by staff.Patients living with dementia were not identified on theelectronic patient record system on the department’swhiteboard or at their bedside. This meant that visitingstaff, such as housekeepers may not be alert to theirparticular needs.

• There was a designated ED consultant lead for care ofthe elderly, who had a special interest in dementia care.The electronic patient record had been updatedapproximately six months ago to include an abbreviatedmental test (AMT) score for patients over 75 years of age.The consultant lead told us they were trying to embedthis into the culture in ED. There were plans to have theAMT score included in the electronically generateddischarge letter to GPs to facilitate appropriate follow upof identified patients. There was joint working ongoingwith the care of the elderly physicians in the hospital todevelop a dedicated pathway for the direct admission of




frail, elderly patients to a care of the elderly ward. Therewere also plans to adapt some ED cubicles to makethem “dementia friendly”, although no funds had beenidentified for this yet.

• We observed and spoke with a patient who was livingwith dementia, who was in a side room on the SSEU.They were anxious, agitated and confused but staff didnot have the time to spend time with them to offerreassurance. They were not easily observed in the sideroom and they had not been given a call bell. We spokewith a consultant later in the day because we wereconcerned that patients living with dementia may notreceive the attention they needed on this ward. Theconsultant explained that the patient had beenadmitted to SSEU because there were no suitablespeciality beds available in the hospital. Theyacknowledged that a side room on this unit was not themost appropriate environment but felt that this waspreferable to spending the night in a busy ED. They toldus that dementia was not an exclusion criterion foradmission to this ward.

• In the 2014/15 Royal College of Emergency Medicine(RCEM) audit: assessing for cognitive impairment, thetrust scored in the lower quartile compared with otherEnglish trusts for the documentation of an early warningscore. The trust scored only 21% against a standard of100%. We looked at a sample of records for older peopleand found that the AMT score was not consistentlycompleted.

• The ED was accessible for people with limited mobilityand people who used a wheelchair. Wheelchairs wereavailable at the department’s entrance.

• Reception staff told us that a telephone interpreterservice was available for patients/visitors whose firstlanguage was not English. They told us they also calledon staff in the hospital to assist with translation. Hearingloops were not provided in reception to assist peoplewho were hard of hearing.

• There were arrangements in place for patients whopresented to ED with mental health issues, includingthose who had self-harmed. There was a mental healthliaison service based in the hospitalED, which wasprovided by the local mental health trust and which

operated from 9am to 5pm, seven days a week. Thetrust could not provide data to demonstrate howresponsive this service was but they captured feedbackfrom staff, who commented as follows:

▪ In hours the liaison team provided a responsiveservice to adults and responded to emergencyreferrals within 60 minutes as recommended by theRoyal College of Psychiatrists (RCP). The standingoperating procedure for the mental health liaisonteam stated that the benchmark standard for urgentreferrals was five hours - same day. It was not clearwhether this was achieved.

▪ Prolonged delays were experienced when a mentalhealth assessment requiring a section 12 approveddoctor and an approved mental healthprofessional was required.

▪ Out of hours, only severe emergencies were seen andonly if there was no concurrent medical problem.The target for seeing emergency patients was fourhours. This did not meet the RCP standard and theconsultant lead for mental health told us it was notfast enough. It was reported that most patientswaited more than 12 hours for a mental healthassessment or were discharged without anassessment. The consultant lead told us that manypatients, who were assessed as a moderate risk, wereadmitted unnecessarily overnight because they werewaiting for an assessment by a mental healthpractitioner. This put pressure on bed availability andwas not responsive to the needs of these patients.The trust had signed up to the mental health crisiscare concordat and was actively working with thelocal mental health trust and other organisations toimprove services. The trust met with the local mentalhealth trust to discuss concerns.

▪ There was a Child and Adolescent Mental HealthService (CAMHS) available during daytime hours. Itwas reported that most patients waited 24 hours ormore for an assessment and there was no emergencysupport available. The consultant mental health leadtold us that the service was limited by thecommissioning arrangements in place and that theyhad written to the commissioners to raise theirconcerns about the level of service currentlycommissioned.




• The 2014/15 RCEM audit of mental health in EDhighlighted that there was no dedicated assessmentroom for mental health patients, as recommended bythe psychiatric liaison accreditation network (PLAN) andendorsed by the RCEM. There was in fact a dedicatedassessment room in the ED. This had two doors asrecommended by PLAN; however, furniture and fittingsdid not comply with guidance because items couldpotentially be used to cause harm to the patient orother service users.

• There was a hospital-wide alcohol liaison service. Analcohol liaison nurse visited the short stay emergencyunit each weekday morning to offer support whererequired. They could also be contacted by bleep atother times of the day and ED staff could arrange afollow up consultation following a patient’s discharge.The service was not provided at weekends or at night. Anumber of staff in the ED had received specialist trainingto become alcohol advisors to support people whopresented with problems relating to alcohol misuse. Ahealthcare assistant who had received this trainingshowed great enthusiasm and had developed aresource folder for staff with guidance to help themsupport this patient group.

• In the Royal College of Emergency Medicine (RCEM)audit: assessing for cognitive impairment, the trustscored in the lower quartile compared with otherEnglish trusts for the documentation of an early warningscore. The trust scored only 21% against a standard of100%. The patient record generated for patients over 65years of age required that an abbreviated mental testwas carried out. Patients were asked four questions togenerate a score out of four. Any patient who scored lessthan four was then required to have a further mentalassessment. We found that this test was not consistentlyrecorded in patients’ notes. We could not be assuredthat a proper assessment of their cognitive ability wasundertaken, which may have impacted on care andtreatment they subsequently received.

Access and flow

• The ED was consistently meeting most of the nationalquality indicators:

▪ 4 hour performance - this standard requires that 95%of patients are discharged, admitted or transferredwithin four hours of arrival at A&E. The departmentwas consistently achieving this target and reported ayear-to-date performance of 96.4% in August 2015.

▪ Left without being seen – this measures thepercentage of patients who leave the ED before theyhave been seen by a clinician and is indicative ofpatient dissatisfaction with waiting times. Thenational standard is that this should be below 5%.The trust reported a year-todate performance of1.2% as at August 2015.

▪ Time to treatment - this measures how long patientswait for their treatment to begin. A short wait willreduce patient risk and discomfort. The nationaltarget is a median wait of below 60 minutes. InAugust 2015 the trust’s year-to-date performance was48 minutes.

▪ Ambulance handovers – this measures the numberof ambulance handover delays of over 230 minutes.The trust reported there had been 28 such delays inthe year to date (April to September 2015, of whichsix were over 60 minutes. Following their visit inFebruary 2015 ECIST reported that the process fortaking ambulance handovers was outstanding andreduced delays in assessment and requests forfurther investigations. Ambulance staff we spoke withtold us that handover delays were infrequent andthey felt that the ED staff dealt with this processefficiently.

▪ Time to admit – this measures the time that patients,who require admission to a hospital ward wait fromthe time of decision to admit. (percentage of patientswaiting four to twelve hours). The trust mostlyperformed better than the England average,although a dip in performance was seen in October2014 and January 2015.

▪ Trolley waits - this measures the number of patientswho wait more than twelve hours on a trolley in ED.There were no such delays reported in theyear-to-date date as at August 2015.

▪ The department consistently achieved the nationaltarget which requires the number of patients wholeave the department before being seen (by a clinical




decision-maker) should be less than 5% (recognisedby the Department of Health as being an indicatorthat patients are dissatisfied with the length of timethey have to wait).

• Patients sometimes queued in the corridor becausethere were no cubicles available. This was the caseduring our unannounced visit at the weekend. Thisimpacted on patients’ comfort, privacy and dignity.

• Patients sometimes stayed in the ED overnight becausethere were no beds available in the hospital. They wereprovided with hospital beds if this occurred.

• Although the four hour standard was being met, it wasbecoming more challenging. Following their visit inFebruary 2015 the Emergency Care Intensive SupportTeam (ECIST) made a number of recommendations toimprove patient flow. Their recommendations resultedin the production of a patient flow action plan that wasmanaged by a project management board, overseen bythe Chief Operating Officer. Theseincluded:recommendations were:

▪ The introduction of a rapid assessment and triage(RAT) at times of peak demand. The trust’s actionplan (November 2015) confirmed that RAT was usedoccasionally. A RAT protocol had been produced andhad been submitted, along with a bid for thenecessary resources to implement this to thedivisional management team.

▪ A review of the management of tertiary referrals.Patients were referred from other centres for plasticsand trauma and orthopaedics and were currentlypresenting in the minors department for review byspecialties. This led to decreased capacity for EDminors and led to delays. At the time of our visitplastic surgeons were holding clinics in the children’sED.

▪ Consideration of extending and improving theinterface with the GP out-of-hours service. It wasnoted by ECIST that the GP out-of-hours service wasworking well in the department but this was variabledepending on the demand for GP home visits. It wasnoted that when the GP was not present in thedepartment the demand defaulted to the ED at itsmost challenging time in terms of the seniority of

staff available. ECIST recommended thedevelopment of a primary care steam, allowing EDmedical staff to focus on the treatment of majorillness and injury.

▪ Undertake a review of appropriate triggers andexpected outcomes/actions to be agreed across theorganisation with standardisation of the clinicalmanagement of the department. The ED haddeveloped internal performance standards aimed atensuring efficient and timely flow of patients throughthe ED. These included:

◦ Standards with regard to the prompt review ofpatients in ED by specialty doctors. Theserequired that referrals to specialty doctors weremade within two hours and that specialty teamsreviewed patients within 30 minutes of thereferral. Response times were not routinelymonitored but delays were highlighted when fourhour breaches occurred as result of delayedresponse times.

▪ As soon as a hospital admission was indicated, or attwo and a half hours from the time that the patientarrived in ED, the majors coordinator or specialtyteam were required to request a bed from the bedmanagement team.

▪ Patients referred by their GP to a named specialtywere to be seen directly by the specialty team if theED consultant deemed this to be clinicallyappropriate.

▪ When the wait to see a doctor in the ED was greaterthan 60 minutes or there was a capacity/flowproblem in the ED, the escalation policy was requiredto be implemented.

▪ The escalation policy outlined a series of actions tobe taken according to the escalation status of the ED.Status was designated ‘green’, ‘orange’ or ‘red’.Designation of orange or red would be triggered by arange of factors, including staffing levels, number ofpatients in the department or expected, waitingtimes and actual or anticipated breaches.

▪ There was an Expedited Transfer Policy which wasenacted when unacceptable delays occurred. Thisallowed for the expedited transfer of adult patientswho had been assessed as clinically stable, to a




ward. A checklist was completed to ensure that allnecessary actions had been taken prior to thetransfer taking place. This included a full set ofclinical observations and the administration ofappropriate pain relief.

• The department operated a ‘see and treatment’ servicein minors. Emergency Nurse Practitioners (ENPs) wereemployed between 8am and midnight. ENPs arespecially trained nurses who are able to see, treat anddischarge patients with minor illness or injuries. Staffinglevels did not allow for this service to be offeredconsistently but the department reported that when themiddle shift was on duty between 10am and 8pm,patient flow was improved, breaches of the four hourtarget were fewer and time to treatment times werereduced. There were plans to extend this service.

• There was a “front door” therapy team which providedassessment, treatment and supported discharge ofpatients. The service was available from 8.30 am to 4.30pm, seven days a week. Therapists visited the short stayemergency unit each morning to facilitate the dischargeof identified patients.

• There were eight beds in the short stay emergency unit(SSEU) which could be used for patients who required ashort stay for monitoring. ECIST noted, following theirvisit in February 2015, that the beds were incorporatedinto the hospital’s overall bed base. This meant the bedswere occupied by patients who were awaiting specialtybeds elsewhere in the hospital. Blockage of these bedsmeant that the ED could not always use the uniteffectively to help to manage patient flow. During ourvisit the SSEU was frequently occupied by morespecialty patients than ED patients.The internalperformance standards developed by the ED stated thatspecialty patients would not be admitted to the SSEUunless exceptional circumstances existed andpermission was granted by the trust seniormanagement and executive team.

• Non-emergency transport was reported by staff to be abarrier to effective patient flow. The agreement with theambulance provider allowed a four hour window torespond to a request for transport. This meant thatpatients who were ready to be discharged sometimesexperienced lengthy waits and unnecessarily occupiedspace in ED and SSEU. Staff also told us that theambulance service did not always arrive within the four

hour window. A nurse who had worked in the short stayunity told us they had recently booked ambulancetransport for an elderly patient at midday and thetransport did not arrive until after midnight. Staff andmanagers told us they had repeatedly raised concernsabout the level of service provided. This did not appearon the ED/SSEU risk register.

Learning from complaints and concerns

• The ED promoted ‘local resolution of patients’ concerns.Posters displayed in the department encouragedpatients and relatives to contact the lead nurse if theyhad any concerns about their experience in ED. Thedepartment told us they had received positive feedbackfrom the public about this process and the number offormal complaints received had reduced.

• Complaints leaflets were available in the ED and in theSSEU for those people who wanted to make a formalcomplaint.

• The ED received few complaints and records showedthat complaints were investigated and response topromptly, with areas for improvement identified whereapplicable.

• Staff told us they were informed about complaints athandover meetings and via email.

• We were told that following a number of complaintsabout staff attitude amongst reception staff, this staffgroup had undergone customer service training.

Are urgent and emergency serviceswell-led?


The service had not developed a clear vision or a set ofvalues .cohesive strategy. There was a strategy which setout a five year plan in respect of staffing. the service hadresponded appropriately to recommendations made by anexternal reviewing body and there were ongoing staffingreviews, which included comparison with other hospitals;however these plans did not form part of an overarchingstrategy. Staff had not been involved or engaged indeveloping a vision or strategy and there was limitedevidence of patient involvement.




Risks to service delivery were understood by themanagement team but risk management processes werenot fully effective. The risk register did not capture themulti-factorial risks to patient safety and quality and wecould not be assured that risks were appropriatelyescalated or mitigated.

Staff enjoyed working in this service and the culture wasone of mutual respect and teamwork. Staff felt supportedand valued by senior managers who were both visible andaccessible. However, morale was overshadowed by issuesrelating to staffing. Staff had little confidence that theseissues would be resolved in the short term and it was likelythat these issues may have, or may in the future, impact onrecruitment and retention of staff.

Vision and strategy for this service

• The emergency department had developed a missionstatement: “Dedicated to providing excellence andcompassion in emergency care.” It was unclear whetheror how staff had been involved in developing this butstaff at all levels articulated similar values and a passionfor delivering safe, high quality and patient-centredcare.

• There was no overarching strategy for the department.An improvement plan had been developed following anexternal review had taken place to examine theeffectiveness of systems affecting patient flow. TheEmergency Care Intensive Support Team (ECIST) visitedin February 2015 and made a series ofrecommendations. Staff’s knowledge of theserecommendations and plans to respond to these wasvariable. There was a review of staffing completed by theED lead nurse which set out nurse staffing requirementsin the context of increasing demand and ECISTrecommendations. An options paper setting outmedical staffing requirements was also underconsideration by the medical division’s managementteam.

Governance, risk management and qualitymeasurement

• There was a monthly meeting of senior nursing andmedical staff. A standard agenda included riskmanagement and complaints, staffing, performanceand teaching and education.

• A risk register was maintained for ED/SSEU but we sawno evidence that it was discussed and reviewed at thismeeting or that risks were escalated for review by thedivision or the board. None of the risks on the ED riskregister were graded at such a level that they would beincluded in the trust-wide risk register.

• The risk register did not adequately reflect either therange or the severity of the concerns that staff andmanagers reported to us or the risks that we identifiedduring our visit. For example:

▪ Nurse staffing levels and the heavy reliance ontemporary staff were cited by almost every staffmember we spoke with as being their biggestconcern. This was not highlighted as a risk on the riskregister dated September 2015.

▪ The risk register identified that the children’s ED wasnot being used due to a lack of nursing staff. Thismeant that children were cared for in the adults’department where there was only one child friendlycubicle and they were not audio-visually separatefrom adults. It did not identify the lack of registeredchildren’s nurses or the steps to mitigate this risk. Weidentified that there were shortfalls in training inpaediatric life support or and children’s’safeguarding training and a lack of information withregard to other specialist training to care for children.This was not reflected on the risk register.

▪ Poor compliance with mandatory training was notidentified as risk on the risk register.

▪ The serious concerns conveyed to us by a seniorclinical in relation to the unresponsive CAMHSassessment service were not identified on the riskregister.

▪ Concerns about the unresponsive patient transportservice were not identified on the risk register.

• Staff reported good working relationships with thirdparty providers and partners, including the ambulanceservices, and the local mental health trust.

Leadership of service

• We saw calm and supportive leadership from the seniornurse and senior medical staff in charge of each shift.Senior staff were respected by the workforce; staff told




us that they were visible, accessible and supportive.Divisional managers and site mangers were regularvisitors to the department and staff regarded them assupportive. The chief executive also had a high profile.

Culture within the service

• Staff told us they felt respected and valued by peers andmanagers alike. Team work was frequently cited as oneof the areas where the department performed well.Managers talked about the staff team with pride andtook opportunities to praise and to thank them.

• Despite staff shortages and pressure of work, weobserved that staff morale appeared to be good,although anecdotally, we heard that the departmenthad lost a significant number of nursing staff over thelast 12 months because staff had been offered betterworking conditions elsewhere. Staff told us thathealthcare assistants were unhappy about their grading,given the range of tasks they were expected to perform.Staff turnover rates (excluding rotational medical staff)ranged between 2% and 7% between November 2014and October 2015. The department had not captureddetailed information from staffdid not conduct exitinterviews to help to inform its recruitment andretention strategy.

• Staff told us that they thought their welfare wasimportant to managers. However, documented actionstaken on the incident log (May to 31 August 2015) whenstaff reported not being able to take breaks did notdemonstrate understanding or a sympathetic responseor a commitment to resolve concerns. For example, in

May 2015 it was reported that staff were unable to takebreaks until eight hours into a 12 and a half hour shift.The action taken was recorded as “department fullystaffed”.

Public and staff engagement

• The service used friends and family test to capture viewsabout the service. We were told that all ED staff receivedthis feedback via email on a weekly basis. This meantthat staff felt valued and appreciated and also ensuredthat areas for improvement could be identified andacted upon quickly.

• No other examples of public engagement orinvolvement were shared with us.

• Staff reported that communication in the departmentwas good. Important messages were communicated athandover meetings. Regular role specific staff meetingswere held and minutes were circulated so that staffwere kept informed of news and developments. Noticeboards around the department displayed a range ofinformation and key messages.

• Staff felt able to raise concerns and felt they would belistened to if they did so. However, there was a feeling ofresignation that nurse staffing issues could not beresolved.

Innovation, improvement and sustainability

• The ED actively participated in research and hadenrolled in three clinical research trials.

• The ED bereavement service introduced in 2010provided ongoing support and advice to bereavedrelatives.




Safe Good –––




Well-led Good –––

Overall Good –––

Information about the serviceSalisbury NHS Foundation Trust provides medical careand services to a population of approximately 240,000 inSalisbury and Wiltshire.

There are a total of 214 medical beds spread across eightwards. The trust provides acute and general medicineincluding the following specialties: care of older people,stroke care, cardiology, respiratory medicine,gastroenterology, haematology, oncology, andendocrinology.

The medical assessment unit has 21 beds in a three wardarea, which included three side rooms and fourambulatory care trolleys. This is a short stay area whichadmits patients from the emergency department orthrough GP referrals. It was open all year round 24 hours aday.

During our inspection we visited the following wards anddepartments and met with patients and staff;

• Durrington – a rapid access care of the elderly ward• Farley – a dedicated stroke unit• Pembroke ward – providing haematology and oncology

with an ambulatory care/day case facility• Pitton – a medical ward which specialises in respiratory

medicine• Redlynch – a gastroenterology ward• Tisbury – an acute medical unit specialising in

cardiology• Whiteparish – the acute medical assessment unit• Winterslow – a care of the elderly ward• Cardiac catheter laboratories and the endoscopy suite

On this inspection, we visited all medical wards during 2,3 and 4 December 2015 and made an unannounced visiton Sunday 3 December 2015. We spoke withapproximately 40 patients, 15 relatives, and 90 membersof staff including doctors, nurses, therapists,administrators and housekeeping staff. We reviewednearly 50 sets of patient’s notes and examinedinformation provided to us by the trust.

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Medical care (including older people’s care)


Summary of findingsWe rated medical services as good overall. Staffunderstood their responsibilities to raise concerns, torecord safety incidents, concerns and near misses, andto report them. Learning from incidents was evident andcare and treatment within the hospital kept patientssafe. Medical cover, nursing levels and skill mix wereappropriate to the needs of the patients on the eightmedical wards we visited, which included the acutemedical assessment unit, the endoscopy suite and thecardiac catheter laboratories.

However, we did identify a breach in regulation inrelation to record keeping, and specifically to thedocumentation of cannulas, catheters and patients’weight.

Care was effective and was delivered in accordance withevidence-based guidelines and current best practice.Staff managed patients’ pain well and feedback frompatients reflected this. The trust ensured staff wereadequately trained and competent to carry out theirrole.

Staff provided compassionate care and patients weretreated with kindness, dignity and respect. Patientsspoke positively about their experience of being caredfor at Salisbury hospital. They felt included in their careand were kept informed about their care and treatmentthroughout their stay.

The provider planned services and coordinated carewell for patients living with dementia. The layout andappearance of wards provided a suitable environmentfor these patients. Patients accessed care and treatmentin a timely way.

Services were not always responsive to patients’ needsand required improvement. The provider could notalways assure adequate patient flow within the hospital.This meant that mixed-sex accommodation breachesfrequently occurred and patients were moved duringtheir stay, sometimes late at night. The hospital couldnot always provide a bed for care and treatment ofmedical patients on a medical ward. These patientswere called medical outliers and were admitted to other

wards, outside of medical services. However, staff andpatients were always aware of which doctors wereproviding specialist medical care and treatment to themand nursing staff were competent to deliver their care.

The medical services were well led. Staff were aware ofthe hospital’s vision and values spoke of the familyatmosphere of working in the hospital. The leadership,governance and culture promoted the delivery of highquality care. There was a clear set of values driven byquality and safety and staff were familiar with these. Thetrust engaged its patients and visitors regularly to obtainfeedback in order to improve the patients’ experience inthe hospital. Staff spoke highly of their managers andfelt their views and concerns were listened to and actedupon. The staff survey showed staff recommended thehospital as a place to work.

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Are medical care services safe?

Good –––

We found safety in the medical services at SalisburyFoundation Trust to be good overall, although there weresome areas requiring improvement.

There was a good culture of incident reporting andlearning. The wards were clean and infection controlprocedures were effective. The design, maintenance, useof facilities and premises kept people safe. Medicineswere stored and managed well. Staff identified andresponded appropriately to changing risks to patients,including deteriorating health and wellbeing. Thehospital joined the national sign up to safety campaign aspart of a programme to reduce avoidable harm. Datapublished as part of this programme showed fallsresulting in injury decreased during between 2011 andthe end of 2014.

Nursing and medical staffing levels were in line withassessed levels and there was access to temporary staffwhen required.

Although overall record keeping was good there wereaspects that required significant improvement. Theserelated specifically to the documentation of cannulas,catheters and patients’ weight. The trust had identifiedthe lack of recording of patients’ weight earlier in the year,but practice had not changed.

The trust had improved the decision making aroundwhich patients should be isolated in side room facilities.However, at times there was some confusion over whichpatients required isolation.

Records showed that the target for 85% of staff to havereceived mandatory training was not met.

Incidents

• Staff understood their responsibilities to raise concerns,to record safety incidents, concerns and near misses,and to report them. The National Reporting andLearning System (NRLS) provide comparative data ofincidents reported by NHS organisations. The mostrecent data between October 2014 and April 2015confirmed Salisbury hospital reported 2,545 incidents, arate of 33.6 per 1,000 bed days during this period, versus

a national average of 35.4. This shows incident reportingat the trust was comparable to the national average. Ahigh level of incident reporting reflects a more effectivesafety culture, as it provides the opportunity for learningand improvement.

• The hospital recently implemented a new, electronicincident recording system. The quality and clinicalgovernance report in May 2015 stated this led to higherincident reporting. The hospital reported 12 seriousincidents requiring investigation during the periodbetween August 2014 and July 2015. Ten of theseincidents were slips, trips or falls. We reviewed a numberof investigations carried out following serious incidents.Evidence provided showed how lessons were learnt andactions and recommendations were made following theinvestigation.

• The hospital had a robust incident reporting procedure.Staff followed the hospital’s policy relating to incidentreporting, which outlined the process for completing anonline incident form. The policy was accessible to allstaff through the intranet homepage. Guidance wasavailable on this page, sought from line management,or the risk management department. The inductionprocess provided training in the incident reportingprocess and was mandatory for all staff at departmentallevel. The hospital did not provide us with data to showthe percentage of staff that had completed this training.Staff felt encouraged and supported to report incidentsand received feedback to enable learning fromincidents.

• The hospital rated falls as the most common incident.The highest reporting wards were Winterslow, Farleyand Redlynch. Senior staff conducted an investigationfor all falls resulting in a fracture or major injury. Thiswas a thorough process which enabled learning to beidentified and actions to take as a result. For example, apatient under sedation sustained a fall following acoronary angiogram, which is an x-ray procedure usedto help diagnose heart conditions. The senior leadershipconducted a route cause analysis and created a newpost angiography policy, which was shared with staffand implemented as a result.

• Lead clinicians met monthly to review incidents. In onemeeting, they discussed two litigation cases. Seniormedical staff ensured all relevant departments and staffwere updated with appropriate learning points andactions.

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• Senior medical staff told us they held well structured,mortality and morbidity review meetings, which used astandardised audit form. Reviews included investigationof mortality groups for evidence of whether deaths wereavoidable. We saw evidence showing that learningpoints were shared, which enabled improvement. Thetrust circulated these as emails to all doctors, seniormanagers and senior nurses.

• The Wiltshire commissioning group found the hospitalregularly admitted frail, elderly patients known to be atthe end of their life, who died within a day or two ofadmission. They were working with commissioners andlocal GPs to enable these patients to avoid admission, ifthey wished to be cared for at home.

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014, is a newregulation which was introduced in November 2014.This Regulation requires the trust to be open andtransparent with a patient when things go wrong inrelation to their care and the patient suffers harm orcould suffer harm which falls into defined thresholds.Evidence received from the trust showed it dealt withsuch incidents in accordance with the Duty of Candourregulation.

• Staff training records showed the hospital did notinclude training for the Duty of Candour in itsmandatory training. However, training was providedthrough directorate and departmental meetings andthrough risk sessions. On two occasions, solicitorsprovided training during clinical governance half daymeetings to advise staff. Staff on the medical wardsspoke competently about the hospital policy whichoutlined the requirements of the Duty of Candour. Theelectronic incident recording system prompted thereporter about the Duty of Candour when an incidentwas recorded.

• Senior staff reviewed incidents submitted to theelectronic data recording system. This included a reviewof the grading of the incident, which identified whetherit had met the threshold for Duty of Candour. If it didmeet this threshold, the ward or department in which itoccurred escalated the concern to senior management.The head of risk or the patient safety facilitator reviewedthe incident to ensure the investigating managercompleted the Duty of Candour documentation.

• When things went wrong, staff conducted thoroughreviews and investigations and involved relevant staff inthe process. We reviewed a serious incident

investigation report following the death of a patient. Itshowed the hospital acted in a clear and transparentway when things went wrong. The trust provided thefamily of the patient a verbal and written apology withsupporting information in a timely manner. Staffconducted the investigation in line with the Duty ofCandour procedures.

Safety thermometer

• The NHS Safety Thermometer is a nationalimprovement tool for measuring, monitoring andanalysing patient harm and ‘harm free’ care. This dataprovides a snapshot of avoidable patient harmsoccurring on one specific day each month. The hospitalreported an upward trend to 98% of new harm free careand a slight decline to 94% of all harm free care, inAugust 2015.

• From July 2014 to July 2015, pressure ulcers occurred ata consistent rate of between one and three per 100patients each month, falling to a low of 0.4 in November2014. Falls with harm peaked in August and November2014, but the rate had otherwise remained below 1.5per 100 patients each month and showed a downwardtrend. It showed a rise in urinary tract infectionsacquired by patients who had catheters, from Octoberthrough to December 2014. However, rates hadotherwise remained below two per 100 patients eachmonth.

• The trust displayed data at the entrance to wards, whichcontained information relating to key quality indicatorsfound in safety thermometer data. This included theincidence of falls, pressure damage, infection controland venous thromboembolism rates. Pitton ward forexample, recorded two falls in May and reported nograde three pressure ulcers since April 2014.


• The provider reported in August 2015 that no bacteriamethicillin-resistant Staphylococcus aureus MRSA orMethicillin-sensitive Staphylococcus aureus (MSSA)bacteraemias had occurred during the previous sixmonths. Elective MRSA screening rates had declinedand the medicine directorate investigated this with theclinical leads in order to gain improvements.

• In August 2015, the hospital reported two cases ofclostridium difficile (a type of bacterial infection that canaffect the digestive system). The hospital remainedwithin its trajectory for the number of such cases.

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• Since July 2014, the trust reported it continued toimprove decision making around which patients shouldbe isolated in side room facilities, in addition to usingthe isolation risk assessment tool. It revised themanagement of patients experiencing diarrhoea andrelevant documentation, and created a new patientmanagement pathway. Staff involved investigated thetime taken to isolate patients from when they firstreported symptoms in order to ascertain the extent ofvariance against best practice guidance. Findingsindicated areas of good practice where staff isolatedsymptomatic patients within two hours and obtainedstool samples. They identified times when patients werenot isolated within the target time for a variety ofreasons. Infection control nurses monitored adherenceto the pathway through daily clinical visits anddiscussions with clinical staff on duty. The directoratesenior nurse observed practices to ensure staffcomplied with policy.

• During the unannounced inspection, we identified thatstaff did not always effectively implement systems toprevent and protect patients from a healthcareassociated infection. There was some confusion overwhich patients required isolation. We found somepatients in isolation rooms who staff said no longerrequired it. However, the signs remained in place. Somepatients who still needed to be in isolation were inrooms with the doors kept open as the patients weresuffering from confusion. Staff had left the doors openas they felt closing the door resulted in the patientbecoming more confused. However, infection rates atthe hospital remained low.

• Medical wards protected patients through effectiveantibiotic prescribing. Staff audited the procedures inplace to prevent the risk of patients contractingClostridium difficile. The audit protocol selected patientrecords at random between June and September 2015.These showed compliance with a high percentage ofaudits. Data provided to us by the hospital related tofive of the medical wards only and showed 84.6 % staffhad completed mandatory training for infectionprevention and control against a target of 85%.

• Staff audited compliance with bare below the elbow,uniform compliance and hand hygiene. Compliancewith this is part of the hospital policy and helps reducethe spread of infection. From February to July 2015, barebelow the elbow scored an average of 97%. Handhygiene audits showed that most wards were compliant

with hand hygiene, with the average for the directorate,achieving 93.5% between January to August 2015. Thepoorest performing wards were Whiteparish, Tisbury,Pitton and Redlynch with average scores of 88.9%,89.7%, 77.4% and 86.9% respectively. Some of thesescores did show an improvement over time. Doctors and‘other’ healthcare professionals achieved the lowestscores for hand hygiene.

• Ward staff used white boards to identify infectioncontrol risks and discussed specific patients as part ofthe handover and safety briefing. This ensured all staffon the wards were aware of the risks and that effectiveinfection control precautions were taken.

• The hospital had a policy in place for thedecontamination of medical devices, patient equipmentand endoscopes to provide guidance for theappropriate cleaning and sterilisation of equipment.

• Trained staff cleaned endoscopes in the centralsterilising unit, which protected patients from the risk ofinfection.

• The infection control team updated senior nursesduring daily bed management meetings with anyinfection control concerns and highlighted which bedsrequired a deep clean.

• The wards used green labels to identify when cleaningof the equipment and environment had occurred andwho had carried out this process. One commode whichhad been given a green label was found to have a markon it. However, it was not clear as to whether this was astain or dirt and staff took immediate action toinvestigate this to ensure its cleanliness.

• Chemicals and substances that are hazardous to health(COSHH) were used for cleaning and were storedsecurely in locked rooms which were inaccessible topatients and visitors.

• Sharps bins were available throughout the medicalwards and departments for the safe disposal of usedneedles and other sharps equipment. Staff used theseaccording to manufacturer’s guidance. They kept binsclosed when in use and not overfilled, which protectedstaff from the risk of a needle stick injury.

• Each ward had hand-sanitising gel located at theentrance to the ward. Within the wards, hand sanitisinggel and hand washing facilities were availablethroughout. Posters displayed gave guidance forappropriate usage and correct handwashingtechniques. Staff used hand gel and washed hands inline with infection prevention and control guidelines.

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• We saw, and patients confirmed, staff used personalprotective equipment such as aprons and gloves whenperforming procedures and carrying out patient care.

• A number of areas within the medical directorate werepart of the national PLACE audit. This is a patient ledassessment of the care environment. Durrington, Pitton,Redlynch and Winterslow wards were rated as 98.9% forcleanliness.


• The design, maintenance, use of facilities and premiseskept people safe. The PLACE audit rated Durrington,Pitton, Redlynch and Winterslow wards as: 86.2% forprivacy, their condition, appearance and maintenance,and 88.4% for a dementia friendly environment. Overallresults for 2015 showed an improvement on theprevious year and rated better than the Englandaverage.

• The provider held guidance and policy documentsrelating to medical device training, maintenance andmanagement on its website for staff to access. Staffknew how to access a range of policies the trust kept onits website.

• The hospital changed the layout on Redlynch and Pittonwards and refurbished Durrington ward to provide acalm and relaxed environment for its patients.

• The medical directorate reported in August 2015 it hadcompleted its programme of deep cleaning and wardpainting within the medical division. This includedDurrington ward, Farley stroke unit, Tisbury coronarycare unit, Whiteparish acute medical unit and Pittonward. Wards we inspected were clean, bright and ingood decorative order.

• The hospital refurbished Redlynch ward with the aim ofproviding a light, bright and social environment. Staffused the refurbishment as an opportunity to changepractice. These changes included the removal of thenurse’s station, which meant staff planned care at thebedside. The hospital recently reported these changesresulted in a 38% increase in reported nursing visibilityand a 75% reduction in negative comments arounddelayed care related to the perception of staff beingmore available,

• Staff had sufficient access to pressure relievingequipment such as mattresses and cushions, at alltimes, or borrowed equipment from other wards ifneeded.

• Physiotherapists and occupational therapists whoordered equipment from an external company reportedthey had no problems in accessing equipment whichwas delivered to the patients home in a timely manner.

• The hospital also had a central store that provided someequipment for patients to take home. Equipment wastraceable which meant that patients were protected if aproduct needed to be recalled, cleaned, or whenmaintenance and replacement was required.

• We visited the day room on Farley stroke ward andnoted furniture such as armchairs and rehabilitationequipment cluttered a corner of the room, whichpresented a potential trip hazard to patients.

• Each ward and department had a resuscitation trolleycontaining emergency equipment and medication inthe event that a patient suffered a cardiac arrest. Wardskept trolleys secured so that medication did not gomissing and could be ready to be use in an emergency.Hospital policy stated that these should be checkeddaily to ensure reliability and to allow for thereplacement of essential equipment. On some wards wefound omissions in daily checks. Therefore, there was alack of assurance that this equipment was fit for use.

• The hospital reported some delays with the turnaroundof endoscopy equipment. This related mainly to thelength of time needed to decontaminate an endoscopein a safe and compliant manner.

Medicines

• The hospital maintained an up to date medicines policydesigned to safeguard patients and staff from errorsrelating to medicines. The policy outlined safe practicefor the prescribing, ordering, storage, administration,recording and disposal of medicines in the hospital.

• The arrangements for managing medicines kept peoplesafe. Ward staff stored medicines in lockable storagetrolleys which were chained to the wall when not in use.Staff used the drug trolleys on ward rounds andadministered medication in a safe manner, in line withthe hospital’s policy.

• The endocrine team raised concerns that there was asignificant risk in relation to insulin prescribing. Weexamined insulin prescribing in a number of patients’medical records and found appropriate insulinprescribing in all cases. A sister we spoke with felt herstaff were adequately trained in insulin managementand they had good support from the diabetes specialistnurse.

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• Medication, prescribing and insulin errors weresignificantly lower than the England average and had allimproved since the 2012 audit.

• Wards did not have a local intravenous policy and usedan externally developed injectable medicinesadministration guide. We did not identify any localaudits of medication practice with injectable medicines.

• The provider conducted audits of antibiotic prescribingat approximately six monthly intervals. Thisdemonstrated a 93.1% compliance with prescribing andappropriate documentation.

• As part of a health improvement project, junior doctorscarried out a review to see how they could reduce out ofhours prescription errors via access to a new electronicsystem for on call medical teams. As a result, juniormedical staff reported a reduction in errors andimproved access to clinical information, such as GPrecords and prescribing information.

• Staff implemented safety systems, processes andpractices and monitored these in order to identify if anyimprovements were necessary. Ward sisters audited thesafe and secure management of medicines using achecklist. Reports identified areas where medicineswere not stored and managed effectively. For example,on Farley ward an audit carried out in July 2015identified that staff left medications out on worksurfaces and bags of medications prepared for patientsto take home were left on the floor. During theinspection, we found medications were stored safelyand in lockable cupboards. Staff kept doors locked andaccess could only be gained with an electronic swipekey device worn by staff. This practice safeguardedpatients from harm.

• Wards provided patients with lockable cupboards forthe storage of their own medicines. The acute medicalunit (AMU) had a dedicated full time pharmacist workingon the ward and a member of the pharmacy teamchecked medicines that patients brought with them intohospital.

• Staff identified and documented patients’ allergies well.We saw the allergy status of patients’ recordedappropriately in documentation such as prescriptioncharts and health care records. Patients with a knownallergy status wore red wristbands.

Records

• The trust maintained a record keeping policy that wasaccessible to staff from the hospital’s website. It stated

that all patients must have a nursing assessmentcompleted within six hours of admission to hospital. Wedid not receive audit data that could confirm whetherthis was regularly achieved.

• It was noted in the directorate risk register that therewere concerns that limited estate capacity madeconsistent delivery of ambulatory emergency care andassessment of new admissions a challenge.

• Hospital policy stated staff performing care or carryingout treatment should effectively record planned carethat had been delivered. This should be documented inthe patient’s healthcare record at the time of theassessment or treatment. We found that staff did notalways maintain accurate and complete patienthealthcare records in line with the hospital’s policy andbest practice. We identified a poor standard ofdocumentation with regard to intravenous cannulasand urethral catheters and the recording of patients’weight.

• When patients were admitted, staff completedindividualised care plans and carried out riskassessments. These included for example, identifyingany areas of pressure damage to the skin, a nutritionalassessment with a patient’s weight, appetite and abilityto eat. Documenting a patient’s weight is important formonitoring their nutritional status and managing theirfluid balance, as well as calculating accurate doses ofsome medicines. Following a medicine departmentalmeeting, senior staff recorded on the risk register inJune 2015, a lack of accuracy of admissiondocumentation. This was attributed to a high volume ofadmissions and patient acuity. It resulted in gaps innursing assessments and the recording of patients’weight. Actions to improve practice were put in place.However, during the inspection, we identified that staffwere still not routinely documenting patients’ weight intheir care records.

• The practice of caring for cannula and catheter devicesdid not always protect patients from the risk of hospitalacquired bacteraemias. A nurse we spoke with told ustrust wide learning from an MSSA bacteraemia in theprevious year meant an additional box was added to thedaily nursing management plan in order to record avisual infusion phlebitis (VIP) score. This is a toolrecommended by the RCN for monitoring infusion sites.It is used to determine when a catheter should beremoved, but was often not completed. Variations inpractice related to the documentation of insertion and

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removal of cannulas and catheters. There was no recordof ongoing management and staff we spoke with couldnot access a policy regarding cannulation. We foundinconsistencies on wards and between wards. Therewere at least four different places where cannulainsertion could be recorded. The hospital did not have areliable system to record the length of time a catheter orcannula was in place that did not involve looking backthrough patients’ notes, which were filed daily.

• Across wards, we found many of the forms used fornursing assessment documents and patient recordswere poor photocopies. This made it difficult toeffectively interpret some of the information thatappeared in them. For example, the Bristol Stool Chart isa pictorial scale designed to classify faeces into groups.The pictures on the scale were too poor to be able toprovide an accurate reference. It was often impossible tosee where a document originated or whether it wascurrent, as the date and title had been moved off thepage due to repeated copying.

• Patient records were stored securely within themedicine directorate, which maintained patientconfidentiality and safety. The hospital providedlockable trolleys to keep patients’ records secure. Wefound trolleys on wards locked and kept secure whennot in use.

Safeguarding

• There were systems, processes and practices in placethat kept patients safe which were understood andimplemented by staff. The provider maintained asafeguarding policy which identified the roles of key,senior personnel and their responsibilities in ensuringthe hospital complied with relevant legal and statutoryrequirements.

• Staff understood their responsibilities to adhere tosafeguarding policies and procedures. We spoke with avariety of clinical and non-clinical staff who told us theyfelt confident about what constituted a safeguardingconcern and able to discuss concerns with more seniorstaff.

• The hospital provided us with a number of sets of datafor safeguarding training it provided to staff annually.Some data only related to five of the eight medicalwards, for which training for adult safeguardingdemonstrated a high level of compliance of 90.5%, andsafeguarding children for clinical staff at 74.3%. Datarelating to three wards showed 83.3% of non-clinical

staff received safeguarding training for children. Otherdata showed 86% staff completed adult safeguardingtraining, but this included some data from areas otherthan medical services.

• We reviewed quality and clinical governance reportsproduced every three months by the medicinesdirectorate. It included safeguarding alerts reportedabout the hospital. The provider shared learning fromthis, even when the claim was not upheld.

Mandatory training

• The trust provided a basic level of information todemonstrate completion of mandatory training thatrelated to a small number of topics, such as infectionprevention and control, hand hygiene and safeguardingadults and children. It covered five out of the eight adultinpatient medical wards. This showed 77.8% of staff hadcompleted this training, which was below the trust’starget of 85%. It was not possible to comment upontraining for topics such as dementia awareness, basiclife support, or other topics normally reported on in thissection.

• Staff on Winterslow ward told us that mandatorytraining was 80-85% completed against the hospital’starget of 85%. Data provided showed staff on the wardhad completed 74.5% of mandatory training inDecember 2015. Some staff told us completion data wasnot always reliable or up to date. Some staff told us thatdespite having completed mandatory training modules,the electronic database still showed modules as notcompleted.

• Staff received email alerts to alert them when theyneeded to complete mandatory training modules. Anumber of staff told us that it was difficult to get thetime to access mandatory training modules and so didsome of it in their own time.


• Healthcare staff performed a range of patient riskassessments in order to identify patients at risk ofpressure damage, blood clots, falls and malnutrition.

• The medicine directorate assessed 96.6% of its patientsfor the risk of a venous thromboembolism (VTE) versus a96% national average, for April 2014 to March 2015. Thismeant it protected a high proportion of its patients fromdangerous and potentially life threatening blood clots.

• The hospital recently began auditing a combination ofdata related to falls assessments, accuracy of falls

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assessments and whether intentional rounding wasimplemented for those identified at risk of falls.Intentional rounding is where health professionalsperform regular checks with individual patients at setintervals. Data was collated from July 2015 although notall wards entered audit data systematically or used thesame paperwork. Winterslow ward demonstrated moreconsistent data, and showed that by October 2015, itwas risk assessing 83% of its patients, of which auditsrecorded all were done correctly. Data showed allpatients identified at risk of a fall received increasedmonitoring through intentional rounding.

• The hospital joined the national sign up to safetycampaign as part of a programme to reduce avoidableharm. Data published as part of the sign up to safetyprogramme showed falls resulting in injury decreasedduring between 2011 and the end of 2014. The hospitalattributed this to an emphasis on reliable assessment,identification of high risk patients and implementationof intentional rounding as an intervention.

• The hospital reported a good level of recording ofpressure ulcers on admission, which ensured they wererecorded correctly as hospital acquired, or already inplace on admission.

• A medical photographer photographed pressure ulcerson admission and had trained other staff on thisprocess. This ensured accurate recording of pressureulcers in line with national guidance.

• A Tissue Viability Specialist Nurse led cluster reviews ofpressure ulcers to determine causes and learning fromincidents. It reported a decrease in grade 2 pressureulcers in August 2015 with a downward trend since Aprilthis year.

• The provider did not have specific training for staffrelating to ligature risks. However, it stated that as anorganisation it responded to the estates alerts aroundligature points and a resource checklist could be used toassess any environmental hazards in the presence of ahigh risk. This would normally be done in conjunctionwith the mental health liaison team. Data relating to arisk assessment completed for the AMU was datedOctober 2006.

• The trust did not ensure that all urgent or unplannedmedical admissions were seen and assessed by aconsultant within 14 hours of admission. The NHS sevenday forum report recommends patients admitted as anemergency should be seen within 14 hours by aconsultant. The majority of emergency medical

admissions patients in the UK are admitted through anacute medical assessment unit. Nurses at Salisburyassessed 100% of patients within 30 minutes.Consultants reviewed 90% of patients within 14 hoursand saw all patients within 20 hours. The hospital wastherefore not meeting this guideline.

• The National Institute for Health and Care Excellence(NICE) clinical guideline 50 recommends the use of anearly warning scoring system (EWSS) to recognise andrespond to acute illness or a deteriorating patient inhospital. The hospital used a modified early warningscoring system to monitor changes in a patient’sphysiology. Staff converted patients’ observations into ascore and followed an escalation protocol if a patient’sscore reached a certain threshold. Staff also recordedthe patient’s oxygen saturation and urine output as partof this monitoring process.

• The hospital had onsite access to levels two and threecritical care. Where necessary, patients were referred tothe intensive care team or the critical care outreachteam to review the patient. The hospital’s policy statedthat for patients whose scores triggered concern, theywere added to the hospital at night handover list anddiscussed at the meeting. The hospital provided trainingon EWSS and escalation information aimed at differentstaff roles during hospital or ward induction.Compliance with the use of EWSS was 96% during thefirst quarter of 2015, versus a trust target of 95%.

• On Pitton ward there was a respiratory high dependencyunit used for patients receiving non-invasive ventilation.These patients had their needs met without needing tobe on the intensive care unit. The critical care team gavesupport and advice regarding these patients.

• When the medical wards were full, the hospital admittedmedical patients to other wards outside of medicalservices, such as surgical wards. These patients areknown as medical outliers. Medical outliers receivedappropriate care and treatment. Staff carried out aclinical assessment to ensure only suitable patientswere transferred to another area. Surgical ward staff feltadequately skilled to manage these patients andsupported by both medical and surgical doctors to doso. Staff told us that they were always aware of whichdoctors were providing specialist medical care andtreatment to the medical outlier patients and medicalconsultants reviewed these patients daily. They wereconfident they had the appropriate staffing levels andskill mix on the ward to manage medical patients

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effectively. They refused to take the patient if they feltthey could not give them the right level of care. Severalnursing staff on surgical wards described the medicalpatients they received as the same type of patientwithout having had surgery. Nursing staff reported thatit was easy to access the designated consultant and thatmedical staff on the surgery wards were happy to treatpatients on their wards.

• We observed two safety briefings during the handover ofday staff to the evening shift. Ward sisters in charge gavea concise, detailed account of the important issues tohighlight to the night staff for their attention. Forexample, the briefing identified patients at risk of falls,those who were confused or had special nutritionalneeds. On the acute medical unit, the sister flagged sixpatients waiting to transfer out to receiving wards and apatient with diabetic ketoacidosis who was ready foradmission. This is a potentially life-threateningcomplication of diabetes and as such, the sisterorganised one-to-one care for the patient during thisshift and cover for the following day.

• During the inspection, we heard the cardiac arrest alarmsound on a ward. Staff of all disciplines from all over theward attended rapidly to the situation, which turned outto be a false alarm.

• When therapy staffing was lower than demand, theyprioritised duties so that they saw new patients first,followed by those patients who needed care to preventthem from deteriorating, and then reviewed patients tofacilitate their discharge. These groups of patients tookprecedence over routine rehabilitation.

• Staff were in the process of auditing compliance withsepsis screening and antibiotic prescribing as part of anational CQUIN (Commissioning for Quality andInnovation) for 2015 to 2016. The most recent dataprovided related to the period from January to March2015 in the quarterly stocktake report for the medicinedepartment. It showed a 77% compliance with thisCQUIN which was above the trust’s target of 65%. Staffwe spoke with were aware of the high risks of sepsis andthe Sepsis 6 pathway to follow.

Nursing staffing

• The provider reviewed staffing levels and skill mixregularly and appropriately to ensure people receivedsafe care and treatment, in line with relevant guidance.The provider used an electronic rostering system fornurse staffing which the medical directorate senior

nurse oversaw. It was one of the 22 trusts under the LordCarter scheme, which is looking at acuity data for theDepartment of Health. This system uses a model tomeasure patient acuity. Staff entered information threetimes per day. Senior leaders collaborated with othertrusts that had used this tool and believed inputtingdata this frequently would enable them to have themost accurate acuity data. The trust recently beganreviewing this data to ensure its accuracy.

• The Director of Nursing and Deputy Director of Nursingcarried out six monthly skill mix reviews with theDirectorate Senior Nurse and each ward manager.This ensured consistency and compliance with NICEstandards. The most recent skill mix review wascompleted in September 2015. Senior managementapproved an increase in the number of nurses onRedlynch and Pitton wards at weekends on a sixmonth pilot, in October 2015.

• Whiteparish ward was the acute medical assessmentunit. The directorate planned a further skill mix review,subject to the outcome of a pending business case torelocate this unit. A further skill mix review was plannedfor Durrington ward following the full implementation ofthe rapid access care of the elderly model. Winterslowward planned a reduction in their band fiveestablishment by four whole time equivalent staff whowere to be replaced with band fours (trainees in post)due to vacancies that were continuously experienced.

• Directorate senior nursing staff visited each ward daily inorder to check staffing levels by looking at the skill mixand bed occupancy. They sometimes moved staffbetween wards or to another directorate, or deployedbank and agency staff to fill any gaps in the shift.

• We attended four bed management meetings whichtook place twice and sometimes three times a day.Within this meeting senior staff gave an update ofcurrent staffing levels to establish bank and agencystaffing requirements. A bank and agency coordinatorattended and immediately acted on this information.

• Staff on wards felt they had adequate access to bankand agency staffing when needed. A senior ward nursesaid they did not feel too pressured and the trust couldaccess bank staff who were appropriately trained.

• Planned staffing levels were comparable to actualstaffing levels. The trust provided data which showed

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the nursing and nursing assistant shift fill rates for themonths of May to August 2015. All eight of the medicalwards were given a rag rating of green, which wasawarded for a greater than 80% fill rate.

• We visited the trust during the day, evening and at theweekend and found staffing ratios fell within therecommended ratios for safe patient care. Patients toldus there were sufficient staff on the wards in order tomeet their care and treatment needs.

• Wards remained compliant with nationallyrecommended ratio of one nurse to eight patients. Theratios of registered nurses to nurse assistants differedfrom ward to ward depending on the care needs ofpatients. The supervisory ward sister or charge nurserole was supernumerary.

• Staff on the acute medical unit told us they oftenfinished after their allocated shift time and did notalways get breaks. Staff often had to take patients onthis ward for tests or move beds, and felt nursingassistants frequently acted as porters.

• Staff commented beds never closed due to a shortage ofstaff, as they could pull staff in from other wards. Thehospital site management team stepped in to help ifneeded, and the hospital outreach team could becontacted for assistance to ensure the safe care ofpatients on the wards.

• Arrangements for handovers and shift changesmaintained patient safety. During the safety briefing thattook place during a shift handover, we saw how wardsisters delegated staff with tasks according to skill set,patient risk and acuity.

• Agency staff completed a ward orientation inductionprior to starting work on the ward and a record of thiswas kept on file within the trust. Agency staff told usthey felt supported to carry out their role on the ward.Agency and bank staff could be booked in advance toprovide consistency to the ward staff and to patients.

Medical staffing

• Medical staffing levels and skill mix was planned so thatpatients received safe care and treatment in line withguidance. Guidance from the Society for Acute Medicineand the West Midlands Quality Review Service (2012)suggested that a consultant should be on site or be ableto reach the acute medical unit within 30 minutes. Staffconfirmed that they had access to an on call consultantrota and that they were able to contact a consultant atall times for support and guidance.

• Physicians and surgeons provided care for medicalpatients outlying on surgical wards. Patients had anamed consultant who visited them on the wards daily.Nursing staff felt supported by consultants in caring forthese patients. Boards at the patients’ bedsideidentified the consultant and nurse in charge of theircare.

• The hospital at night team within the medicinedirectorate consisted of a coordinator, junior andmiddle grade doctors.

• The medical assessment unit (AMU) consultantsreviewed all patients within a set time scale inaccordance with the initial triage assessment. Urgentpatients classed as ‘red’ were seen within 30 minutes,amber 60 minutes and green within four hours. Duringout of hours, consultants aimed to review patientswithin 14 hours. AMU consultants were availablebetween 09:00 -19:00. A medical consultant covered theon call hours between 17:00-09:00, which included17:00-20:00 for MAU admissions, the 08:00 ward roundand were contactable for advice or to come in betweenthe hours of 20:00-08:00.

• Two general medical consultants covered weekendsand bank holidays. Other on call cover was forhaematology ward rounds during weekend mornings.Cardiology had 24 hour seven day cover with a formalward round on Saturdays and Sundays, although not allpatients were reviewed. Those who were sick, admittedto AMU and those waiting for discharge were seen overthe weekend.

• The AMU held a board round daily which included theconsultant, junior doctors and nursing staff. A detailedhandover regarding each patient took place for eachnursing bay. During daily safety briefings patients wereprioritised for a visit from a consultant.

• Patients told us they felt safe and well looked after andthey saw a doctor regularly.

Major incident awareness and training

• The hospital had a major incident policy which could beaccessed through its website. Some staff were aware ofthe major incident policy and procedure but told usthey had not practiced this for some time. The policywas under review at the time of the inspection.

• The plan outlined roles and responsibilities for all staff,designated a control room within the orthopaedicdepartment.

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• To enable the hospital to manage winter pressures, anadditional ward opened for several months in Januaryof each year.

Are medical care services effective?

Good –––

Patients received effective care and treatment. Staffdelivered care in accordance with evidenced-basedguidelines and current best practice. Patients’ pain waswell managed by staff in the hospital and feedback frompatients reflected this.

The hospital participated in local and national clinicalaudits and information was shared internally andexternally in order to improve care and treatment. Themajority of patient outcome data for the hospital showeda performance in line with, or better than the nationalaverage.

Medical staff were having regular appraisals. However,although nursing staff reported they had received anappraisal in the last 12 months the data provided by thetrust showed only 40% of its nursing staff had received anappraisal in the last twelve months.

There was good multidisciplinary working between wardsand departments in the hospital and all relevant staff anddepartments were involved in assessing, planning anddelivering people’s care and treatment in order to meetpatients’ needs.


• The hospital kept a wide range of policies andprocedures accessible to staff on the intranet. Itreviewed policies and procedures to align them withguidance provided by the National Institute of CareExcellence (NICE) and other expert professional bodies.

• The inpatient diabetes team continually reviewed anddeveloped protocols and management guidelines inline with best practice. Specialists recently developed achart for the management of diabetic ketoacidosis, apotentially life-threatening complication of diabetes.This was instigated following an audit which suggestedvariations in compliance with a previous care pathway.

• The diabetes inpatient foot care service reported it wasunable to meet the current NICE guideline and quality

standard consistently and especially at weekends. Thestandard requires diabetic foot patients are reviewed bya multidisciplinary team within 24 hours of admission tothe hospital.

• The hospital’s endoscopy service held accreditationthrough the Joint Advisory Group (JAG) forgastrointestinal endoscopy. Endoscopy records were fedinto national surveys through the JAG accreditationsystem. This accreditation demonstrated theeffectiveness of its endoscopy service.

• The hospital provided a stroke pathway for all patientspresumed to have had a stroke or transient ischaemicattack. This is a mini stroke, caused by a temporarydisruption of blood supply to the brain. Farley strokeunit received all stroke patientsreferred directly fromtheir GP or the emergency department 24 hours a day,seven days a week.

• Consultants reviewed patients on medical wards on adaily basis Monday to Friday and some patients over theweekend where it was deemed necessary.

• Cardiologists provided evidence to show how they hadremained up to date with best practice, and reviewedand implemented up to date guidelines byincorporating this into educational presentations.


• The hospital’s food and nutrition policy and practicewas overseen by the trust’s food and nutrition group.

• The hospital enforced a policy of protected mealtimesso that patients’ meals were not interrupted byprocedures or assessments unless urgent. Wardmanagers ensured activities during mealtimes focusedon the service of food and staff provided patients withappropriate assistance with meals.

• A food and nutrition mid-year report in August 2015showed 93% of patients had their dietary requirementsdocumented. This included a reference to the type ofdiet the patient wanted, for example, diabetic,vegetarian or vegan. Staff also documented mouth anddental assessments.

• Speech and language therapists and specificallytrained carried out swallow assessments within fourhours of admission. This was a recognised target withina national stroke audit.

• Staff carried out nutritional screening on admission andduring subsequent assessments, then documentedactions to reduce the risk to patients. Hospital policystated all patients should be weighed on admission and

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during re-assessment. In September 2015, the trustre-assessed NICE quality standard 24 for nutritionsupport in adults and judged it partially met. The use ofa validated nutritional screening tool achieved a 98%compliance. However, the trust documented a concernwith the recording of patients’ weight, as only 34% ofpatients had weight recorded.

Pain relief

• The hospital’s nursing assessment policy stated apatient’s pain should be assessed within six hours ofbeing admitted and after each set of cardiovascularobservations. We saw evidence of pain assessmentswithin nursing records and these were in line withpolicy.

• Pain relief on medical wards was well managed,including for patients with difficulties in communicating.Staff used a pain assessment to chart the causes andcharacteristics of the pain, and used a scale of one toten to document the patient’s current perception ofpain.

• Patients told us and we observed staff ask if they were inany pain and medicines were administered to thosewho needed it.

• For patients who were less able to communicateverbally, staff explained how they would use facialexpression, changes in mood and other non-verbal cuesto assess pain. On Durrington ward, staff trialled a newpain assessment form for such patients to see if thiscould provide an even more accurate reflection of thepatients’ level of pain. Staff spoke with relatives or useddocumentation such as the ‘this is me’ dementiadocument, so they were more likely to recognise anychange in the patients’ level of pain.

• Staff accessed an on-site pain team for furtherassistance and advice where necessary, in order to meetthe patients’ needs.

• Inpatient feedback about pain management on thewards as part of the trusts ‘real time feedback’programme showed pain was well managed withaverage scores reaching almost ten out of ten.

Patient outcomes

• The hospital regularly monitored outcome data inrelation to patients’ care and treatment. The majority ofpatient outcome data for the hospital showed aperformance in line with the national average or better.

• The trust regularly reviewed the effectiveness of its careand treatment through local and national audit andacted upon the information. The hospital contributed toa national audit plan which where appropriate followedNICE guidelines. National audits such as; chronic heartfailure, chronic kidney disease, diabetes in adults, acutekidney injury, and acute upper gastrointestinal bleedingwere used to develop services and improve patientoutcomes. For example, the hospital’s stroke servicesachieved an overall rating of ‘B’ in the June 2014 to July2015 sentinel stroke national audit programme. A wasthe highest score relating to occupational therapy inputinto stroke patient care, and E was the lowest scorewhich related to speech and language therapy input.There was an action plan in place to address the lowerperforming score.

• The medical director reported good performance withstroke care in the October 2015 quality indicator report.Stroke patients spent 90% of their time on the strokeunit versus a target of 80%.

• The NICE guidelines recommend the measurement anddocumentation of the surface area of pressure ulcers. Amedical photographer photographed pressure ulcerwounds when the patient arrived at the hospital toensure the effective monitoring of pressure sore healing.One patient told us how they had arrived at the hospitalwith a pressure sore, which healed well under the careof the hospital. “The wound has improved considerablyunder the hospital’s care and has almost healed.”

• The standardised relative risk of an elective patientreadmission for the trust was 96 and for non-electivere-admissions it was 90. A value of less than the Englandaverage of 100 was positive, as it meant the patient wasless likely to be re-admitted.

• The hospital achieved good patient outcomes in thenational heart failure audit with inpatient hospital careachieving as good as, or above the England averagescore. These four scores included: input from aspecialist, input from a consultant cardiologist,cardiology inpatient care and whether the patient hadreceived an echocardiogram (a test used in diagnosingheart disease).

• The myocardial ischaemia national audit project(MINAP) is a national clinical audit of the managementof heart attacks. The hospital performed better than theEngland average across all parameters in this auditwhich related to care of patients with non-ST-elevation(nSTEMI) infarction.

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• The hospital performed better than the England averagein 11 out of 20 parameters of the national diabetesinpatient audit. Some areas in particular performedsignificantly better than the England average. Forexample, patients visited by a specialist diabetes teamachieved 96.7% versus the England average of 34.7%.Poorer performing areas related to staff knowledge andthe timing and suitability of meals. The hospital’sendoscopy service held accreditation through the JointAdvisory Group (JAG) for gastrointestinal endoscopy.This accreditation was achieved because the hospitaldemonstrated a range of standards including, quality,effectiveness and safety.

Competent staff

• The appraisal of doctors and consultants within thedirectorate was 84% and the remaining appraisals wereunder review. Appraisals for non-medical staff within thewider medical directorate was 52%. We did not receivedata for this group which was specific to adult inpatientmedicine which is the focus of this report. In April 2014the trust introduced a new electronic appraisal systemfor non-medical staffing. The trust informed us thatduring the transition to this system it experienced someissues with non-medical staffing data.

• The trust did not have adequate arrangements in placeto support and manage nursing staff through appraisals.Nursing staff we spoke with who had received anappraisal during the year spoke highly of the process.However, the trust reported that only 40% of its nursingstaff had received an appraisal in the last twelvemonths.

• The medical directorate did not include bank staff in itsappraisal system as it classed them as temporaryworkers, not employees. As such, they only received anannual review

• The majority of nursing staff we spoke with felt they hadreceived sufficient training to perform their role and thatthey were able to access further role specific training ifrequired. For example, a nurse on the stroke ward wespoke with received role specific training relating tonaso-gastric tube insertion and swallow assessmentcompetencies, and was given permission to attendfurther training.

• On one evening during the inspection two members ofagency staff were allocated to a night shift on the acutemedical unit. Staff told us they lacked some commoncompetencies that made them less able to support staff

in the management of patients on the ward. Forexample, they lacked skills in venepuncture andcannulation. These are essential procedures to aid themonitoring and diagnosis of a patient’s condition andare one of the most common procedures in hospitals.

• The coronary care ward, Tisbury, reported in November2015 it experienced difficulties in the recruitment ofexperienced nursing staff. However, training was put inplace for the 12 band five nurses which includedcardiology specific education. Management ensured asenior nurse was rostered on the ward at all times fornewer nurses to go to if they needed support.

• Some staff informed us the trust had provided themwith opportunities for further development. Forexample, one member of staff explained how theysecured funding for university accredited trainingthrough an application to the trust with the support ofward management. A number of nurses we spoke withhad accessed further training specific to their role, suchas intravenous cannulation. They felt they couldapproach seniors for further training if needed.

• Nursing staff recruited from overseas felt supported bytheir colleagues. Some of these nurses were also newlyqualified and told us more experienced nurses, nursingassistants and medical staff on the wards supportedthem to become competent quickly. After an inductionprogramme, overseas nurses worked as supernumerarystaff for six to eight weeks and longer if needed.

• Staff knowledge was identified as a concern within thenational diabetes audit. We spoke with staff on the wardwho informed us that there was only one diabetesspecialist nurse, leaving a gap in the service when noton duty and little resilience in the service.

• Some nursing assistants we spoke with told us they hada higher level of skills than their grading and feltfrustrated they were unable to employ these skills andwork at a higher grade.

• Trainee doctors told us they felt supported by moresenior peers and were provided with opportunities tolearn from them.


• We saw evidence of good multidisciplinary workingbetween wards and departments in the hospital. Allnecessary staff from a variety of teams were involved inassessing, planning and delivering people’s care andtreatment.

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• A broad spectrum of staff on AMU worked together tocoordinate the patients onward care in the hospital andfor their discharge. These included consultants, doctors,nurses, pharmacists, nursing assistants,physiotherapists, occupational therapists, socialworkers, the access to care team, administrators anddomestic staff. Daily board rounds took place wheredetails of patients admitted were displayed on a boardand a multidisciplinary team discussed and coordinatedtheir care collectively.

• Staff worked together to assess and plan ongoing carewhen people were due to move between teams andservices. A discharge coordinator worked on every wardand we observed multidisciplinary team meetings andsaw actions taken which worked towards the patients’discharge. For example, staff coordinated tests andassessments, the care delivered to patients andorganised medications with pharmacists to ensurepatients were ready to go home.

• Patients told us that they felt their care was wellcoordinated in the hospital. Staff worked well tocoordinate care between internal departments andoffered timely access to services such as physiotherapyand occupational therapists. Therapy staff coordinatedonward care for patients by liaising with carers, familiesand community therapy staff to assess the patient’senvironment at home. Therapists carried out homevisits if needed to make an assessment of the patientshome environment. This made it less likely the patientwould be readmitted.

• Physiotherapists and occupational therapistscoordinated therapy support across all wards within themedicine directorate. They met in the mornings todiscuss and prioritise their patient caseload and todistribute work accordingly.

• Staff on Tisbury ward raised a concern that the numberof patients with a tracheostomy on the ward sometimesincreased. Staff accessed support by contacting thedirectorate senior nurses or the critical care outreachteam when needed.

• Therapy staff worked closely with elderly care wards,dementia leads on the wards and attended weeklymultidisciplinary team meetings.

• The diabetes team admitted patients with diabetic footproblems as their primary reason for admission to amedical ward, but worked closely with the foot team to

ensure they were seen as part of their weekly wardround or when required. This team included a surgeon,podiatrist and microbiologist, with input from orthoticswhere needed.

• The provider had a close working relationship with anumber of hospitals and community hospitals within a20 mile radius. For example, a consultant told us how hehad taken a patient to the emergency departmentbecause they had developed chest pain whilst undertheir care. The patient was transferred to Southamptonhospital that evening due to the rapid review andtransfer process within the hospital.

• The trust worked with its community partners wherepossible to enable early supported discharge. Forexample, some stroke patients were discharged earlieras staff coordinated care within the community forrehabilitation to continue at the patients’ home, so theyspent less time in hospital.

• Durrington ward was established as rapid access care ofthe elderly ward which aimed to treat and dischargepatients within five days. The ward admitted patientsfrom the acute medical unit (AMU), the short stayemergency unit, and occasionally directly from clinic.The ward aimed to offer an immediate, comprehensive,geriatric assessment through a daily multidisciplinaryteam meeting structure, and by working withcommunity and social work in-reach teams. Cliniciansused an ‘access to care’ screening tool to coordinatecare with different services within the locality.

• Cardiologists had regular multidisciplinary teammeetings and linked with Southampton hospital todiscuss patient cases and shared learning by linkingpresentations screens via the internet.

Seven-day services

• In December 2014 the trust held a review of its sevenday services in which clinical assessment by a suitableconsultant within 14 hours, seven days a week wasconsidered a priority. The trust was in the process ofimplementing a range of innovations to assess andmonitor this and in order to make effective changes.Plans for seven day working were on going at the time ofour inspection.

• Patients in the hospital had access to a number ofdiagnostic services, some of which were accessedthrough arrangements with neighbouring hospitals.

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• The trust worked with Royal Bournemouth andChristchurch Hospitals, to provide on call rotas in strokeand vascular services. Arrangements were also in placeto provide joint care for some patients who requiredinterventional cardiology.

• The Stroke Network ensured 24 hour seven day coverwith emergency transient ischaemic attacks (TIA) clinicsrunning every weekend, with one in three being atSalisbury District Hospital and the others at RoyalBournemouth and Christchurch Hospital and PooleHospital. Arrangements were also in place to providejoint care for some patients who required interventionalcardiology. Stroke consultants carried out ward roundsat 9am and 5pm Monday to Friday within the hospitaland a general physician was available out of hours. Thetrust was trying to recruit a third consultant at the timeof the inspection.

• The hospital provided a service for percutaneouscoronary intervention (PCi) during Monday to Fridayfrom 8am to 5pm. This is a non-surgical procedure usedfor treating the narrowing of the arteries of the heartfound in heart disease. Outside of these times, out ofhours care took patients to either Bournemouth orSouthampton hospitals.

• The pharmacy provision was from 9am to 5pm on theacute medical unit, 9am to 12pm on Saturday and therewas access to some medicines on a Sunday. Pharmacytechnicians had laminated a specific out of hour’sprotocol for nurses to use for dispensing medication.

• Pathology, blood and diagnostic services such as X-rayand computerised tomography (CT) scans wereavailable over seven days.

• A mental health liaison team saw patients between 9amand 5pm, seven days a week.

• The trust employed one diabetic specialist nurse whoworked across the wards. This left a gap in the service atweekends, but the directorate organised coverduring annual leave.

• Therapy services were available over seven days to thegeneral inpatient areas Monday to Friday and from08.45-12.30 on a Saturday and Sunday. Therapy servicesensured an overnight rota for respiratory physiotherapywas in place. This meant that patients with respiratoryproblems were supported during the night and could becared for on the ward, rather than being moved to thecritical care unit.


• All the information needed to deliver effective care andtreatment was available to relevant staff in a timely andaccessible way. Patient records were accessible to staffand were generally well managed. Records were paperbased and were either archived when they were not inuse, kept with the consultant, in the clinical area or inlocked trolleys. A ward clerk confirmed 75% of notesarrived with the patient on entering the ward or werereceived within 24 hours.

• Access to patients’ diagnostic and screening tests wasgood. Staff in the acute medical unit reported bloodresults were available within one and a quarter hoursand chest X-ray reports within one hour.

• GPs could talk to consultants on AMU directly via adedicated phone line giving them direct access toinformation about their patients.

• The hospital’s intranet site ICID: Integrated ClinicalInformation Database had a wide range of informationaccessible to staff and the public. Policies, documentsand clinical guidance were accessed through the searchfunction.


• The hospital policy outlined the reason, legal frameworkand processes for gaining a patient’s consent to careand assessing a patient’s mental capacity whereappropriate. Staff filled in a specific form for use withpatients who did not have mental capacity. It identifiedhow the clinician had come to the decision and whereother parties, such as close relatives and carers wereinvolved in making decisions in the patient’s bestinterests.

• Data provided to us by the trust, which included somestaff outside of medical services showed 68% staffcompleted mental capacity training and 86% of staffwere trained in safeguarding adults.

• Staff had a good understanding of Deprivation of LibertySafeguards (DoLS). Guidance on the trust’s internetprovided clear steps for the decision making process tofollow when considering a DoLS application and we sawthis implemented well. For example, on Winterslowward staff carried out DoLS assesments for threepatients, two of whom required a DoLS. These werecompleted appropriately however, both had expired.

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• The trust commented in a recent report that very fewDoLS applications had led to a “Best Interests” meetingand as a result, this was followed up by hospital staffvisiting the local authority to discuss.

• We observed and patients told us staff attending to theirhealthcare needs sought verbal consent before aprocedure or treatment.

Are medical care services caring?

Good –––

Caring for patients in the medical services was rated asgood. Feedback from patients about the care theyreceived at Salisbury hospital was positive. Staff treatedpatients with dignity, kindness and respect. We heard callbells being answered quickly and call bell audits reflectedthis.

Staff were updated on a regular basis with patientfeedback about their experience of care and treatment atthe hospital and we saw evidence of staff learning fromthis to improve care.

Staff engaged with families and carers about the patients’care and treatment in the hospital and in managing theirdischarge and ongoing care.

Patients felt involved and informed in decisions madeabout their care. Their choices and preferences weretaken into account when staff planned their care andtreatment. Staff communicated effectively with patients,in a way they could understand.

Compassionate care

• Staff on medical wards treated patients with kindness,dignity and respect. Patients told us they received agood standard of medical care and had the opportunityto discuss their care with their doctor or consultantregularly.

• Staff treated patients in a manner that maintained theirdignity. On most occasions, we saw staff ensuringcurtains were drawn when carrying out personal care.However, on one occasion, we saw staff removing acannula in front of visitors at the patient’s bedside.

• We heard staff seeking permission as to how the patientpreferred to be addressed and staff spoke in a kind andrespectful manner.

• In the patient led assessments of the care environment(PLACE) 2015, the hospital scored 89.5% for privacy,dignity and wellbeing. The England average score was86%.

• The trust collected its own feedback called ‘real timefeedback’ by talking to inpatients across all wards on amonthly basis. Some areas of concern in 2015 includedcall bells not being answered. During the inspection,staff answered call bells promptly and we observed callbells were within patients’ reach. An audit of call bellresponse times across three days in October 2015showed that on average staff answered over 70% of callbells in less than four minutes.

• Real time feedback showed patients felt they weretreated with care and compassion. Patients gave this anaverage score of just under ten out of ten.

• The medical directorate used the Friends and Familytest to seek feedback about the patients’ experience inthe hospital. Data was provided from individual wards.The average response rate in England between July2014 and June 2015 was 34.5% and for the trust was34.4%. The response rate varied between wards for theperiod of time between August 2015 to October 2015with between 12% and 44% of patients responding. Thehighest patient response came from Redlynch ward inOctober and the lowest response rate was from Farleyward in the same month. Patient satisfaction variedfrom month to month and ward to ward but wasgenerally at a high level. The acute medical unitconsistently had slightly lower scores, but were stillpositive.

• Staff received friends and family test feedback everycouple of weeks by email in order to learn from patients’feedback.

• On some wards, staff displayed comments of thanksfrom patients which talked about the care they hadreceived and the kindness of the staff on the wards.Patients we spoke with were also complimentary aboutthe nursing and nursing assistant staff in particular,saying that nothing was too much trouble and they hadbeen well looked after during their stay. We saw anumber of compliments which had been sent bypatients to the customer care team. These examplestalked about the care and compassion patientsexperienced directly or was observed by carers andrelatives of patients treated in the hospital.

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• A patient we spoke with commented positively aboutthe friendliness of staff: “If you asked for something, itwas done straight away”.

• We saw staff rubbing hand cream into patients’ hands,applying makeup to patients who valued this and heardthem talk affectionately about patients within their care.

• During the inspection a relative on a ward whose fatherhad just passed away, approached us to tell us aboutthe care they had received. They said, “The care andsupport staff gave us was excellent and we could nothave wished for more”.

Understanding and involvement of patients andthose close to them

• We heard staff communicating with patients andrelatives with respect and in a way they couldunderstand.

• Handovers at the patients’ bedside kept the patientinvolved in the discussions about their care andrelatives and visitors were included in these discussionswhere appropriate. During the inspection, we saw staffexplaining treatment to both patients and visitors.Relatives told us they had the opportunity to askquestions and raise concerns about the patient’s care ifthey needed. They told us they could phone the wardand speak to someone about the patient if needed,especially if they were worried or anxious.

• Patients and their relatives informed us staff discussedthe patients’ needs, care and treatment with them. Staffconsulted with families and carers to understand theonward care needs of the patient once they weredischarged.

• Staff recognised where people who used the serviceneeded additional help and support in order to involvethem in the decisions about their care and treatment.For example, staff supported a patient who had justbeen admitted and who was unable to communicateverbally, by helping the patient to use a pen and paper.They liaised with the patient’s family so they could bringin appropriate communication aids that the patient wasfamiliar with.

Emotional support

• The hospice at the hospital had a pet as therapy PATdog and patients on medical wards had access tosupport from this service. PAT dogs can help patientsfeel calm, happy and bring joy to patients being caredfor in hospital. Staff reported patients who were unable

to communicate easily really benefitted from theresident pat dog. For example, a patient who hadsuffered a stroke and was distressed became visiblycalmer after spending time with the pat dog.

• The hospital on occasion allowed patients’ pets to comeinto the hospital which staff reported was of greatbenefit to patients’ emotional wellbeing.

• Qualified volunteers provided complimentary therapiesto patients such as aromatherapy, reflexology, massageand Indian head massage to help patients relax, sleepbetter, and feel better at a difficult time.

• An ecumenical chaplaincy team was available duringworking hours and on call 24 hours a day throughoutthe year. The chapel was open to people of all faiths ornone and regular services were advertised on noticeboards throughout the trust. Visits from the chaplainwere arranged for patients and visitors on the wards.

Are medical care services responsive?


We found medical services required improvement.

The limited bed capacity, particularly in the acutemedical unit, along with recent high bed occupancylevels affected the hospital’s patient flow. Some mattersoutside of the hospital's control also affect this, such thelack of availability of care in the community. The processfor discharging patients was not always managedeffectively within the directorate. This meant the hospitalwas not always able to deliver same sex accommodation,although an action plan was developed in August 2015which aimed to address this. Medical patients wereregularly cared for on surgical wards, but with processesin place to ensure their safe care. Some patientswere moved during their stay, of which some were movedat night.

The hospital provided a suitable environment and a goodlevel of care for patients living with dementia.

Staff were familiar with the complaints process and knewhow to escalate a patient or relatives concern.Complaints and concerns were responded toappropriately by the trust and staff received learning andfeedback from complaints.

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On the whole, referral to treatment times were above theEngland average which meant patients accessed careand treatment in a timely way.


• The acute medical unit (AMU) also known asWhiteparish ward provided rapid assessment,investigation, diagnosis, and treatment for adultpatients over the age of 16. GPs had a dedicated phonenumber for AMU, and consultants liaised with GPs priorto the patient being admitted. Patients received careand examinations in a private trolley area and thenreturned to a seated area if well enough to do so. Aconsultant decided if patients went home or admittedthem to the hospital for further care and treatment. Amultidisciplinary team operated within the departmentmade up of medical staff, nurses, pharmacists,physiotherapists, occupational therapists, domestic andclerical staff. The AMU, was open 24 hours all year round.Patients were clinically triaged using a set criteria. GP’sreferrals accounted for approximately 40% of patientswho attend the AMU, 40% arrived via the emergencydepartment and 20% from elsewhere in the community.There were 21 beds within the unit including threesingle rooms and four ambulatory care trolleys. The 18beds were divided between three bays.

• Each year an additional escalation ward was opened tomanage winter pressures, usually from January forseveral months. Staffing for this ward was organised wellin advance using staff from existing wards and theirpositions were backfilled. The medicine directorateused the opening of the ward in January 2015 as anopportunity to test ward-based medical teams and totrial a new ‘triage to speciality model’. This meant thatwards in the hospital became more specialised as staffcould develop specific skills to care for patients with thesame medical conditions who were grouped onto thesame wards. National Institute for Health and CareExcellence guidelines for a broad range of differentrespiratory conditions recommended patients are caredfor on a specialist respiratory ward. The clinical lead forrespiratory medicine reported in March 2015 that wardremodelling resulted in Pitton ward becoming aspecialist respiratory ward in January 2015. The numberof respiratory patients on the ward increased from 41%to 70%. The spread of respiratory patients acrossmultiple wards also reduced.

• The endoscopy service operated five days a week at thetime of the inspection. It began an ad-hoc ‘SuperSaturday’ model in September 2015 for endoscopicprocedures. This is a consultant led service and hadbeen run on one Saturday at the time of our inspection.A nurse rota for this was in place but staff told us therewas no consultant support. One super Saturday hadtaken place at the time of our inspection.

• In the July 2015 mortality working group minutes, aclinician raised concerns about the lack of formalgastrointestinal (GI) bleed rota and referred to a newrecommendation that patients with any acute GI bleedshould only be admitted to hospitals with round theclock access to endoscopy and interventional radiologyor a local network arrangement. The provider outlinedin this meeting, it needed to develop a networkarrangement for interventional radiology due to animminent vacancy and an inability to recruit for thepost. However, interventional radiology was available atthe time of our inspection.

Access and flow

• The bed management team (the team made up ofprofessionals involved in ward management, bank andagency staff management, infection control andhousekeeping) met two to three times a day to manageaccess and flow through the hospital. We attended fourof these meetings during the inspection. During the bedmanagement meetings, the team reviewed admissionsand discharge numbers, the current bed occupancyposition, the number of medical patients admitted tosurgical wards, mixed sex accommodation breachesand staffing or cleaning issues on the wards.

• Access and flow within the hospital was not alwaysmanaged effectively. At times, limited capacity affectedthe hospital’s flow and its ability to deliver same sexaccommodation. This resulted in unjustifiable breachesof mixed sex accommodation, according to the trust’spolicy for eliminating mixed sex accommodation.Furthermore, in order to improve flow through thehospital, patients were moved a number of times duringtheir stay, sometimes after 10pm at night. According tothe trust’s policy, ward moves after 10 pm at nightshould be exceptional. During a 4pm bed managementmeeting, staff flagged six patients as being ready tomove from AMU to a ward by 6pm that evening. Wefollowed the pathway of these patients and found thatstaff only moved one of these patients before 10pm, at

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8.35pm that evening. Staff moved the remaining fivepatients after 10pm, at 22.44pm, 23.00pm, 23.26pm,00.30pm and 03.07pm respectively. We attended thebed management meeting the following morning andfound that despite staff having ensured patients wereready to move by 6pm, there was no challenge betweenthe wards as to why this had not occurred.

• Bed moves affected over a fifth of patients at thehospital between September 2014 and August 2015.During March to July 2015 approximately 150 patientswere moved after 22:00 hours of which two thirds werefrom the acute medical unit. In the previous 12 monthsto September 2015, there were 979 mixed sex breaches,of which just over a fifth related to non-clinical breaches.A number of patients we spoke with said they hadexperienced a bed move and were sometimes moved atnight. Some patients had complained about the noiseat night within the hospital, relating some of this topatients being moved. Senior medical staff from AMUconfirmed that staff moved patients at night. Of the totalpatients admitted in the previous 12 months 16% hadone bed move, 5% had either two or three bed moves. Atotal of 12 patients had four or more bed moves.

• The average occupancy rate for all NHS beds openovernight was 85.7% in quarter two 2015, ending inSeptember. Research suggests that bed occupancy ratesgreater than 85% can increase the risk of harm includinghospital acquired infections and it can start to affect thequality of care provided to patients and the orderlyrunning of the hospital. During the period from June2015 to November 2015, the hospital’s bed occupancyrate was on average 96%. Senior staff confirmed thatbed occupancy was generally near 100%.

• Senior AMU staff expressed concerns relating to thelimited estate capacity. It was felt this made consistentdelivery of ambulatory emergency care and assessmentof new admissions difficult. AMU meeting minutesdocumented concerns relating to frequent delays whichhad the potential to cause both a clinical risk and acorporate risk, due to increased admissions and poorerflow. At the time of the inspection, senior leadershipstaff told us about the plans submitted in September2015, for a business case to relocate the AMU whichwould lead to an increase in assessment capacity. Adecision on this was not made by the time we inspectedthe hospital.

• In the medicine directorate’s October 2015 meetingminutes, it stated single sex accommodation was both a

challenge and a big concern for clinician’s in thedirectorate. NHS policies outline a clear commitment toprivacy and dignity, stating that same-sexaccommodation can dramatically improve how patientsfeel about their care. The hospital had a policy foreliminating mixed sex accommodation in which it madeclear its intention to avoid breaches. This document wasaligned to NHS policy.

• Feedback from the executive led safety and quality walkrounds to AMU in November 2015 raised concerns thatachieving single sex accommodation caused patients tobe cared for on wards other than their medical specialityneeds and could impact their treatment and length ofstay. When there was sufficient capacity within the trustand on AMU, the hospital reported that inappropriatemoves and mixed sex accommodation breaches did notoccur. The trust formulated an action plan to reducenon-clinically justifiable mixed-sex accommodationbreaches in August 2015. One of the actions that wasoverdue related to a business case submitted toredesign the patient bays within AMU. The deadline forthis was in September 2015 and a decision had not beenreached by the time of our inspection. In November2015 the trust reported only one non-clinical mixed sexaccommodation breach occurred, which was animprovement.

• Senior staff visited other acute medical units in differenthospitals to understand how to manage this issuebetter. The hospital had assured the ClinicalCommissioning Group (CCG) of its board and directorlevel engagement to resolve mixed-sex accommodationbreaches. However, the CCG in September 2015reported they were unable to gain assurance thatpatients would not be subjected to unjustifiablebreaches in mixed-sex accommodation until the actionplan was agreed. Senior leadership within thedirectorate stated flow was the main cause of single sexbreaches although a breach was a last resort.

• On one day of the inspection, there were eight medicaloutliers and 13 on the previous day. Senior staff in thedirectorate reported the highest number of outliers as30 in one day, within the last 12 months. All outlierswere risk assessed and patients with specialised needswere only treated on the speciality ward. Seniorleadership confirmed outlying patients happened onwards all year round. The discharge team visitedmedical outliers daily.

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• Durrington ward provided rapid access to care andtreatment for frail and elderly patients and aimed totreat and discharge patients within five days. Aconsultant from the ward felt that discharge could beimproved if they had better links with community teams.

• The process for discharging patients was not alwaysmanaged effectively within the division. Policy statedbeds must be declared to the clinical site teamimmediately once vacated and the discharge loungeused whenever possible to ensure that once a patientwas ready for discharge the bed can be made available.The discharge lounge was open from Monday to Fridayfrom 8.30am to 5pm. Patients who needed to use thetransport service to get home needed to allow a fourhour window from the time of booking. This meantpatients needed to be admitted to the discharge loungeby 1pm in order to meet this timescale. During ourinspection we heard numerous examples of issues withthe transport company which resulted in delays topatients being discharged and caused distress topatients waiting to leave the hospital. The trust reportedit had raised concerns about delays with patienttransport with the clinical commissioning group. Duringa bed management meeting we spoke with sisters incharge of wards who confirmed that there did not seemto be a deadline for discharges to be planned andactioned by and the discharge lounge was not beingeffectively utilised. Bed management staff confirmed itwas very likely that at the 4 pm bed meeting, patientswaiting to be transferred to a ward who were flagged inthe morning, would still be on the ward. There seemedto be limited urgency or accountability for this.

• Senior medical staff attributed the main cause of delaysto patients being discharged to the lack of care in thecommunity.

• Patients told us different teams within the hospitalarranged for them to be discharged effectively, with theright care package and equipment in place to be able toreturn home safely. One patient told us how they feltsafe in the hospital and would now feel safe at home.Staff had organised a new bed and hoist, and for carersto visit the patient once at home.

• Gastroenterology consultants confirmed waiting timesfor a range of gastroenterology and endoscopyprocedures fell well under the 18 week waiting time. Forexample, oesophago-gastro duodenoscopy the waitwas four weeks, flexible sigmoidoscopy was a two tothree week wait and colonoscopy was a six week wait.

• The hospital achieved a cancer referral two weekwaiting time RAG rating of green during 2014 to 2015and ensured it saw 94.7% of its patients within this timescale. Cancer waits at 31 and 62 days were met.

• The national operational standard for referral totreatment times states that 92% of admitted patientsshould commence consultant led treatment within 18weeks of referral. Data relating to October 2015 showed92.3% of NHS hospitals achieved this. The hospitalexceeded the threshold for gastroenterology (94.1%),Cardiology (97.3%), Geriatric medicine (98.5%), andrheumatology (99.5%). Data for neurology was notavailable.


• The customer care team provided access to trainedinterpreters to support communication with patientswho were non-English speakers or for people for whomEnglish was a second language. It provided services forsign language, the deaf, blind or partially sighted. Wardand departments booked appointments for patientsand staff could access a 24 hour telephone interpretingservice for emergency situations or short non-complexappointments.

• Some staff located information about the translationservice via the intranet, although not all staff werefamiliar with how to access the service.

• Staff told us that management sent out hospital-wideemails to seek immediate help from staff who couldspeak different languages and were therefore able tohelp patients for whom English was not their firstlanguage.

• We saw on a number of wards people who weredeemed as vulnerable, with complex needs had extrastaff looking after them. Patients were grouped withinthe same bay and received enhanced nursing care,sometimes on a one to one basis.

• To support patients with learning disabilities, staffconsulted with the next of kin or carer in order to meetthe needs of the patient and included them inhandovers or ward rounds where possible. Staffexplained their aim was to mimic the care the patientwould receive in their home setting.

• On Pitton ward, we saw an easy read, learning disabilitypassport in use. This was a traffic light based document,which captures important information about the patientsuch as their likes and dislikes, health status,medication and captures the family or carers input.

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• There was no specific learning disability team at thehospital but for planned care, policy stated staff liaisedwith the community team for people with learningdisabilities or ‘Key Worker’ in the community to helpwith assessments and care planning. The Director ofNursing was the executive lead for services for patientswith a learning disability.

• A senior directorate manager informed us that staffflagged patients with a learning disability whilst in AMUbut no specific actions were taken. During daily safetybriefings on wards, staff alerted colleagues to anypatients with a learning disability so they could managetheir care accordingly.

• The medical wards provided a suitable environmentand a good level of care for patients living withdementia and received the Dementia Charter in 2013.

• Several medical wards at the hospital had undergonechanges to make them dementia friendly. On Pittonward, each bay was painted in a different pastel shadewith the entrance-facing wall a darker shade so patientscould easily distinguish between different areas. Allbathroom doors were painted blue and had blue handrails in the toilets or on toilet door frames so they wereeasy to distinguish. Flooring was non-slip andnon-reflective and did not present a trip hazard topatients living with dementia. There were areas ofdifferent coloured ceiling lighting with changing coloursto change the mood. There was good signage on doorsat appropriate heights.

• The ‘John’s campaign’ enabled carers of people livingwith dementia to stay with their relative round the clockand this permitted them to help care for the patient.

• Volunteers along with specialist staff ran a carers cafétwice per month. Carers with relatives or friends inhospital shared experiences and got support and advicefrom trained staff from the Alzheimer’s society, Age UKand Care Support Wiltshire. A geriatric medicineconsultant and psychiatric liaison nurse conducted adementia specific ward round. The hospital haddementia champions on each ward.

• Staff reported that the use of the ‘this is me’ documentworked well. This is a document which informs the careras to how best to communicate with the patient, theircare needs and personal preferences. The hospital hadtrained dementia champions and a consultant and amental health liaison nurse ward round took placeweekly.

• Staff served food using blue plates for patients livingwith dementia, the elderly or those patients at risk ofmalnutrition. The contrast in colour was particularlyhelpful because it made food look more appetising andhas proven to increase food consumption during testsconducted on a number of wards within the hospital.Red trays were used to identify patients who neededextra help and support with eating.

• Staff offered relatives meals to encourage patients to eatsocially.

• Food being served to patients looked appetising, andpatients told us that food on the whole was of anacceptable standard and nutritious. Patients felt thefinger food, which was often presented to patients withdexterity issues was well presented and there was agood variety and choice.

• We saw staff encouraged patients to eat and drink andoffered help where needed. Patients told us staffencouraged them to drink in order to keep hydrated.The majority of patients we visited had a drink withintheir reach.

• Volunteers supported patients to eat and drink meals.Occupational therapy staff enabled patients to becomeincreasingly independent with eating and drinkingthrough mental and physical encouragement.Therapists also undertook assessments on some wardswhich had a kitchen installed where they assessed thepatients’ ability to cater for themselves and theirreadiness to cope at home.

• The hospital collected ‘real time feedback’ frompatients. This was an initiative where staff spoke withpatients and collected feedback about their experienceof the hospital. It published monthly updates anddiscussed learning with its staff. Whilst there was amixture of positive and negative comments, on average,food scored 9.8 out of 10.

• The ‘engage programme’ was a scheme staffed byvolunteers to support the psychological wellbeing ofolder adults to alleviate distress and prevent depressionand anxiety. It was available on all wards. Patientsenjoyed singing, music, dance and storytelling to helpkeep their minds active. A programme called ‘Elevate’delivered creative arts activities and workshops on thewards. These services were aimed at keeping patients’mood positive, and acted as a distraction to hospitallife.

• As part of the Engage programme, we saw a 1950’s styletea party on one ward. Volunteers dressed up and

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served tea to patients, and there were musicianspresent. The event took place at visiting time, which wewere told is usual for such events. Patients clearlyenjoyed the experience and we were informed the trustreceived positive feedback for this initiative.

• ArtCare provided art activities to patients where theycould participate in different activities or view artworkdisplayed in the hospital. Two walking routes passed bya range of artwork around the hospital site. The indoorand outdoor routes were accessed by staff and patients.A representative from the service carried out one-to-oneand group Artcare sessions weekly.

• Senior managers supported a social enterprise websitewhich provided information to the families and friendsof patients in hospital. Authorised staff and memberscould post updates to the site and messages could besent and received between patients and carers.


• Some patients we spoke with told us they knew how tomake a complaint should they wish to do so.Information on how to make a complaint was found onwards, which included details about the process formaking a complaint, how it would be handled and whatwould happen if they were not satisfied with theresponse. It informed the patient about their rights andwas available in different languages and formats.

• A Customer Care Team was accessible to patients andvisitors on level two of the hospital to deal withconcerns and complaints.

• Staff were familiar with the complaints process. Staffknew how to escalate a patient or relatives concern butnot all staff had experienced the need to raise acomplaint.

• The majority of complaints within the medicinedirectorate related to communication and in particularto medical staff. As a result, the trust documented that itwould share anonymised complaints with consultantsto identify themes and learning.

• Displays outside of each ward within the medicinedirectorate highlighted patient complaints andcompliments. Wards displayed both negativecomments, such as “the ward was noisy and chaotic”, aswell as positive ones, “Extremely well looked after”. Thisshowed an openness and transparency.

• The hospital reported a reduced number of complaintsfor July to September 2015 and time to resolvecomplaints in under 25 days significantly improved.

• The trust handled complaints effectively andconfidentially and provided regular and timely updatesfor the complainant. The medical directorate arrangedmeetings with complainants as a first response to theircomplaint, particularly if it was complex or involvedbereavement. The aim of this was to resolve thecomplaint in one attempt, rather than responding andthen having the complaint reopened. On occasions, the25 working day target was breached when trying toarrange a resolution meeting due to the availability ofrelevant staff members and the complainant. However,the complainant was kept informed of the timescales.

• The provider sometimes reopened some complaints ifcomplainants felt their questions were not answered.Senior staff arranged face-to-face meetings withcomplainants to discuss their unresolved concernswhere appropriate.

• Senior medical directorate management shared anexample of how they dealt sensitively with a bereavedrelative following the unavoidable death of a patient.

Are medical care services well-led?

Good –––

We rated medical services as well led. The leadership,governance and culture promoted the delivery of highquality care. There was a clear set of values driven byquality and safety and staff were familiar with these.

There was a clear governance structure within thedirectorate. Governance, quality measurement and riskmanagement featured regularly in a wide variety ofmeetings throughout the service.

The trust engaged its patients and visitors in regularfeedback in order to improve the patients’ experience inthe hospital. Staff were committed to delivering a highquality of patient care.

Staff were familiar with the hospital senior leadershipteam and told us senior leaders were approachable. Staffspoke highly of their managers and felt their views andconcerns were listened to and acted upon. The staffsurvey showed staff recommended the hospital as aplace to work.


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• Staff we spoke with understood the trust’s values ofpatient centred and safe care, professional, responsiveand friendly. The values were developed with staffthrough consultation and focus groups in 2014, andwere displayed around the hospital areas we visited.

• Senior staff did not communicate to us a clinical servicestrategy or vision for the future of the service, other thanthose plans linked to a single sex accommodationaction plan, activities to improve patient flow and newmodels of patient care. The new models of careincluded changes to the elderly care model and theplans to relocate the acute medical unit to level 2 toprovide a co-location with the rapid access care of theelderly ward Durrington. There was also a focus onimproving the discharge process in collaboration withcommunity providers. These were schemes that thetrust reported would enable earlier discharge from thehospital and support improvements in patient flow.

• Workforce priorities included recruitment anddevelopment of the medicine service. Staff were awareof the recruitment strategy that was ongoing in thehospital and senior leaders communicated a policy forrecruitment and retention which included furtherrecruitment of oversees staff.


• The trust had an effective governance framework whichsupported the delivery of good care. The trust heldregular clinical governance half day meetings wherepart of the meeting was departmental governance andthe other part was for the clinical specialities. Eachspeciality held monthly business meetings and clinicalgovernance and quality was a standing agenda item. Forexample, the cardiology division governance group gavean overview of their services and covered a range oftopics including updates and presentations, research,patient safety and mortality and morbidity. It conductedseparate mortality and morbidity reviews at twomonthly intervals.

• Governance within the medical directorate followed thestructure outlined by the trust. All staff reported to thedirectorate management through ward and departmentleads. Medical directorate management met weekly andgovernance was a standing agenda item for allmeetings. At this level, information was fed up to the

trusts governance structure on a monthly basis. Staffcould report directly to the directorate managementteam if they were not happy with the response theyreceived from ward leads.

• There were arrangements in place for identifying,recording and managing risks, issues and actions tomitigate these. The medicine directorates risk registerwas reviewed regularly and high risks items whichscored 12 or above were monitored through quarterlyquality performance meetings. Monitoring of this wasdocumented with the minutes and the trust risk registerupdated.

• The medical directorate conducted ‘stocktake’ meetingsthree monthly, which covered all specialities andactions were documented and reviewed.

• Lead clinicians within the medical directorate met everymonth except for August and December. This processwas established to ensure clinicians across thespecialities shared learning from their fields, inparticular from mortality and morbidity reviews.

• The acute medical unit held monthly risk meetings thatincluded input from a senior consultant, a senior sisterand a representative from the risk management team.

• Senior leaders within the organisation visited wards aspart of the ‘executive led quality and safety walk rounds’.It grouped feedback to individual wards under theheadings of safe, effective, caring, responsive and wellled. This provided an overview of some of the key areasof concern or strength and progress against issueshighlighted for improvement.

• Senior therapy staff felt information flowed up anddown through the governance structure easily. Quarterlygovernance meetings changed to accommodate thehospital’s spinal unit.

• Staff were relatively aware of the risks that were on therisk register at a divisional level and those risksidentified on the ward were verified by the divisional riskregisters.

• Senior staff within the directorate articulated a clearplan to address the top risks within the directorate, andthese were evident within the strategy and workforcepriorities. On the whole, items on the risk register werealigned with what staff told us was on their worry list.

• Mixed sex accommodation breaches appeared on themedical services risk register, for which an action planwas attributed. However, non-clinical bed moves didnot appear on the risk register, despite theacknowledgement by senior staff that this occurred.

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This issue was attributed to flow issues within thehospital in general due to the limited estate capacity. Aplan to address limited estate capacity had beensubmitted at the time of the inspection and wasawaiting a decision.

• There was a systematic programme of clinical audit,which was used to monitor quality. The auditprogramme looked at local and national audits for themedical division. Each audit had a named lead person,showed whether the trust was compliant with thehospital’s policies, local and national guidelines, a datefor completion and whether an action plan was signedoff.


• The medicine directorate was divided into specialitiesand included the acute medical unit, the emergencydepartment and palliative care, all of which were led bya directorate managers, clinical director and a seniornurse. Directorate leadership met with senior staff onthe wards regularly to discuss care, safety and staffing.

• The directorate senior nurses visited each ward everymorning Monday to Friday to discuss incidents,concerns, staffing discharge and flow. A senior bandseven nurse performed this role at the weekend andprovided a report to the directorate senior nurses, sothey felt assured they had a good oversight of care onthe wards at all times.

• We reviewed departmental and medical specialitymeeting minutes and the senior directorate nurseinformed us of a number of meetings that took place ona regular basis that ensured learning and informationwas shared effectively within the directorate. Forexample, senior band seven nurses met on a monthlybasis with the senior directorate nursing team to discussa wide range of quality and safety measures. Thisincluded, all safety incidents, dementia care, falls,infection control, and grade two or above pressure ulcercluster reviews with root cause analyses. The wardsister, supported by the directorate senior nursesconducted a root cause analysis for every fall resultingin fracture or significant harm. Together with a memberof the risk management team, they presented thefindings to the Chief Executive. This demonstrated agood flow of information and learning within thedirectorate, from board to ward.

• Staff told us the chief executive and the seniorleadership team were visible in the hospital and theywere offered a range of opportunities to speak withthem to discuss ideas for improving the service or toraise any worries they had.

• Staff were able to raise concerns in line with the Trust’sWhistleblowing Policy. This policy enabled staff to raiseconcerns about misconduct or wrongdoing at work in away which protected their interests, and which ensuredconcerns were investigated properly.


• Staff within the hospital spoke highly of the culturewithin the organisation and felt respected and valued.Nursing staff on the acute medical unit felt there was aculture of openness where they were supported by staffof all seniority. One nurse commented that allconsultants were approachable and interacted well withall levels of staff. Other staff concurred they would feelable to question or challenge all levels of seniority ifthey had a concern about that person or their actions.

• Trainee doctors told us they were attracted to thehospital as it had a reputation for being friendly andsupportive. They felt encouraged by senior staff whowere open and approachable, which enabled theirlearning. One trainee doctor told us that senior staffsought them out when they first arrived on the ward andalways got involved if they had concerns or if issuesarose.

• Many staff across a wide variety of roles and gradesspoke of the familial culture within the hospital. Somestaff had worked within the trust for many years andother said how they travelled past a hospital that wasmore local to them, in order to work at Salisburyhospital.

• Nurses recruited from overseas from a number ofdifferent countries could not speak highly enough abouttheir experience in working for Salisbury hospital. Theyfelt well supported to carry out their role and were ableto request further training or remain as supernumeraryfollowing their induction programme, if they felt theyneeded more support. They told us that colleagues ofall seniority were willing to help and support them withtheir learning for the role and with other concernsrelating English being a second language for them.

• Staff spoke highly about their managers and we sawsenior medical staff interact positively with therapists,nursing staff, nursing assistants and auxiliary staff.

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• There was a culture which centred on the needs andexperience of patients using the hospital and this wasreflected in staff’s behaviour and through the trustsvalues.

Public engagement

• In the national inpatient survey, patients rated their carewell and they felt that they were treated with respectand dignity. Areas of concern such as noise at night waswell documented within the directorate’s meetingminutes and action plans were in place to address this.

• There was a willingness within the trust to engage withpatients and visitors demonstrated through the realtime feedback initiative which was carried out on amonthly basis. The person conducting the interviewsfed back to the wards immediately and followed this upwith emails to the relevant areas and their managers.The trust analysed and distributed quantitative data torelevant areas the following month. This gave patientsand their carers an opportunity to address any issues orconcerns there and then, as well as the opportunity todiscuss positive aspects of their experience within thehospital.

Staff engagement

• We saw evidence of internal staff engagement via a staffsurvey and an action plan was in place to address issuesarising from the staff survey. The top five ranking areaswere: staff motivation at work, job satisfaction, supportfrom immediate managers, recommending the trust asa place to work, and the percentage of staff reportingerrors, near misses or incidents witnessed.

• The trust issued weekly newsletters and sent out anemail broadcast to pass information and messages fromthe senior leadership team.

• Staff within the endoscopy unit ran an initiative called‘rate your room’ where nurses and endoscopists ratedtheir service, collated comments and published aquarterly report based on their opinions of how theservice ran on a daily basis. It included positivecomments, areas for improvement and actions to be

taken as a result. Comments related to the flow of theservice, equipment issues, team working and both thepositive or negative attitude of some staff which theteam felt needed to be recognised and addressed.

• There was a good level of interaction between staff andthe board and we heard a number of examples of howward staff had interacted with the board to presentideas and proposals.

• Cardiologists had good access and input to the board,which they said worked very well. For example, theboard accepted seven business cases in recent yearsand was considering two others. They felt proud of theirservice and that there was a good level of interactionbetween medical specialities.


• Salisbury hospital were one of 22 trusts nationally whotook part in the Lord Carter staffing acuity work. Seniorleaders working on the project told us staff on wards willsoon begin using hand held computers to input staffingdata, patient acuity and dependency, and are pilotingthis on five wards. This project aimed to ensure staffinglevels and skill mix were appropriate, safe andsustainable for the future.

• A number of developments within the medical servicesthat will affect the bed base model were underway.Senior leadership informed us the plan to relocate theacute medical unit to level 2 in the hospital, on Farleyand Nunton ward areas, would enable the expansion ofthe AMU footprint. The directorate submitted a capitalbid in September 2015. They report this will “improvethe efficiency of ambulatory care and maximise theeffectiveness of Salisbury hospital’s ‘front door’”. Incombination with the ongoing ‘referral to specialitymodel’, it is predicted that this will enable the hospitalto better manage the rising demand in non-electivepressure, both now and in the future.

• Therapy staff created a poster with rehabilitationobjectives, which they presented at a quarterlygovernance meeting. Other areas of the hospital such asthe stroke ward were considering a way of developingthe tool to support stroke patients.

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Information about the serviceSalisbury District Hospital provides a range of surgery andassociated services and is the regional centre for specialistburns and plastic surgery. Within the hospital, the surgeryteams were either part of the musculo-skeletal directorate,or the surgery directorate. These directorates included anumber of services written about elsewhere in this reportand some data, such as training for example, refers to thewhole directorate.

The hospital had a main operating theatre unit with eightoperating theatres and an 11-bed recovery area (inpatientsurgery). There was a day-case surgery unit with sixoperating theatres, recovery areas, and two wards forpatients to stay while they were assessed before goinghome. The Burns Centre also had a dedicated operatingtheatre and recovery area for burns and plastic surgery.

Surgery performed included urology, trauma andorthopaedic, spinal surgery, general surgery, breast,colorectal, vascular, ophthalmology, oral, Maxillofacial, ear,nose and throat, burns and plastic surgery. Surgery wasprovided as both elective (planned) and in an emergency.The hospital also carried out interventional radiology: aprocess of using minimally invasive image-guidedprocedures to diagnose and treat diseases.

The hospital had six surgery wards. Amesbury Suite, a32-bed ward for patients predominantly having planned orelective orthopaedic or trauma surgery; Britford ward, a23-bed ward for patients having general surgery; ChilmarkSuite, a 24-bed ward for patients having trauma ororthopaedic surgery; Downton ward, a 27-bed ward for

short stay patients undergoing general surgery. Laverstockward was the 26-bed ward for patients having specialistplastic surgery and the Burns Centre was the 17-bedspecialist burns unit. Clarendon was the trust’s four-bedsurgical unit for privately-funded patients.

Surgery services also ran a weekday pre-operativeassessment unit; a surgical admissions lounge within theoperating theatre suite; and a seven-day surgicalassessment unit currently located temporarily withinWilton ward while the usual unit on Britford ward was beingupdated and refurbished. This was used for patientscoming through the emergency department or admittedvia their GP to be assessed for potential surgery. Otherservices included a hospital sterilisation anddecontamination service.

On this inspection we visited the surgery services onWednesday 2, Thursday 3 and Friday 4 December 2015 andmade an unannounced visit for the day on Sunday 13October 2015. We met with patients and their relatives andfriends. We visited all the surgery wards, the regional burnsand plastic surgery centres, main theatres including therecovery area, the pre-operative assessment department,surgical admission lounge, the day surgery unit, surgicalassessment unit, and hospital sterilisation anddecontamination services. We spoke with staff, includingnurses, practitioners, and nursing assistants, the maintheatres and day-case unit managers, and the recoveryteam. We met the senior management teams for thesurgery and musculo-skeletal directorates, senior ward

Surgery

Surgery


staff, consultants, senior doctors, and junior doctors. Wealso talked with pharmacy staff, housekeeping staff, andphysiotherapists. We observed care and looked at recordsand data.

Salisbury District Hospital carried out around 23,000operations in 2014. Of these, 52% were carried out asday-case procedures, 21% as inpatient elective (planned)cases, and 27% as inpatient emergency cases.

Summary of findingsWe have judged surgery services overall as requiringimprovement.

As the hospital recognised, nursing andoperating-department practitioner staffing levels werenot always at established or recommended levelssafe.In some wards the established levels of nursing careprovided at night were not following recommendedguidance and unsafe. There were shifts not fully coveredbyu nursing and healthcare staff on all wards, despitehigh use of agency staff. Patients praised the care but anumber felt reluctant to call for support due to aperception of nurses and nursing assistants being toobusy.

Safety in operating theatres was good but someimprovements were needed in assurance and culture.Problems with surgical instrument sets neededresolution. Reviews of deaths in the hospital needed tobe improved to show learning and improvementhappened. Security of patient charts needed to beimproved as some were not being kept confidential.Staff mandatory training updates was not meeting trusttargets.

The hospital was clean and infection prevention andcontrol protocols followed. Incidents and near misseswere being well reported and investigated. There was asafe level of cover from the medical staff anddeteriorating patients were recognised and respondedto.

Length of stay in the hospital was mostly better than theEngland average. Patients’ pain, nutrition and hydrationwere well managed with specialist input when needed.Staff were skilled and experienced, although not all hadreceived an annual performance review. There wasstrong multidisciplinary input to patient care. Importantservices were provided seven days a week and therewas good access to information. The majority of auditsshowed patients were getting good outcomes, but someaudit results needed more attention where they werenot being used to demonstrate change, learning orimprovement.

Feedback from patients and their families had beenalmost entirely positive overall and several patients

Surgery

Surgery


described their care to us as excellent. The Friends andFamily Test produced excellent results. Patients we metin the wards and other units spoke highly of thekindness and caring of all staff, although not withoutmentioning how busy staff were. Staff ensured patientsexperienced compassionate care, and worked hard topromote their dignity and human rights.

The hospital had not resolved the conflict betweenmeeting targets for patients to have treatment andputting undue pressure on services to perform. Therewere many aspects of good responsiveness, butpressure for beds was leading to too many patientsbeing inappropriately discharged from the maintheatres or day-surgery unit. As with most NHShospitals, this hospital was regularly faced with a highnumber of patients who were fit for discharge, butwithout transfer of care packages.

Patients were complimentary about the food. There wasa wide-range of leaflets and information for patients andpeople with additional needs were being looked after.Cancelled operations were low, and the pre-admission,admission and discharge services provided goodsupport.

The surgery service had an effective governanceprocess, although some areas needed to be improved toshow a consistent approach. There was good leadershipand local-level support for staff. All the staff we metshowed commitment to their patients, theirresponsibilities and one another. There was a strongcamaraderie within teams. We were impressed with theloyalty and attitude of the staff we met, although somewere stressed and anxious, and this did not alwaysappear to have been recognised. Staff were recognisedthrough awards made by the trust for theircommitment, professionalism and going the extra milefor the patient.

Are surgery services safe?


We have judged the safety of surgery services as requiringimprovement. The nursing and operating-departmentpractitioner staffing levels in some of the wards andoperating theatres were not sufficient to provide safe careat all times. There was a relatively high use of bank andagency staff to fill vacant shifts and although not all shiftswere filled, the position had improved over the last sixmonths.

The audit of the World Health Organisation surgical safetychecklist had in the recent past been inadequate. This hadrecently been recognised with a new audit and observationprotocol. As yet there were no results to review todetermine if the checklist was being used safely as it wasearly days with the new regime. There was, however, noevidence from our observations of the safety checks intheatres not being performed effectively. Policies andprocedures for use of the checklist had not beendeveloped.

There were continuing and as yet unresolved problemswith damage to the drapes wrapping sterilised surgicalinstrument sets. Measures put in place had yet to find asatisfactory solution. The review of hospital deaths wasbeing carried out, but there was no evidence from reportsof any actions to improve patients care or learning beingshared. There was no systematic review of high-risk deaths.There was a lack of security with some patient charts,including medicine charts, which were left unsupervisedoutside of patient rooms. In terms of training, staff were notmeeting trust targets for updating their knowledge inmandatory subjects and safeguarding.

Otherwise, incidents and near misses were being reported,investigated and actions and learning shared with and fedback to staff. Avoidable patient harm was relatively lowwith equipment readily available and used to preventavoidable harm. The surgery wards, operating theatres andequipment were clean and well maintained. Staff adheredto infection prevention and control principles andguidelines. Medicines were well managed and patientrecords were well completed and practical. The surgeryteams assessed and responded well to deterioratingpatients.

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There was safe cover from the medical teams. There was acommitted team of consultants, junior and trainee doctorswho put patients at the centre of their work.

Incidents

• The surgery services acted upon significant incidents.The hospital had reported one Never Event in adultsurgery services in the last 12 months (February 2015).This event related to a retained swab following anoperation and resulted in the patient needing toundergo further surgery after developing subsequentproblems. The safety procedures in the operatingtheatre did indicate there was a missing swab at the endof the operation, but, despite some extensive review bythe surgical team, it was not located. Consequently,tThe root-cause analysis report into the event containedclear details of the procedure and examined andinvestigated where failings had occurred. A number ofareas for change and improvement were identified. Anaction plan was produced with staff made accountablefor the changes to be made.

One area of the investigation did not have sufficientprofile in the root-case analysis action plan. This relatedto staff treating the patient in the two weeks followingthe operation not being aware of the potential for theretained swab. The patient’s notes did not make thisclear enough.

• All staff we met were open and honest about reportingincidents. Staff we spoke with in theatre, surgery unitsand wards said there were no barriers to reportingincidents. We were told how the recent implementationof an electronic system had made this easier. Access tothe system was on the front page of the trust intranet.Staff said they were encouraged and reminded to reportincidents by senior staff. Incidents were investigatedwhen this was required, actions identified, and moststaff said they received feedback. The statistics for eachward and unit showed a fairly regular number ofincidents reported each month. The highest number ofincidents (often indicative of a good culture of reporting)was within main theatres. Many of these were related toproblems with damage to wrapping on sterilisedsurgical trays. The trust, overall, was above the NHSEngland average for reporting incidents. Again, thiscould be taken as an indicator of a strong reportingculture by staff.

• Staff were aware of the need and importance ofreporting and acting upon near misses. There had beentwo notable near miss incidents in the main operatingtheatres and one in the day-surgery unit which wereavoided by good use of the surgical safety checklist andthe diligence of the staff team. These were recognised,reported, investigated, and learning was shared acrossthe service.

• There had been eight serious incidents in surgeryservices in the 12 months from August 2014 to July 2015.Four of these had been surgery-related, discussedabove, two were serious hospital-acquired pressureulcers, one was a patient fall, and the other described asa ‘adverse media coverage or public concern.’

• Patient mortality and morbidity (M&M) was reviewed bythe surgical teams and hospital-wide. There wereactions and learning identified within the hospital-widemortality working group, but with insufficient evidenceat speciality level to show how agreed actions werebeing delivered, reviewed, and led to improvements.Also, Ppatient deaths were not categorised within sixclassifications which ranged from 'no evidence foravoidability' to 'definitely avoidable'. under the NationalConfidential Enquiry into Patient Outcome and Deathfive classifications, but were classified by a similarsystem . This would provided staff with data todetermine how many deaths had taken place withinnationally recognised categorisations. The M&Mmeeting minutes did not demonstrate if or how staffwere accountable for actions agreed from reviews ordemonstrate improvements from actions taken. Wereviewed sets of minutes provided for the generalsurgery team and a set from part of themusculo-skeletal division (it was not clear which partand there was no indication of who attended). Therewas also a mortality working group held every twomonths. The minutes from this group had morestructure, although the role of the staff who attendedwas not shown. There were also a number of staff whodid not attend any of the three meetings between Marchand July 2015. The meetings showed there re wereactions attributed to staff and, but no evidence to showif these had been completed. The actions and learningwere distributed to clinicians within the trust.In theminutes we reviewed, there were no investigations intogroups of deaths and no evidence of a complete reviewof all high-risk deaths. Some of these gaps had been

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partially recognised at the working group meeting, butwithout any actions being agreed. The speciality M&Mmeeting minutes did not demonstrate if or how staffwere accountable for actions agreed from reviews ordemonstrate improvements from actions taken. Wereviewed sets of minutes provided for the generalsurgery team and a set from part of themusculo-skeletal division (it was not clear which partand there was no indication of who attended).

• Duty of Candour had been introduced to staff, althoughit was not referred to in the serious incident report wereviewed. Those staff talked with were aware of the newregulation to be open, transparent and candid withpatients and relatives when things went wrong, andapologise to them. From November 2014, NHS providerswere required to comply with the Duty of CandourRegulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. This related toincidents or harm categorised as ‘notifiable safetyincidents’. The incident referred to above, where apatient suffered from a retained swab after anoperation, did not mention whether the Duty ofCandour had been applied in this case. It referred to aconversation with the patient and the family, but nothow this had been conducted.

World Health Organisation Surgical Safety Checklist

• The hospital used the internationally recognised WorldHealth Organisation surgical safety checklist (‘thechecklist’) in all surgical procedures, although had workto do to embed the practice more consistently andprofessionally. The checklist was a procedure carriedout to review all safety elements of the patient’soperation including, for example, it was the correctpatient, the correct operating site, all instruments andswabs had been accounted for, and all the staff wereclear in their roles and responsibilities. Following theintroduction of the National Patient Safety Agency ‘FiveSteps to Safer Surgery 2010’ guidance, practice wasextended in operating theatres to include a briefing atthe beginning of a surgical list and a debriefing beforemembers of the team left the theatre or department.Senior staff in directorate management team and thoserunning the theatres were open and honest in disclosingto us there were some cultural issues with somemembers of the surgery team. This had led to adifference in quality and compliance with the way the

list was used. As a result there was a recent relaunch ofthe checklist and requirement for professionalism,openness, and challenge from theatre teams. Therewas, however, no policy guiding staff to how thechecklist was to be used and best practice to befollowed. It was not referred to in the theatreoperational policy.

• Although we heard of some issues with culture andconsistency with the checklist, we observed goodpractice in the operating theatres, both main andday-surgery. Staff adhered to those parts of the checklistprotocol we observed. All staff involved were presentand included in working through the checklist asrequired. There were no distractions. We observedpractice and felt it appeared ‘natural’ (not beingperformed for our benefit). The trust was nowanaesthetising almost all patients in the operatingtheatre rather than in the preceding anaesthetic room.This was improving teamwork and the culture amongteams (often known as ‘human factors’).

• The service had recently recognised the previous auditwork for the determining compliance with the checklistwas not providing any assurance, and the wholeprocedure had just been relaunched. In the previousprocedure, the checklist was completed electronically.Compliance with the requirements of the checklist wasbeing audited by checking there was a tick in therelevant box on the computer system. It had beenrecognised this did not show if staff were, as required,included in the reading and approval of the elements ofthe checklist and indicate any quality measurements.The audit did not demonstrate due process beingfollowed and, it was agreed by senior staff, providedinsufficient assurance. The paper checklist hadtherefore been reintroduced to provide a more inclusiveand quality process. A system to audit futureperformance with compliance had been developedwhich included observation. There were, as yet, noresults to review as the newly relaunched auditprogramme had yet to be conducted within ameaningful time frame. The new system had yet to beextended to production of a checklist compliancepolicy. Links had now been made with another NHStrust known for expertise in peri-operative safety toreview practices and procedures in Salisbury operatingtheatres.

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Safety thermometer

• Data on aAvoidable patient harm data was collectedand reported for all surgical areas using the SafetyThermometerand was relatively similar to other acutehospitals when compared nationally. As required, thehospital reported data on avoidable patient harm to theNHS Health and Social Care Information Centre eachmonth. This data provideding a snapshot of avoidablepatient harms occurring on one specific day eachmonth and could be measured against other hospitalsand wards in the NHS. Data included hospital-acquired(new) pressure ulcers (the three more seriouscategories: two, three and four) and patient fallsresulting in harm. The report also included incidences ofcatheter and urinary tract infections and venousthromboembolism. Within this snapshot view, thehospital overall had shown an improvement within thedelivery of harm-free care in the 12 months from August2014 to July 2015. It had improved from 88.2% in August2014 to 94.16% in July 2015. By July 2015, the result hadimproved to meet the NHS average level of acutehospitals. There was an average overall of 91% ofharm-free care delivered for 4,795 patients in these 12months. This showed the hospital was slightly below(that is worse than) the average for NHS acute hospitalsof 93.9% for the same period.

• AAt surgical ward level there was a varied but not poorperformance. Amesbury Suite, the Burns Centre, andLaverstock ward had the best overall performance in thesnapshot view. They all had six out of 12 months with100% harm-free care. Otherwise in surgery wards, therehad been only infrequent months where harm-free hadfallen below 90%.

• In terms of harm, falls causing harm were lowthroughout the surgical wards. There had been just fourreported across the surgical wards in the snapshot ofdata for the 12 months. There had been three categorytwo 'new' pressure ulcers and four category three 'new'pressure ulcers. New pressure ulcers are those acquiredwithin 72 hours of the patient's admission to hospital.three of which were the second highest grade (categorythree) and two the highest category (category four).. Theavoidable harm with the highest occurrence was 16catheter and urinary tract infections – with six of theseoccurring on Chilmark Suite and seven on Downtonward.

• There was senior nurse review of pressure ulcermanagement. Nursing audits looked at pressure ulcerprevention and a report was produced each year. In thelatest report from May 2015, the audit report looked at90 patient records in relation to pressure ulcer care. Thetrust was using the Braden Scale as the tool forassessing pressure ulcers. This assessed patients fordifferent things including the patient’s sensoryperception, activity levels, mobility and other medicalareas. The majority of the assessments were workingwell but the accuracy of the assessment measuredagainst the Braden Scale left room for improvement.Thirty of the 90 records did not give an accurateassessment of the injury. Otherwise, the mostappropriate equipment had been used for all the 90patients checked. The SKIN bundle (a care plan torecognise Surface, Keep moving, Incontinence andNutrition) was looked at within the 35 records wherethese had been required, and 30 of these werecompleted well – which met the trust target. OnChilmark ward, staff had recognised pressure ulcerscould develop below plaster casts. A review of anincident had led to the creation and use of a plaster-castskin check tool.

• There was senior nurse review of falls risk assessmentsand prevention. The audit report from May 2015 lookedat 85 records for quality of the assessment on admissionof the patient for risk of falls. Of these, all but one hadbeen completed appropriately. Of 39 records looked atto see if the reassessment of the patient was carried out,80% were completed. There was therefore some roomto improve in this area. Records for 90 patients werelooked at for appropriate completion of bed-railassessments and 86 of these were acceptable. Inpractice, staff were proactive in helping patients avoidfalls. On Downton ward, for example, anti-slip footwearwas provided to patients after an analysis of the causeof a small number of falls leading to fractures. Patientswho were at risk from falls were reminded to use theircall bells and wait for someone to support them.

• There was good use of equipment to help patients atrisk from avoidable harm. This included the use ofpressure relieving mattresses. Staff and patients saidthese were readily available when needed and careplans would indicate when they should be used. Therewere bed rails which could be used when patients wereassessed as being at risk to falls. Patients were carefully

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assessed before these were used to ensure they werenot just a form of restraint. Patients were provided withanti-embolism stockings when they were assessed as atrisk to a blood clot (venous thromboembolism).


• The inpatient ward areas of the hospital were visiblyclean, tidy and well maintained. This included patientbed spaces, corridors, staff areas and equipment usedboth regularly and occasionally. Patient bed spaceswere visibly clean in both the easy and hard to reachareas such as beneath beds and on top of highequipment. Bed linen was in good condition, visiblyclean and free from stains or damage to the material.Storage cupboards were well organised with mostequipment on shelving units to prevent dust and dirtgathering around and beneath objects. Several patientswe met on the wards said the cleaners were regularlyseen. They regularly dusted at height (such as curtainrails), cleaning floors, bathrooms, and under beds.

• The main and day-surgery operating theatre units wevisited were visibly clean, well-organised andmaintained. The recovery areas in both units could beeffectively cleaned at the start of the day, as they wereempty of beds or trolleys. The manager of the maintheatres commented upon how they valued theirexperienced and trusted cleaner. Members of staff knewwho was responsible for the various cleaning roles. Thisensured complex machines, equipment and areas weremaintained and cleaned by trained personnel.

• The surgery services had an exemplary result for levelsof hospital-acquired infection. There were zero levels ofmethicillin resistant Staphylococcus aureus (MRSA) andmethicillin-susceptible Staphylococcus aureus (MSSA) inthe six months from April to October 2015. There hadbeen just two incidences of hospital-acquiredClostridium difficile, one in May and one in August 2015.

• There were reasonable investigations into any incidenceof hospital-acquired infection, but some sections ofreviews we saw were not fully completed. We looked atincident investigations for the two most recentincidences of Clostridium difficile. The basis for thereviews was good. It focused upon which areas of thehospital/ward had been visited by the patient, anypressures on staff, what equipment had been used, andthe results for cleaning and hand hygiene around the

time of the incident. In the report for Britford ward inApril 2015, the section on whether the patient wasisolated and equipment was designated for single usewas not completed. There were some shortcomingsidentified in the Burns unit when the investigation intothe Clostridium difficile incident was undertaken inAugust 2015. There were, however, no actions to requirestaff to re-audit the wards and areas of the investigationonce the shortcomings had been addressed.

• All staff we met and/or observed followed infectionprevention and control protocols. Nurses, allied healthprofessionals (physiotherapists and occupationaltherapists) and nursing assistants wore clean andwell-maintained uniforms. They were adhering to therules around minimal jewellery, short and clean nails,and being bare below the elbow. Medical staff and staffnot required to be in in uniform (such as pharmacists)adhered to trust policy in the same way. All the staff weobserved washed their hands and used hand gel asrequired. Visitors were encouraged to do the same. Wesaw staff wearing personal protective equipment(aprons and gloves) when required. There was sufficientstock of personal protective equipment and hand-washsinks, soap, paper towels and hand gel in clearly visibleareas. Patients commented how they had observed staffwashing their hands “all the time” and “they don’t goanywhere without washing their hands. I’ve been mostimpressed.”

• There was a protocol for staff to follow to treat andmanage a patient with diarrhoea or recognised orsuspected Clostridium difficile. This raised the level ofinfection prevention and control for the patient, staff,visitors and the environment. One area of a higher levelof practice was around hand-washing. The hospital hadrecognised the use of alcohol hand gels had limitedeffectiveness against Clostridium difficile and was notrecommended for patients with diarrhoea. All thosecoming into contact with the patient were thereforerequired to wash their hands with soap and waterbefore and after every contact with the patient or theenvironment.

• There were variable results from hand-hygiene audits.Although the majority of nursing audits scored 100%,there were some failures in observed hand-washingprotocols among the medical staff. We were providedwith data of observation audits from April to July 2015.

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In forty sets of data for surgical units/wards, maintheatres and recovery, the day-surgery unit,pre-operative assessment there were only three out of39 measures (one set of data was missing) where thenurses did not score 100%. The sample size of aroundeight nurses assessed on each observation was a goodratio. It was noted as good practice there was a largersample in May 2015 in Laverstock ward (20 nursessampled) as this ward had an incidence of Clostridiumdifficile in that month. This was one of the results whichdid not return 100% compliance (90%). It was noted theaudit for Laverstock ward for June 2015 was then notdone or provided to the infection prevention andcontrol team. In July 2015, however, Laverstock nurses’compliance was 100%. Compliance for nurses onAmesbury Suite, Chilmark Suite, Britford ward, Downtonward, main theatres and recovery, the surgicalassessment lounge and pre-operative unit was 100%throughout this period.

For medical staff there were 16 occasions out of the 39measures (one set of data was missing) where medicalstaff fell below 100%. Improvements were made,however, over the time period. In the surgery wards ofthe musculo-skeletal division, seven out of 12 of theaudits in April to June 2015 were below 100%. By July2015, however, all medical staff scored 100%. There wasa 100% performance over the four months for medicalstaff in the surgical assessment unit, but Britford wardmedical staff had not scored 100% since April 2015.Allied health professionals, so physiotherapists,occupational therapists and dieticians, for example,scored mostly 100%.

• Patients recognised good cleaning, and results fromsurveys showed improvement. The trust had scored wellin cleanliness in the Patient-Led Assessment of the CareEnvironment (PLACE) surveys in 2013, 2014 and 2015. In2015 the trust improved to score 99/100 (up from 87 in2013) which was the just above (better than) the NHSEngland average of 98.

• Clinical waste was well managed. Single-use items ofequipment were disposed of appropriately, either inclinical waste bins or sharp-instrument containers. Noneof the waste bins or containers we saw on the wards orwithin the theatre units were unacceptably full. Nursingstaff said they were emptied or removed and replacedregularly.


• Most arrangements for the delivery and removal ofreusable sterile surgical instruments were appropriate,but there was an area where they were not always safelyremoved in the day-surgery unit. In the day-surgery unit,clean instruments were stored outside of the sluiceareas. Used instruments, which were re-wrapped in theiroriginal packaging, were taken past these cleaninstruments on an open trolley, before being depositedin a closed trolley for transport to sterile services.Although there was minimal risk ofcross-contamination, staff admitted they had notrecognised or addressed its potential. In main theatres,sterile instruments were stored on shelves in their setsand wrapped in surgical fabric drapes. Any usedinstruments were removed in an area at the rear of theoperating theatres designated as a ‘dirty’ corridor. Usedinstruments were taken through the rear of the sluicearea and deposited into a closed trolley for collectionand processing by the decontamination and sterileservices unit. There were storage problems with maintheatre, in that there was little available space. However,there were surgical stocks in the ‘dirty’ corridor whichshould have been elsewhere. This included breastimplants. Although there was minimal risk as they weresealed and in locked cupboards, this was the wrongenvironment for them to be stored.

• There were recognised, but nevertheless, slow to resolveproblems with damage to the wrapping of sterilesurgical instruments. Any sets of instruments could notbe used if the wrapping they came with was damaged.This resulted in some operations being cancelled orrescheduled at very short notice if there was no otherset available. The issue in main theatres had beenimproved to an extent by changing the storage racking,but the storage shelves were high, so this did not alwayssolve the risk for sets stored at height. The wrappingcould still be damaged when they were taken downfrom a high shelf. Day-surgery staff said they also had atleast one set each day with packaging damaged. Therehad been some discussion about improving this in maintheatres with marks being added to shelves to alert staffto not place heavy sets above these marks and on thehigh shelves. This had, however, not yet been properlyimplemented. The trust was trialling stainless steelboxes for surgical sets, but these were very expensive. A

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different type of more resilient wrap was also beingtrialled. The issues had been placed on the trust riskregister although there did not appear to be a clearresolution.

• There was safe provision of resuscitation equipment,although a lack of clarity around the checking of onedifficult-airway trolley in main theatres. Resuscitationtrolleys and equipment including defibrillators on eachward and in the units were checked daily, with recordsshowing completion on the vast majority of days in thelast three months. The trolleys were a standardrecognisable type, constructed from metal and red incolour. They were well placed within wards and units sothey stood out and were easily accessible. Trolleys werelocked with a breakable seal and, of those we checked,this number was recorded as part of the checkingroutine. This demonstrated the trolley had not beenopened or equipment used or tampered with since itwas last used. When we looked, the difficult-airwaytrolley in main theatre did not have a checklist to showit had been monitored and this could not be easilylocated when it was required.

• There was no resuscitation trolley in the upstairs area inthe day-surgery unit. There was one located downstairsand this would be relocated to the upstairs area whenthis was used to admit patients overnight (which was afrequent occurrence). The requirement to locate thetrolley was part of the protocol for staff to follow (andsign) when the day-surgery was opened for inpatients.We were impressed to see oxygen and suctionequipment had been fitted into the patient lift betweenthe two floors in the day-surgery unit. This improvedpatient safety in the event the lift failed when it wasbeing used to move a patient.

• Surgery areas were mostly supplied and fitted withappropriate emergency equipment. Each bed space hademergency call buttons clearly marked. Recovery areasand ward beds had oxygen and suction at each bedspace. There was, however, no piped oxygen or suctionwithin the ward areas of the day-surgery unit. Thiswould be acceptable if these wards were used asdesigned only for low-risk day-case surgery patients, butthe unit was being used regularly for inpatients and alsofor more complex patients. There was portable oxygenavailable, and patients admitted to these wardsovernight were assessed for their risks of needing a

higher level of care. We were told that any patients whowere likely to need oxygen and suction would not beadmitted to the day-surgery unit for an overnight stay.This was backed-up by the patient admitting protocol,and staff said there had been no incidents reportedfrom unsafe patient care of the availability ofequipment.

• Almost all medical equipment in theatres had beenserviced and maintained as required. We reviewed theservicing dates for equipment as at the end ofSeptember 2015 including things like scopes, operatingtables, anaesthetic machines, ventilators and scanners.The exception to this comprehensive list was a numberof items, mainly different scopes in the day surgery unit,which were due for servicing in early September, andtwo flowmeters due in August 2015 which had not beenrecorded by the end of September as now beingcompliant.

• In the areas we checked, all consumables andequipment were within their expiry date. The staff wemet said the stocks, stores and trolleys were regularlychecked by one of the nursing or healthcare team, orthe theatre stock team in the operating theatres. Staffchecked for evidence of damage to packaging orconsumable stock (damaged items were then disposedof) and for items approaching or past their expiry date.We saw consumables and equipment in thedepartments were kept to a minimum of those thingsused often in order to reduce waste and the risk ofexpired equipment.

• Equipment was stored safely. Flammable products werein locked steel cabinets. Products deemed as hazardousto health were in locked cupboards and often in sluiceor clinical rooms which were also locked and onlyaccessible to approved staff.

• Almost all areas of the hospital we visited were secure.Staff had close-proximity cards to give them access toareas not open to the public. Some wards were secureat the front door and visitors were required to announcethemselves before entering the area. People coming tothe operating theatres who should not have directaccess were met by a receptionist who, as they did withus, checked people’s identity and asked them to wait tobe escorted any further into the unit. Some of the wardswere designed without doors at the entrance. Patientswere, however in side rooms or bays and visitors had to

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walk past staff offices and nurses’ stations which wereoften occupied. Security in these areas was, however,not ideal and this led to our concerns around thesecurity of patient charts (see ‘Records’).

Medicines

• Almost all medicines were supplied and stored securelyon the wards, theatres and departments. Medicines,including liquids, were in locked cupboards withappropriate staff being responsible for the keys. Therewas one trolley in a locked room, but the trolley itselfwas not locked as required. There were arrangementsfor the supply of regular medicines. An inpatientpharmacy service supplied stock medicines to all wardsand departments and dispensed discharge medicinesfor patients to take home. There was an emergencymedicine stock which all staff we asked knew about andhow to access it out of hours. Medicines’ refrigeratorswere available with temperatures recorded daily toshow medicines requiring refrigeration had been storedat a safe temperature. There were some liquidmedicines without a date recorded on which they wereopened, which was not in line with medicine practiceand hospital policy.

• The ordering, receipt, storage, administration anddisposal of controlled drugs were in accordance withthe Misuse of Drugs Act 1971 and its associatedregulations. We checked a number of stocks and theregisters and found them to be accurate. There weremanageable levels of stocks to prevent medicines goingout of date and the risk of errors.

• In the patient records we reviewed there was consistentrecording of patient allergies. We saw patient allergies(such as allergy to penicillin) transcribed to prescriptioncharts and patients were wearing wristbands to indicatethey had an allergy or intolerance.

• There was a regular audit for the use of antibiotics. Thiswas work undertaken to improve the management ofantibiotics by checking the duration of their use withpatients, the route of administration and how they werebeing used. One ward was audited each fortnight and allpatients receiving antibiotics were included in the audit.The most significant shortcoming determined by theaudit was with wards documenting a date for when theantibiotic should be stopped or a review date. In auditssince October 2014 to September 2015, there were 15

occasions where the surgery wards were not meeting anacceptable score of above 80% of records showing thisdate. This was from 26 audits, so more than half werenot achieving 80%. There was no action plan presentedwith the report and we could not see this discussedthrough clinical governance in those minutes wereviewed.

Records

• Records we reviewed were well completed, legible,timed and dated. We looked at 20 sets of nursing notesand 10 of medical notes. All those we saw werecompleted well. Notes made by all those involved withthe patient’s care were clear, contemporaneous andattributable to the member of staff writing them. Thename and grade of the doctor reviewing the patient, thepatient being seen within 12 hours of admission, themanagement plan for the patient, and ward rounddecisions, were documented in the notes. There wasalso good recording of input from the multi-disciplinaryteam; assessment of pressure ulcer, falls, and nutritionalrisks; and all the consent forms we saw were completeand appropriately signed.

• On a number of the wards there was some inattentionto patient record safety and confidentiality. Somepatient charts were stored in pockets on a rail outside ofthe patients’ room. This included nursing charts andprescription charts. On some wards, as is trustpractice, they were covered with a notice stating theywere ‘confidential’ but not all. Staff said these recordswere only stored in this way if a patient was beingbarrier-nursed due to an infection. However, this wasnot the case as many patients were not beingbarrier-nursed but had their charts stored in this way.This left the charts open to be read, removed orpotentially changed. The staff we asked admitted theyhad not considered situations where a patient’sprescription chart should be kept highly confidential.They had not considered what confidential informationcould be revealed about a patient’s health from, forexample, prescription charts.

• Other patient notes and records were held securely instaff-only locked or lockable office, with the exception ofnotes in the surgical pre-operative assessment office.This lack of security would exist when the unit was open

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and the office unstaffed, as otherwise the whole unitwould be locked. The senior sister on the unit said thishad been raised with the estates’ division, but the lockhad yet to be fitted.

• There was a monthly audit of patient records to checkfor their completeness. There were nine differentmeasures including if the patient had an observationchart, and all the right areas were completed and scoredaccurately. In the data we were provided with forJanuary to June 2015, the surgery wards and unitsscored highly. There were just 13 occasions from 252where the wards were not at 100% for these audits. Inthe January to March 2015 quarter there had been nineoccasions which had reduced to four in the April to June2015 quarter.

Safeguarding

• Not all medical staff were up-to-date with their trainingto recognise and respond in order to safeguard avulnerable person. The training compliance withsafeguarding vulnerable adults and safeguardingchildren (level 2) as at September 2015 showed 70% ofmedical and dental staff were compliant with thetraining. The trust target was 85%. Nursing staff did,however, meet targets in adult safeguarding refreshertraining and were just below for the child safeguardingcourse. There were 91% of the nursing staff up to datewith the safeguarding adults training and 83% with thesafeguarding children update.

• There were policies, systems and processes forreporting and recording abuse. The safeguarding adults’at risk policy had been implemented in accordance withnational guidelines and was due for review in June 2017.The policy did not yet mention, however, the Care Act(2014) which had superseded the government’s ‘NoSecrets’ paper of 2000. The policy did, however,reference the local authorities’ policies to ensureapproved and recognised local safeguarding systemsand processes were adhered to. The policy listeddefinitions and types of abuse and who might be at riskand from whom. It was linked with the provisions of theMental Capacity Act (2005) in relation to deciding if aperson was vulnerable due to their lack of mentalcapacity to make their own decisions. The policies(including the policy for child safeguarding which wasdue for review in November 2015) clearly described theresponsibilities for staff in reporting concerns for both

adults and children, whom, as required, were subject todifferent procedures. There were checklists andflowcharts for staff to follow to ensure relevantinformation was captured and the appropriate peopleinformed.

• Staff we spoke with were clear about reportingsafeguarding, allegations or suspicions of abuse. Theyunderstood their responsibilities and the trust’sprocesses for reporting any suspected abuse. Staff saidthey would report concerns about a patient, but alsoconcerns for someone who was either accompanying apatient or might be affected by the patient (such as achild or carer in the family home).

Mandatory training

• Mandatory update training was not meeting trusttargets. Staff were trained at induction and thenupdated in a wide range of statutory and mandatorysubjects at various intervals. The staff (in themusculo-skeletal and surgery directorates) were notmeeting trust target levels overall for 85% havingupdated their training. The training included a widerange of topics such as mental capacity, infectioncontrol, and health and safety topics. Compliance withthe mandatory training requirements at the end ofSeptember 2015, against the trust target of 85%, showedmedical and dental staff at 64% and nursing staff at78%.

• In terms of subject matter, there was good compliancewith update training in health and safety, equality anddiversity, and, infection prevention and control amongthe nursing staff. There was poor performance from themedical staff in updating training in mental capacity andinfection prevention and control. The nurses andmedical staff were poor in updating their informationgovernance training, fire safety and safeguardingchildren (level 1 and 2).


• Surgical patients admitted to the day-surgery unit forovernight care were assessed for their suitability tominimise the risks of staying in a unit not designed forovernight stays. There was a protocol used for anypatients being suggested for admission to the unit. Thecriteria included patients being clinically stable; havingno complex mental health needs (such as living withdementia); and being independently mobile.

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• The hospital had a policy for monitoring acutely illpatients which was being audited for effectiveness. Thehospital had implemented and was using the ModifiedEarly Warning Score system for the monitoring of adultpatients on wards. The hospital policy recognised bestpractice in this system as promoted by the NationalConfidential Enquiry into Patient Outcome and Deathand the National Institute for Health and CareExcellence (NICE) guidance on care of the acutely unwellpatient in hospital (NICE 50). Hospital staff used asystem of raising alerts through numerical scoring ofpatient observations. The system was used on wardsand also in recovery areas. In patient records we saw theearly warning score charts completed and in useappropriately. The hospital carried out a quarterly auditof the charts, reviewing five on each ward. In the dataprovided for April to June 2015, the hospital scored 96%for completion and accuracy of the charts. The bestresult was for observation charts being used (100%) butthere were less good results in this quarter for theescalation of patient care being documented. This wasonly done in 71% of records in the period audited.

• The hospital had an outreach team (the critical careoutreach team) to respond to deteriorating patients andemergencies around the clock. The outreach team wasstaffed by trained critical care nurses, and providedcover 24 hours a day, as recommended by the Faculty ofIntensive Care Medicine Core Standards.

• Patients were assessed pre-operatively for any risks toor from their proposed surgery. The nurse-led team inthe pre-operative assessment unit assessed bothday-surgery and main-surgery patients. Patients wereassessed for their general health and any medicine orother potential complications to be considered beforesurgery could take place. Anaesthetists also providedpatient assessment and consultation through thepre-operative clinics each Friday morning.

Nursing staffing

• A number of patients we met were concerned aboutnursing-staff levels. We heard numerous concerns aboutstaff being “rushed off their feet” and “just doing toomuch.” We also heard how staff were very caring forpatients, but not enough about themselves. One patientremarked on one member of staff feeling faint as theyhad not found time to take their break. They left the bay

for five minutes to get something to eat. Another patientsaid they had heard a nurse crying as they felt unable togive a patient as much time as they needed. Othercomments included:

▪ A patient waiting for 30 minutes on a bed pan as noone came back to take it away.

▪ A patient was having their bed changed at 9:30am.The member of staff was called away and eventuallythe bed was changed at 5pm when the patient feltthey could not sit in their chair any longer soreminded staff. They said staff were apologetic, buthad too much to do.

▪ Several patients told us they felt they could not usetheir call bells as either there were patients whoneeded the nurses more than they did, or they feltthey were being unhelpful.

▪ A number of patients commented how they felt theyhad to wait a long time at night to see a member ofstaff. We were told by three patients in side roomshow this could be unsettling as they were in a closedroom and were never quite sure if they had beenheard. They said staff always apologised for how longit might take them to come, but patients said staffsometimes appeared even more rushed off their feetat night.

• Staff on the day surgery unit told us they felt underenormous stress to safely care for patients when theward was open to overnight patients. The ward wasbeing used now on a very regular basis toaccommodate surgery patients overnight when therewas no ward bed for them. The unit was staffed throughwith regular use of bank or occasionally agency staff,and the supernumerary (supervisory) nursing staffworking or helping with more and more clinical shifts.Staff said this meant they were not always able to gettime for training, supervision, or administration tasks.This was also impacting on patients as staff said theovernight patients were getting rushed care, as the staffwere also admitting day-case patients. They saidday-case patients were being asked to leave sometimesbefore they felt fully ready. Although additional staffwere provided to work shifts, staff said this did notrecognise the workload or the low morale of staff.

• There were established shifts at night which did notmeet recommended levels. The level of nursing staff

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established for Amesbury Suite at night was not safeand significantly failed to follow recommendedguidance. Amesbury Suite was a 32-bed trauma andorthopaedic ward. During the day there was one nursefor between six and eight patients, depending onwhether this was early in the morning or later in thedaytime. However, at night there were only tworegistered nurses on duty and therefore one nurse for 16patients. These nurses were supported by threehealthcare assistants at night. None of the other surgerywards had this low ratio of registered nurses, althoughChilmark Suite and Downton ward had one nurse to 12patients, which was not at recommended levelsideal,but others had a good ratio of one nurse to eightpatients. The establishment on Amesbury ward had notbeen particularly seen as a risk within the last skill mixreview (August 2015) apart from a comment of how itwas “currently under review to explore the use oftwilight shifts.” Staff in the musculo-skeletal directoratehad been tasked to assess this establishment, butwithout deadlines.

• There was a high use of bank and agency staff in certainareas. This was specifically in the main operatingtheatres which had a high number of vacancies andsickness absence. The main theatres were short of sixanaesthetic practitioners, had three on maternity leaveand two coming up to retirement. The staff were flexibleand plans were being made to trainoperating-department practitioners to become trainedin both scrub and anaesthetic roles. One member ofstaff was currently being trained. There were highvacancies on Amesbury ward and therefore a high use ofagency staff. When we visited on 2 December 2015, threeof the four nurses rostered to the daytime shift wereagency staff. On our unannounced visit on Sunday 13December there were, however, substantive staff onduty all weekend, as was the case for the other threewards and the surgical assessment unit when we visited.

• There was an induction checklist for temporary staffemployed to wards and theatres. A checklist provided tous by Downton ward, for example, included anintroduction to the nurse in charge; layout of the ward;procedures for use of and location of emergencyequipment and telephone numbers to use; procedurefor reporting incidents; review of staff being able tosafely use relevant equipment; and awareness ofhospital policies and protocols (such as for infection

control). There was also a comprehensive localinduction checklist for temporary operating theatrestaff. This included an introduction to staff, systems andprocedures and ensuring a copy of the person’ssignature was obtained to cross-reference againstprescription charts and registers.

• Nursing and healthcare assistant staffing levels (actualshifts covered by substantive, bank or agency staff) weresometimes short and not filled to safe levels, althoughthere was a much improved position in the last sixmonths. Ward staffing levels from March to August 2015were provided in terms of percentages of shifts coveredor not. Most of these across the various wards were inthe high 90% for cover. However, in this result weresome shifts where there were more nursing or nursingassistants than planned (so over 100% - and some ashigh as 200%) and this skewed these average figuresupwards.

When looking at the detail the following shifts werebelow 100% staffing at some point between thosedates:

▪ On Laverstock ward there was an average of 27% ofnursing shifts and 19% of healthcare assistant shiftsnot filled to 100%. The problem worsened over thetime-period with 40% of nursing shifts not reaching100% in August 2015. This ward would be up toestablishment by February 2016 with new starterscoming into post.

▪ There was an average of 10% of nursing shifts and13% of healthcare assistant shifts unfilled onChilmark Suite. The shortage of nursing shifts hadimproved from 21.5% below 100% staffing in Marchto 9% in August 2015.

▪ There was an average of 14% of nursing shifts and 8%of healthcare assistant shifts unfilled on the Burnsunit. As with Chilmark Suite, the shortage of nursingshifts had improved from 23% below 100% staffing inMarch to 12% in August 2015.

▪ Amesbury Suite had also seen improvements in thenumber of shifts being filled, although only by August2015. Overall, there were 19% of nursing shifts notcovered to 100% and 14% of healthcare assistantshifts. The shortage of nursing shifts had improvedslightly from 27% unfilled to 100% in March to 20% inAugust 2015.

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▪ Britford ward had around 27% of nurse shifts and26% of healthcare assistant shifts unfilled to 100%(this was for June to August 2015 as earlierinformation was not provided.

▪ Downton ward performed relatively better. Around5% of nurse shifts and 11% of healthcare assistantshifts were unfilled in the six months from March toAugust 2015.

• The sickness levels within nursing in surgery serviceswere, overall, below the NHS national average of around4%. Data for the musculo-skeletal directorate reported2.5% sickness absence in the year from April 2014 toMarch 2015, but this was higher in the surgerydirectorate at 4.1%. Within the larger staffing groups,sickness was higher in day surgery and theatre staff(both at 5.4%), but low on the surgery wards.

• There were handover meetings, ward rounds and safetybriefings involving the nurses each day. The safetybriefing was held three times a day to review all patientsand areas of concern. It included, for example, anyissues with infection control; whether the ward wascaring for patients from other disciplines (such assurgery wards accommodating medical patients); anystaffing issues; and patients receiving specific care, suchas for central lines, sepsis, or subject to Deprivation ofLiberty Safeguards. The forms for safety briefings wesaw were all completed and information handed over tostaff. We observed they were slightly different betweenwards. The briefing on Amesbury Suite (where therewere more complex patients) was more extensive thanthe briefing completed on Britford ward, for example.

Medical staffing

• There was good coverage from experienced and seniormedical staff. The hospital had a medical staffing skillmix, which was slightly different to the England averagewith more consultants in post in percentage terms.Around 48% of medical staff were consultant grade(England average 40%) and there was a lower ratio ofregistrars (37% against the England average of 47%).There was a similar rate of foundation year trainees tothe England average (16% against 15% nationally). Wemet a large number of consultants during our visit andfound them open, honest and committed.

• The surgery wards and services were appropriatelystaffed by doctors, although they were stretched at busy

times, and when there were increasingly unwellpatients. We met a registrar on our unannounced visit,who had a wide range of responsibilities with around 60to 70 patients to care for including surgery patients whowere in other wards. This doctor and other juniordoctors we met said they felt very supported by theconsultants and could contact them at any time whenthey needed clarification, opinion or support.

• Use of locum doctors was reported by the trust to bevery low in the surgery division and across the wholehospital. In data for the previous financial year (April2014 to March 2015) use of locum doctors was below 1%overall.

• Consultants and doctors carried out appropriate timelyward rounds. Staff on all the wards and units we visitedsaid the ward rounds took place twice every day.Patients we met told us they had seen a doctor everyday. We observed a number of ward rounds and sawgood practice. On our unannounced visit on a Sunday,staff on the wards and the surgical assessment unit saiddoctors came to see patients twice a day and wheneverthey were called for an opinion or to assist. The nursessaid they were involved with the ward rounds asappropriate, and the nurse in change would completethe whole round with the multi-disciplinary team. Staffon Laverstock unit (the plastic surgery ward) weretrialling a ‘paper round’ (where staff sat together andreviewed the patients’ records) before undertaking abedside review with patients. This was proving relativelyefficient. Staff were able to discuss various options fortreatment away from the patient so as to have moredecisive information and choices to bring to the patient.

• Nursing staff and particularly the student nurses we metat a focus group said they felt well supported by themedical staff. When we visited the hospital on both theannounced and unannounced visits we observeddoctors reviewing patients and coming onto wardswhen requested by nursing staff. The doctors wereworking alongside the nurses and acted as a team, witha multi-professional approach to the patient. Thestudent nurses told us they had been particularlyimpressed with the willingness of the medical staff toinclude them and encourage them to put theory intopractice as much as possible. They said this built theirconfidence both now and for the future.


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• The trust had a current major incident plan producedoriginally in 2013 and updated last in August 2015. Keystaff knew how to access and distribute the policy and inwhat circumstances it was relevant. There were otherplans associated with the major incident plan,including, for example, the national burns majorincident plan and the pandemic influenza plan. Therewere key staff with named responsibilities listed in thepolicy along with key locations, such as the commandcentre and places for relatives to stay. There were alsoinstructions for obtaining medicines and equipment formajor incidents.

Are surgery services effective?

Good –––

We have judged the effectiveness of surgery services asgood, although some areas required improvement. Lengthof stay in the hospital was good, being mostly below (betterthan) the England average. Patients’ pain was wellmanaged with specialist input and nutrition and hydrationwas well supported. There was effective assessment forpatients with the risk of developing blood clots, and goodwork being done to get people back on their feet and homeas quickly as possible. The hospital performed better thanthe England average in the national hip fractureperformance audit, but performance had declined from theprevious year. The hospital performed well in the nationallung and bowel cancer audits in 2014. Post-surgeryreadmission rates were generally good, although this variedbetween planned and emergency surgery. The hospitalperformed relatively well in the patients’ review of theiroutcomes following hernia and hip/knee replacement andvaricose vein surgery. There was a low level of surgical siteinfections reported.

The hospital had, however, performed less well in theNational Emergency Laparotomy Audits of 2014 and 2015.There were actions plans to address the shortcomings, butnot all of these had been completed. Not all staff had beengiven their annual performance review and this was notmeeting trust targets. There was, however, a good standardof competence among the staff teams and encouragementand opportunities for professional development. There wasstrong multidisciplinary working with a common sense ofpurpose among staff. Important services were provided

seven days a week and there were no problems withgetting access to information, although the trust’s databasewas criticised by a lot of staff for being hard to navigate.There was a wide range of policies and procedures draftedalongside best practice and national guidelines. Consentand knowledge of mental capacity was good, althoughthere were some actions from a yearly audit which had notimproved in the last two years.


• Despite delays in discharges, predominantly for patientsneeding social care packages or continuing healthcare,the length of stay for surgical patients within thehospital was mostly below (better than) the Englandaverage. It is recognised as sub-optimal for patients toremain in hospital for longer than necessary and abarrier to other patients being admitted. The latestavailable data produced for the trust by the Health andSocial Care Information Centre covered 2014.

For all elective (planned) surgery patients, the length ofstay was 2.9 days (England average 3.1 days) and foremergency surgery patients, 4.2 days (England average5.2 days). Within elective surgery there were, however,longer stays than average for patients having traumaand orthopaedic surgery (3.8 against 3.1 days) andplastic surgery (3.1 against 2.4 days), but these wereoffset by much shorter stays in other specialties.

In emergency surgery, trauma and orthopaedics wasjust marginally above the England length of stay average(8.6 against 8.5 days) although general surgery wasbelow (3.5 against 4.2 days).

• The hospital reported a high level of compliance withassessment for patients developing venousthromboembolism (blood clots). The wards wereaudited each month to check completion of anassessment by a doctor of the risk to the patient fromdeveloping a blood clot. Most wards had 100%compliance in the months from April to October 2015.We also saw completed assessments in patient recordswe reviewed. There was a risk assessment tool fordoctors to consistently determine risk. There wererecognised risk factors for patients, such as obesity,dehydration, and medical history (including familyhistory and risk of clotting). Regardless of actualassessed risk, all patients were automaticallyconsidered high risk and treated in advance

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(prophylaxis) if their surgery was expected or known tobe longer than 90 minutes, or 60 minutes if theprocedure involved a lower limb or the pelvis. Otherassessed risks were then treated appropriately. Patientswere either given medicines to prevent or reduce therisk of a blood clot, and/or encouraged to be active andmaintain adequate fluid intake. There was a leaflet forpatients to take home called ‘Help us ‘Stop the Clot’.This gave advice to patients when they went homeabout ways to prevent a blood clot in the three-monthrisk-period after surgery. It explained what things to lookout for and what to do about any concerns (contact theGP). The hospital had won a national award fornurse-led services in venous thrombosis andanticoagulation services.

• The surgery services operated an enhanced recoveryprogramme (‘the programme’). This was for patientswho were post-operative in a number of procedures. Itincluded total knee replacement, colorectal surgery,breast reconstruction, stoma patients, and total hipreplacement. There were information leaflets providedfor patients to guide them through the programme, andhow it should be delivered to them. The leafletsexplained how the programme was designed to getpeople up and mobile as quickly as possible, to speedup recovery, and reduce the length of stay in hospital.The trust was in the process of auditing the programmefor hip fracture therapy in more depth but results werenot yet available. Previous reviews of the programmeshowed how the trust had been seventh in the countryfor getting patients home within three days in 2014. Theaverage length of stay was 18.1 days compared with anational average of 19.8 days.

Pain relief

• Pain relief on wards and theatres was well managed.Patients prescribed pain relief to be given ‘whenrequired’ were able to request this when they needed it.Patients told us, and we observed, how they were askedby staff if they were in any pain and medicines wereprovided in line with the patients’ prescriptions. Onepatient we met on Amesbury ward had been givenspinal anaesthesia and commented upon how theprocedure had been “amazing and almost totallypainless. It was over before I even realised they haddone anything.”

• Pain was managed well for patients unable to alwaysexpress themselves. The hospital was using a tool forpain assessment for patients living with dementia orcognitive impairment who may not be able to expresshow they felt. It involved checking if a patient wasshowing signs of pain from breathing patterns, facialexpressions, if they cried out, whether they were anxiousor withdrawn, and clues from body language. Theseareas were scored and actions taken if the tool showedany evidence the patient was in pain. Other informationcould be taken from the ‘This is Me’ document producedfor patients with cognitive impairment to describe howthey normally acted or behaved.

• Patients were advised about when pain might increaseand how they and staff should respond. For example,patients who underwent emergency abdominal surgery(laparotomies) were advised they could experiencehigher levels of pain after their surgery. Patients weretold the pain would be likely to ease after a few days,but use of strong painkillers was common during thefirst few days after surgery. There was a hospital painteam providing specialist input into pain management.Staff were aware of how and when to contact the teamfor advice and guidance. The patient information foremergency laparotomies indicated the specialist painteam would be called to best advise patients on painmanagement.

• There was a measurement of pain managementprovided to post-operative patients, although thesurgery directorate accepted more work was requiredon measuring and managing post-operative pain. Therewere local audits for pain management in line withNational Institute for Health and Care Excellence (NICE)guidance. For example, there was an audit against NICEguidance 173 for neuropathic pain (pain caused bydamage to nerve fibres). The hospital had beencompliant with all the 14 standards assessed in 2014,including considering referring a patient to a specialist;regular review; and looking at switching medicines ifthey were not working within a specific time. There hadalso been some work carried out on pain managementfor post-operative patients. For main theatre patients,this indicated there were far more patients experiencinga higher level of post-operative pain than the target. Theresults gathered from August 2014 to August 2015 statedaround 20% of patients experienced a high pain scoreon waking after surgery. The performance target was

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5%. Staff were not sure how this target had been chosenfor measuring performance of pain management inmain theatres. They told us it needed furtherexamination if it was to be a useful tool forimprovement. Patients on the day-surgery unit were,nevertheless, mostly achieving the targets set forpost-operative pain, which had been set as the same asthose on the main theatre unit.


• Initiatives had been rolled out to improve patientnutrition and hydration. The trust had a nutrition andhydration committee as part of the clinical governancestructure. The group met every six weeks, and waschaired by the head of estates. An annual report wasproduced for the clinical governance committee. Itreceived reports from the dementia steering group andpatient food forum. A number of changes had beenintroduced in relation to nutrition and hydration in2014/15. This included the introduction of blue crockeryto help people living with dementia to be able todistinguish food on the plate and therefore be able tohelp themselves more often and effectively. Menus wereimproved to support patients with swallowingdifficulties. More choices were added at mealtimes andchoices for patients with coeliac disease were increased.

• There were innovations in nutrition, which endeavouredto support people who needed help with eating anddrinking, but not make this stand out unnecessarily. The‘red tray’ which had been used in the past, and is notuncommon in NHS hospitals so staff can recognisepeople needing support with eating, had been phasedout. It had been replaced with a gold tray, which wasless distinctive and therefore more subtle alongside theregular pale yellow trays. There were also green trays inuse to highlight patients with food allergies orintolerance, although we did not see any of these in use.

• There was audit of patient nutrition and hydrationsupport with some good results and areas forimprovement. The nutritional audit in May 2015identified 94% of patients were assessed for nutritionwithin six hours of admission. There was, however, apoor uptake in the number of patients who had beenweighed (38%). Hospital dieticians had produced acampaign focusing upon raising awareness of whyweighing patients was important, but ward staffadmitted there was more work to do.

• There was a food and nutrition policy based uponguidance from the British Association for Parental andEnteral Nutrition. The policy guided staff to use thenutritional risk assessment tool (including bothnutrition and also hydration) to monitor patients whowere at risk of malnutrition. Patients were scoredagainst their risk of malnutrition/dehydration, and planswere then developed to address the risks. Those recordswe saw on ward we visited were well completed.

• Protected mealtimes had been introduced at the trustto provide an atmosphere and environment moresuitable for patients when eating. This limitedinterruptions and gave staff time to make sure peoplewho needed help with eating and drinking wereprovided with that. Visitors, unless they were specificallyhelping patients at mealtimes, were discouraged fromcoming in at mealtimes. This gave patients theopportunity to also rest after a meal and equally gavevisitors a break. Doctors and other clinical staff onlycarried out essential visits with patients. This wassupported by a trust protocol on protected mealtimes.

• Patients were fasted appropriately pre-operatively whenadmitted as inpatients prior to their surgery althoughthere were no tailored regimes. Therefore, all patientswere given the same instructions irrespective of theirplace in the operating list, although this was dividedinto morning and afternoon regimes. Patients who camefor day-case procedures were given appropriateinstructions about food and drink intake before theirprocedure. If a patient was operated on in an emergencysituation, their response to the risk of nausea andvomiting was managed in theatre and recovery eitherwith appropriate medicines or close monitoring.

Patient outcomes

• The hospital performed relatively well in the PatientReported Outcome Measures (PROMs) for April 2014 toMarch 2015. These were patients who reported back tothe hospital on their outcome following surgery for groinhernias, hip replacements, knee replacements, andvaricose veins. With the four procedures, and as with theEngland average, almost all patients reported theirhealth had improved when measured against acombination of five key general health-relatedindicators. Almost all patients having kneereplacements and all those having hip replacementssaid they experienced improvements when asked more

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specific questions (called ‘Oxford scores’) about theircondition. The hospital exceeded the England averagefor patient improvements in their health for groin herniasurgery and was much the same as what was a verygood national average for improvements in healthfollowing hip replacement surgery. The results for kneereplacement and varicose vein surgery for healthimprovements were good as well, but not quite as goodas the England average.

• The hospital performed well in all measures of thenational hip fracture audit, although the performance in2014 had slipped over 2013 for four of the sevenmeasures. In 2014 the hospital was better than theEngland average for patients being admitted toorthopaedic care within four hours; surgery beingcarried out on the day or day after admission;pre-operative review by a geriatrician; and patientsgoing on to develop pressure ulcers. All of thesemeasures had declined, however, when compared withthe performance in 2013, which has been excellent.Particularly good outcomes were: 71% of patientsadmitted to orthopaedic care within 4 hours in 2014,against an England average of 48%. Also, 71% ofpatients had a pre-operative assessment by ageriatrician, against an England average of 52%. Both ofthese performance measures had, however, declinedsince a better result in 2013.

In two other measures, namely bone-health medicineassessments and falls assessments, the hospital had a100% performance rate (England averages both 97%).Length of stay of patients had improved to just over 18days in 2014 (from 21 days in 2013) which was a day lessthan the England average.

• There were low levels of surgical site infections reported.The hospital reported to Public Health England (PHE)post-operative infections to patients followingprocedures for hip and knee replacement. A PHE reportthen compared the hospital’s results with nationalstatistics. The hospital last reported on hip replacementstatistics for April to June 2015. There were 23 patientssubmitted to the review in this period. None of thesepatients had to come back to the hospital to be treatedfor a post-operative infection. In data for 2013/14, therewere 98 operations reported on. Of these two patientswere readmitted to treat an infection. Kneereplacements were last reported on for the period

October to December 2014. There were 83 operationsand just one readmission for an infection. In the year2013/14 there were 72 operations reported on. Of these,three patients came back for an infection to be treated.

• The hospital performed well in national cancer audits asthey relate to surgery. In the lung cancer audit, at thehigh-end of the results, the hospital achieved 100% fordiscussing patients at a multidisciplinary level. At theother end of the results, only 86% of patients receivedan appropriate scan against the 91% England average.In the bowel cancer audit, the hospital also achieved100% for discussing patients at a multidisciplinary level.It was above the England average (so better) for theother measures including patients being seen by aclinical nurse specialist, and receiving a relevant scan.The hospital was also credited for havingwell-completed patient data.

• The hospital did not comply with 16 out of the 28measures for the first National Emergency LaparotomyAudit (NELA) 2014. This included there being not havingan operating theatre reserved for emergency patients 24hours a day; no formal rotas for associatedinterventional and diagnostic procedures (although thisis not uncommon in trusts of this size); some policiesnot relating to the seniority of operational staff(although a number of these had since beendeveloped); and no pathway for the enhanced recoveryof emergency general surgery patients.

• In the 2015 first NELA patient report (focusing on patientoutcomes), the hospital achieved the 70% target to becompliant with recommendations in only one of the tenstandards. Results were between 50% and 69%compliance in eight of the others, and less than 50%compliance in the remaining one. The compliantstandard was for a consultant surgeon and anaesthetistto be present in theatre. The standard failed (achievedfor less than 50% of patients) was for patients over 70years of age to be reviewed by a specialist in medicinefor care of the older person. This is a common failureamong almost all NHS trusts in England.

• The trust had produced an action plan following the2014 NELA audit, but accepted this was incomplete andprovided no assurance. There was, however, a NELAreview presented within clinical audit documentation.

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This described a joint clinical governance meeting withsurgeons and anaesthetists. This demonstratedimprovements had been made since the 2014 auditincluding:

▪ All patients having an early review (within six hours)by a consultant surgeon.

▪ All patients were admitted to theatre within six hoursof a decision to operate.

▪ A consultant surgeon was present at 97% oflaparotomies and 100% of those performed aftermidnight.

▪ The trust introduced mortality risk-scoring and 80%of patients now had their risk calculated prior toemergency laparotomy surgery.

▪ Areas for improvement identified in January 2015included (and if they had been improved by the nextgovernance meeting in September 2015):

▪ January 2015: Documentation of risk was very poor.Not progressed by September 2015.

▪ Consultant anaesthetists were present at only 40% oflaparotomies. This had improved to 80% bySeptember.

▪ Requirement for an integrated care pathway. Thishad not yet been produced.

• Patients we met on trauma and orthopaedic wardsreported good therapy services. Patients who neededactive and regular physiotherapy said this was providedseven days a week. We were told the physiotherapistswere good at motivating people and had a positiveoptimistic attitude. Some patients had also met with anoccupational therapist who provided practical supportto adapt to different temporary or permanent changesto a person’s mobility or living arrangements.

• Patient readmission rates after surgery (due tocorrective measures needed or infections) were abovethe England averages, showing, overall, more patientswere readmitted after surgery than expected. It shouldbe noted, however, that these statistics can fluctuateand are relatively sensitive to small numbers of patients.The data can also include patients returning for plannedreadmissions. However, overall, in data for July 2014 toJune 2015, there were 2% more patient readmissions forelective surgery than the England average, and 18%

more than average for emergency surgery. The positionfor emergency surgery had deteriorated in the month ofJune as the rate for the period June 2014 to May 2015was just 1% of patients readmitted. This was due to arise in readmissions for general surgery and plasticsurgery and urology.

Within the detail there were variable rates ofreadmission. Data for the top three elective specialtiesbased on the number of procedures carried out showed:

▪ Urology surgery had 32% more readmissions overthe England average. Some of these were plannedreadmissions for procedures such as 'trial withoutcatheter'.

▪ Plastic surgery had 13% more patients beingreadmitted. Some of these readmissions related to aplanned series of operations or wound and dressingchecks.

▪ Trauma and orthopaedic surgery performed betterwith 7% less readmissions.

In emergency procedures:

▪ General surgery had 23% more readmissions overthe England average. Some of these readmissionswere related to on-going intravenous therapy, woundand dressing checks.

▪ Plastic surgery had 32% more patients beingreadmitted. Some of these readmissions related to aplanned series of operations or wound and dressingchecks.

▪ Urology surgery had 7% more patients readmitted.

Competent staff

• The directorates incorporating surgery services(musculo-skeletal and surgery), were not meeting thetrust target for 85% of staff to have had their annualperformance review. Data provided to us showed thatby the end of September 2015 the non-medical staff, sonurses, operating department practitioners, nursingassistants, and other relevant staff, had achieved 64% inthe musculo-skeletal directorate and 57% in the surgerydirectorate. The compliance level was worse in the yearto the end of March 2015 when 44% of non-medical staffin the musculo-skeletal directorate had received anannual review, and 39% in the surgery directorate.Senior staff did tell us, however, the current system for

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recording performance appraisal data was poor andthey believed the numbers we had been given were notthe true picture. All the staff we asked, which was inexcess of 30, said they had their appraisal and had doneso each year.

• Medical staff were evaluated for their competence, andmet targets to have had an annual performance review(appraisal). This had improved significantly since itbecame a requirement of doctors’ registration to havean annual performance review as part of the‘revalidation’ programme. This was a 2014 initiative ofthe General Medical Council, where all UK licenceddoctors are required to demonstrate they are up to datewith the professional development and performancereviews and fit to practise. This is tested in part bydoctors participating in an annual appraisal leading torevalidation by the GMC every five years. By the end ofSeptember 2015 the medical staff had achieved 88% onaverage for performance reviews to be completed.Revalidation is due to be implemented for nursing stafffrom April 2016.

• There were guides for newly employed staff to helporientation and induction. Downton ward had producedan excellent ‘Useful Guide for New Staff’ for new nurses.This described the ward, staff who worked there, anduseful explanations of terms and acronyms in regularuse. There was also a comprehensive local inductionguide for new operating theatre staff. This included anintroduction to staff, systems and procedures.

• The hospital had a number of training and developmentopportunities for staff. There was a developmentprogramme recently introduced for nursing assistants inthe operating theatre department. The objective was forband two staff to work through an education anddevelopment programme to progress to band four.There were 23 staff now on the education programmewhich was being run by an experienced theatre sister.Other staff spoke of various courses and programmesthey had been enabled to attend. Staff said there wereno barriers to professional development as long as itwas relevant to their responsibilities or their futureobjectives. This included a physiotherapist who saidthey had been encouraged and enabled to progresstheir career.


• There was consistent collaborative working from staffcontributing to patient care, but with improvementsneeded in some aspects of culture within the operatingtheatres. There was a common sense of purpose amongstaff with the patient at the centre. We observed, andwere told, there was mostly no obstructive hierarchicalstructure and staff were valued for their input and roles.Staff said, however, there was some work to do to bringfully collaborative teamwork into theatre. For patientsafety, it is essential teams function effectively at alltimes. The collaborative and team-focused approach ofuse of the World Health Organisation surgical safetychecklist was mostly embedded well, but there weresome aspects of culture not working as well as it should.This had been recognised by senior staff and was beingaddressed.

• Therapy staff worked closely with the medical andnursing teams to provide a collaborative approach topatient rehabilitation. Staff and patients spoke highly ofthe physiotherapy care provided to surgery patients.There was multidisciplinary input involved with allpatient care. The patient records demonstrated inputfrom therapists, including dieticians, speech andlanguage therapists, and occupational therapists, aswell as from the pharmacist team, the medical team,and diagnostic and screening services.

• There was evidence of a strong multidisciplinaryapproach contained in national cancer audit results. Inthe 2014 bowel cancer and lung cancer audits, therewas 100% compliance with there being amultidisciplinary discussion in the 228 cases reviewed.This was above the England average of 99.1% in thebowel cancer audit and 95.6% in the lung cancer audit.

Seven-day services

• Cover out of hours for anaesthesia was appropriate tothe service. There had recently been some changes tothe anaesthetic cover as the trust had opened theobstetric theatre in the maternity unit 24 hours a day.This unit was located in a different part of the hospitalfrom the main theatres and a three-minute walk away(we estimated). Before implementing the change, astudy had been done to model the anaesthetic coverwith staff now no longer being within the same maintheatre location. The quantifiable risk of the change hadbeen measured as negligible, although some staff werenot yet convinced about the recent change. The clinical

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director, who we found was open to hear concerns andlisten to staff, had decided to review the practice againat the next clinical risk meeting. There had, however,been no impact on patients from one of the night-timedoctors working on occasions physically further awayfrom the main theatres as in the past.

• There was good support from consultants on callout-of-hours. Registrar and junior doctors told us theyhad good support from them either by telephone, or inperson when this was needed.

• The trust provided serious emergency surgery servicesaround the clock. There was a surgery team on site 24hours a day with support and specialist surgeons on calland able to attend the hospital within 30 minutes.Surgery after midnight was only that described as ‘lifeand limb’ and therefore in order to save life. The hospitalsterilisation and decontamination services alsooperated seven days a week to provide services totheatres and elsewhere. The surgery wards were openand admitting patients seven days a week around theclock and the surgical assessment unit was open forreferrals seven days a week from 8am to 8pm.

• As well as the 24 hour emergency theatre, there weretwo operating theatres open on weekdays andweekends from 8am to 6pm for emergencydaytimesurgery. One theatre was for trauma and orthopaedicsurgery, and the other for plastic surgerywhich usuallycovered orthopaedic and plastic surgery, and the otherfor more general surgery. The theatres operated from8am to 6pm. The service is was supported by aconsultant anaesthetist, a specialist registrar, and a coretrainee in anaestheticsa foundation year two doctor orspecialist registrar year one.

• Access to clinical investigation services was availableacross the whole week. This included X-rays, MRI scans,computerised tomography (CT or CAT) scans,electroencephalography (EEG) tests to look for signs ofepilepsy, and echocardiograms (ultrasound heartscans).

• There were arrangements for the supply of medicineswhen the hospital pharmacy was closed. A pharmacistwas also available on-call out of hours.

• Therapy staff were available in person or on call acrossthe whole week. If therapy staff were off duty, there wasaccess to certain staff out-of-hours through on-call

rotas. Otherwise, therapy staff (including occupationaltherapists, speech and language therapists anddieticians) were on duty on weekdays, andphysiotherapists worked seven days a week.


• Patient records were well managed. Almost all recordswere on paper, although one ward was trialling anelectronic patient-record system. Staff said they hadrarely experienced notes not being located as required.The notes were held in an electronic booking system,which tracked them when they moved around thehospital. Staff in the pre-operative assessment unitshowed us how records they needed had been recordedas being moved to the unit. These would be thereturned to the record store, or to wherever they werenext needed and the move recorded electronically.

• Access to patients’ diagnostic and screening tests wasgood. The medical and nursing teams said results wereusually provided quickly and urgent results were giventhe right priority.

• There was criticism from a number of staff in differentroles about finding information on the trust intranet.The system, known as ICID: Integrated ClinicalInformation Database had a wealth of information muchof which could be accessed by staff, and also the public.There were policies, care pathways, information leafletsand clinical guidance. Staff concerns were with thesearch facilities. They said unless you knew the exacttitle of the guidance or information you were looking for,it was very difficult to locate the information.


• Patient consent was well managed and appropriatelydocumented. Patients we met all said they had signedconsent forms following a discussion with the doctor.They had been given the opportunity to ask questionsand told the advantages and risks of the process theywere about to undergo. For some procedures, such astaking blood samples or general tests, specific writtenconsent was not required. However, patients would berequired to give implied or verbal consent. Thosepatients we asked said they were always asked for theirpermission for any procedure. One patient said staffwould say: “I am going to need to take your bloodpressure, is that OK?” Another patient said the nurses

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always told them what medicines they were being givenand why. In order to help with making consentdecisions, the day surgery unit had developed consentforms to send to patients in advance for certainprocedures. There was a helpful form with detailedinformation, for example, for patients undergoing abladder examination (rigid cystoscopy). The version wesaw had not yet been updated. It was produced inOctober 2011 and due for update in October 2014.

• Consent was being done well in practice, but recordsneeded improvement, and those areas recognised asweak in 2013 had not improved in 2014. Consent hadbeen audited by the trust to make sure it had beensought and provided in line with the trust policy. Therewere some good results and some were in need ofimprovement.

▪ In the 2014 audit, the correct form had been used in100% of cases reviewed (130 records were checked).

▪ All patients had signed the form where this wasappropriate and 100% of forms had been witnessedwhere this was required.

▪ The type of anaesthesia to be used was recorded on86% of forms.

▪ However, there were some poor areas of compliance.For example:

▪ Only 61% of forms had the name of the healthcareprofessional responsible for the patient. This haddeteriorated following a 70% result in 2013.

▪ Only 56% of forms had the person’s job title (64% in2013). This was particularly weak in general surgeryand orthopaedic surgery.

▪ Another area of weakness was with the requirementfor the person completing the consent form toinclude their contact details. This had only beendone in 15% of the forms. This was down from 20% in2013.

▪ Also, only 20% of forms recorded whether the patienthad been given a copy of the form.

▪ There was an action plan attached to the consentaudit, and comments as to how it would bediscussed at departmental clinical governancemeetings. The audit was undated, but appeared tohave been completed in August 2014. Although we

did not have all clinical governance meeting minutes,those we were given did not include any reference tothis topic being presented and actions agreed atlocal or directorate level.

• There was a standard policy for consent. This coveredwhy consent was legally required, and who wascompetent to provide it. The policy gave staff guidanceon consent for standard procedures, and went intodetail on consent for tissue storage, use and disposal,and clinical photography and video/audio recordings.

• The hospital had documents and processes forassessing a patient’s mental capacity, competence tomake their own decisions, and what to do if that waslacking. Those forms we saw in patient notes werecompleted as required. There were specific forms foruse in the event a person did not have the mentalcapacity to make their own choices. This was referred toas ‘consent form 4’. The form required the healthcareprofessional to confirm how they had determined thepatient did not have the capacity to consent. It went onthe show how the decision had then been made whichwas deemed in the best interests of the patient andinvolvement from the patient’s family or those close tothe patient. The trust policy described well how adecision taken by a patient was specific to theprocedure in question. Patients could also regain theircapacity, and the policy made it clear the decision wasfor that specific time and not for all future decisions. Itexplained how a patient may be able to take somedecisions, but more complex ones would require abest-interest decision. Staff were given a usefulreminder about how consent would be seen from theperspective of the patient.

• Among those staff we spoke with there was a goodunderstanding of Deprivation of Liberty. Staff had beentrained to have a working knowledge of Deprivation ofLiberty Safeguards, and when to apply them. One of theoccupational therapists we met had a clear andintelligent understanding of this subject as well as theMental Capacity Act. The trust had provided guidancearound what actions would amount to a Deprivation ofLiberty, and how to proceed to have the deprivationapproved. There was a decision-making tool on thetrust intranet for staff to follow if there was a situation orpotential situation where a deprivation would occur.There was guidance for staff to follow to apply for an

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authorisation to deprive a patient of their liberty, andwhat to do if authorisation was not given. On thosewards we visited on our inspection, there were,however, no current records to review.

Are surgery services caring?

Good –––

We have judged the caring of the surgery services as good.Feedback from patients and their families had been almostentirely positive. If there was criticism, this was not aroundthe care provided by the staff, but the time the nurses,practitioners, and nursing assistants had to provide careand support. This was echoed by the staff themselves. TheFriends and Family Test produced excellent results.Patients we met in the wards and other units spoke withoutcriticism of the compassion, kindness and caring of all staff.Staff ensured patients experienced dignified and respectfulcare, and worked hard to promote patients’ individualityand human rights.

Patients and their family or friends were involved with theircare and included in decision making. They were able toask questions and raise their anxieties and concerns. Therewas, however, some criticism of communication withpatients who were waiting for procedures. There wasaccess to chaplaincy services and support from nurses anddoctors with specialist knowledge.

Compassionate care

• Patients spoke almost overwhelmingly of the kindnessof the staff. Patients on Downton ward made commentslike: “I have been treated so well”, “they speak so kindlyto me”, and “they look after you so well.” We observedstaff knocking on doors before entering rooms,addressing patients by their preferred name, and gettingdown to the level of a patient to talk with them. OnChilmark Suite, patients said staff were “all a differentpersonality, and each one brings a different talent.” Wewere told all staff introduced themselves to patients. Apatient said: “I obviously did not want to be here, butdespite that, it’s been a pleasure.” Another patient toldus they did not like the bay being really dark at night asthey were nervous of the dark. They said staff made surethe low wattage light over their bed was on at night tomake them more comfortable. Other patients said it was

a dim light and did not cause them a problem. On all thewards and units we visited, we heard positive commentsabout the care they received and the kindness of thenursing staff. On our unannounced visit, a patient inChilmark ward said of the hospital: “sometimes Imistake it for a five-star hotel.” The same patient hadvisited other services within the hospital for various testsand said: “no matter where you go in the hospital thestaff are excellent.”

We have written above about how a number of patients wemet were concerned about nursing-staff levels. We heardnumerous concerns about staff being “rushed off their feet”and “just doing too much.” We heard, nevertheless, howstaff were very caring for patients. The comments aboutpatients having to wait too long for staff to assist werebalanced with staff who we saw:

• Helping a patient who was going home to pack up theirbelongings neatly and tidily into bags.

• Gently helping a patient who was confused to arrangetheir bed clothes to preserve their dignity.

• Giving reassurance to a patient with a learning disabilitywho was going for a day-case procedure.

• Being cheerful and encouraging with a patient who wasrecovering in the main theatre recovery area. Thepatient, who was fully awake from their procedures, saidthey had got to know the staff and “they are wonderful.”

• Patients remarked upon the commitment andindividual approach of the doctors. One patient whohad been in the Burns Centre for a number of weekssaid they thought the care of the consultant was“outstanding”. They said the consultant had visited themregularly both in the daytime and in the evening tocheck if they were okay. They said the care by both thenurses and the medical team in terms of time given tothem could not have been better. Another patient onChilmark ward said their consultant had been honestbut also firm with them to make sure they understoodhow to respond to treatment and advice so they had thebest chance of recovery. A number of patients told ushow they had great faith and trust in the consultantsand junior doctors.

• We observed good attention from all staff to patientprivacy and dignity, although the recovery areas inday-surgery were not ideal. Any patients we observed inthe operating theatres were fully covered in allpreparation and recovery rooms, and when returning to

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the ward areas. On wards curtains were drawn aroundpatients, and doors or blinds closed in private or siderooms when necessary. There were privacy screensprovided in the surgical assessment unit to improveconfidentiality. There was one area where privacyarrangements were not ideal. This was in the tworecovery areas in the day-surgery unit. One was a smalland cramped four-bedded area where patients were ontrolleys in a line with curtains separating them. Thismeant confidentiality could be an issue, as there was noaudible privacy. Patients able to or needing to be movedwould have to be moved past the foot of the trolley ofanother patient if they were in the inner area of the unit.Staff said they endeavoured to use this area asefficiently and sensitively as possible, but with a busydepartment, this was often a challenge. The other was asmall area separated from a corridor by a curtain. Thisarea could be used for two patients, but there was nocurtain available to provide any privacy in thosecircumstances – which staff described as rare.

• The NHS Friends and Family Test results for the surgerywards and units showed excellent results. Patients wereasked to say if they would recommend the ward to theirfamily and friends. In the six months from April toSeptember 2015, 97% of patients were either ‘extremelylikely’ or ‘likely’ to recommend their ward to family andfriends. The test was responded to by an average of 37%of those patients admitted (2,480 patients). Theindividual ward details for September 2015 (the latestavailable data) were:▪ Amesbury Suite (trauma and orthopaedics) would be

recommended by 99% of patients (response rate of56%).

▪ Britford ward (general surgery and urology) would berecommended by 97% of patients (response rate of65%).

▪ The Burns Centre would be recommended by 100%of patients (response rate of 26%).

▪ Chilmark Suite (trauma and orthopaedics) would berecommended by an average of 90% of patients(response rate of 78%).

▪ The day surgery unit would be recommended by98% of patients (response rate of 23%).

▪ Downton ward (general surgery and urology) wouldbe recommended by 100% of patients (response rateof 21%).

▪ Laverstock ward (plastic and oral surgery) would berecommended by 100% of patients (response rate of42%).

• The trust scored well for patient privacy and dignity inthe Patient-Led Assessments of the Care Environment(PLACE) surveys in 2013, 2014 and 2015. The results hadbeen relatively stable in the last three years and were89/100 in 2015. This was against the England average of86.

• Comments made about the staff in more direct patientfeedback comments were almost always positive. Of the105 comments made about staff in the feedback for Mayto July 2015 in the musculo-skeletal directorate, 82 werepositive. Of the 33 comments in the surgical directorate,26 were positive. Written comments included: “My stayhas been brilliant. Staff are wonderful”, “Lovely ward –smiley, happy and chatty staff. Really happy here. Neverhad a bad experience” and “Staff always have a smile oftheir face.”


• Friends and relatives of patients were kept informed andinvolved with decisions when appropriate. Relatives andclose friends of patients we met said they were able toask questions and could telephone the wards anddepartments when they were anxious or wanted anupdate. A comment from a patient in the direct patientfeedback survey carried out on Downton ward was: “Thedoctors were very good and explained everything to myson, even using a model, and he explained it to me. Thedoctor and staff are absolutely wonderful. Nothing is toomuch trouble.” Another comment was: “Most of the staffare very good about explaining everything.”

• Patients were given time to ask questions about theirprocedure and address any anxieties or fears. Thenurses in the pre-assessment clinic, for example,demonstrated a level of understanding of their patients’potential to become anxious, even with day-caseprocedures where the operation was less of a risk orcomplexity. To help support anxious patients or thosewho might be unable to absorb all the informationbeing given to them, families or carers were able toaccompany the patient when and where it was safe andappropriate to do so.

• We met some patients who felt communication withthem could have been better. This was one of the topthemes in complaints made to the trust. One patient

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had been admitted through the emergency departmentwith a fracture. The patient and a relative who was withthem said they had been told at numerous times overtwo days they were being fasted before surgery. Theyeventually were operated on in the third day sinceadmission, but had not eaten prior to this for two days.Another patient said they been seen in the pre-operativeassessment clinic in June 2015 and then not heardanything further. They had called the hospital threetimes without any progress before getting anappointment for an operation the following week. Theysaid this had been really hard on them for the last sixmonths and they now had to prepare for an operationwith almost no notice.

Emotional support

• There was access to a team of chaplains for people of allfaiths or none. The chaplaincy team were available inworking hours and then on call 24 hours a day all yearround. There was a chapel for people to use which wasdescribed on the trust website as “for quiet reflectionand prayer.” There were regular services in the chapeland advertised on noticeboards throughout thehospital. Chaplains also visited patients and families onthe wards by request and were highly regarded by staffon the wards and units. When we visited on ourunannounced inspection, there was a service led by thechaplain and attended by patients in the chapel.

• The need for emotional support was recognised andprovided in certain situations. For example, there wasemotional support provided to a patient we met at theBurns Centre. They spoke with us about this and saidhow the nurses had recognised the patient neededsome support with how they were feeling. Apsychologist came and spoke with them. Consequently,the patient said they were able to feel they were notalone with how they were feeling and it was fairlynormal. They described the care as being individual andtaking into account the whole person and not just theinjury. Wards used the Hospital Anxiety and Depressionscale (known as the HAD scale) to review a patient’semotional state. Staff said they were able to get supportfrom the mental health team if a patient neededsupport for anxiety or depression.

Are surgery services responsive?


We have judged the responsiveness of surgery services asrequires improvement. This was due to the hospital notresolving the conflict between meeting targets for patientsto have treatment and putting undue pressure on servicesto perform to the detriment of patient experience and staffstress. There were many good aspects of responsiveness inthe surgery services, not least the meeting of referral totreatment times, low rates of cancelled surgery, meetingpeople’s needs for information, listening to them andresponding to their complaints.

But the pressure for beds within the hospital meant: toomany patients were being discharged home from the maintheatre department after a long wait in recovery; long waitsfor emergency surgery; patients were being moved to theday surgery along cold corridors either to beaccommodated overnight, or to be checked before thengoing home; and there not being a bed available in themain wards so patients being accommodated in the daysurgery unit when this facility was not designed forovernight accommodation. There were delays, changes tosurgery lists and cancellations resulting from holes indrapes used to wrap surgical instruments, and somesurgical sets not being available at the right time. Theflexibility of the surgery teams was limiting the impact onpatients, but some of this was easily resolved with betterplanning and communication.

Patients were complimentary about the food and drinksserved, and there was some very high praise for the qualityand variety of the food. People who needed more supportcoming to hospital were well looked after. This includedthose without English as a first language, or othercommunication needs, but there were no specialist nursesto support patients with a learning disability or staff caringfor them. Staff were kind and patient with people withdementia, but there were limited facilities on the wards,such as easy to read signage and dining areas being usedto help frail confused patients. There was promotion ofsupport groups for patients and carers, and an excellentrange of leaflets and information provided. There was anexcellent practice in relation to staff with link or championroles. Both nurses and nursing assistants were assignedtogether to be links or champions of certain aspects ofpatient care and support.

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• Surgery services at Salisbury District Hospital wereestablished to meet the needs of local people, but alsothe wider community. This included providingemergency and planned surgical services to patientsneeding the most common procedures such as traumaand orthopaedic (including hip and knee replacements),general surgery and urology. The hospital was alsofunded by local clinical commissioners as the regionalcentre for both burns surgery and plastic surgery.

• The hospital accommodated surgical patients in the daysurgery unit when there were no other beds available,although this area was not designed for this purpose.There was a protocol for staff to follow saying whichpatients could be admitted to this area for an overnightstay and which would not be suitable. So patients whowere not fully mobile, or needed packages of care athome, were not to be considered. If a patient lived witha severe systemic disease which was otherwise notincapacitating, they could be admitted but with theassessment and approval of a consultant anaesthetistor consultant surgeon. There were 101 patients cared forin the day-surgery unit in November over 18 nights. In2015 to date, there had been 508 patients in total over63 nights on the day surgery unit. This was not a newsituation for the hospital and staff said it had beenhappening now for many years and now felt like anormal solution to a growing problem of bed capacity.In 2014 there were 775 patients in day surgery over 92nights. Staff said they were demoralised by not beingable to function as a proper day-surgery unit. A memberof staff said they were “emotionally exhausted” due tofeeling they were treating patients like “they weresomehow second class.”

• Although use of the day surgery for overnight stays wasnot ideal for patients, there were reasonable facilities.Patients would be accommodated in single-sex areas;there were toilets that could be designated then forsingle-sex use; there was a shower and a disabled toilet;and the normal facilities of the hospital such asphysiotherapists, pharmacists, security, food and drinks,and laundry would be arranged to supply theday-surgery unit. However, the unit was some distancefrom the main hospital area and staff said they feltremote at night, although knew the spinal injuries unitwas not too far away.

• There was some poor planning in the availability ofsterile surgical instruments. Combined with holes insome of the drapes used to wrap equipment (discussedabove in the Safe section) was the occasional lack oftrauma equipment, which had not been processed inthe sterilisation service. For example, emergencysurgery on 12 December 2015 required specificcannulated screw sets. Only one set of these wasavailable in theatre, but two were needed. The secondprocedure was delayed by three hours and the order ofoperations changed so as not to cancel other patientswhile another set of screws was prepared. Anotherprocedure was cancelled the following day due to theright size screws not being available. Delays to this typeof surgery run the risk of the outcome for the patientbeing compromised, particularly with younger people.The holes in drapes wrapping the surgical sets alsocaused delays to surgery and cancellations toprocedures.

• The hospital ranchose not to run a dedicatedemergency operating theatre, which was reasonable interms of the population and services provided.However, some patients had to wait a long time foremergency surgery. We reviewed the operating list foremergency patients for 4 December 2015. There were 26patients on the list. Of these, 15 had been waiting morethan 24 hours. At the top end of the scale were threepatients waiting between 94 and 182 hours. Althoughthese patients were classified as emergency, the listreviewed did not have any patients who were of a highpriority and therefore at unacceptable risk. Theemergency operating list included patients waiting forsurgery who were not yet ready for their procedure andwould be taken to theatre when their clinical conditionwas

• Patients were safely admitted for surgery. Patients wereadmitted to main theatres through a dedicated surgicaladmissions lounge. This was an area adjacent to maintheatres and prepared patients for their procedure bydedicated staff. Up to 30 patients could beaccommodated at any time in this area. Day-casesurgery patients were admitted through theself-contained unit. The unit received patients for twolists: one in the morning and the other in the afternoon.Patients were met by a receptionist who booked themin. They were then met by staff and taken to the mostappropriate part of the unit for their procedure.

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• The hospital was meeting or close to NHS Englandconsultant-led referral to treatment time (RTT)standards in the seven reportable surgical specialties. Oflate, the hospital performance had dropped slightly.When taken as an average based on the number ofpatients, in August 2015 (the most recent publisheddata) the referral time for patients waiting to starttreatment within 18 weeks was 94.1% against the NHSoperational standard of 92%. The trust was meetingreferral times in August 2015 for general surgery, ear,nose and throat, ophthalmic, and oral/maxillo-facialsurgery. It was just below for urology, trauma andorthopaedic, and plastic surgery, but over 90% in thosespecialties.

• Looking back at this financial year, the hospital hadbeen meeting all RTT standards in April and May 2015,but saw general and urology referrals drop below the92% standard in June. The position had recovered forgeneral surgery by August at 92.8%. Urology hadimproved, but was still slightly below standard in August2015 at 91.7%. Plastic surgery waiting times dropped to91.4% in July and dropped again to 90.8% in August.Trauma and orthopaedic referrals had dropped to90.9% in August 2015, which was the first time below92% in these five months.

• Some waiting lists for treatment were increasing whileothers were reducing. Overall, since April 2015, thewaiting list had grown by 2.6% or 194 patients.Incomplete pathways (patients waiting to starttreatment) had improved by August 2015 for somesurgical procedures, but had increased for others. Therewere 433 patients waiting for general surgery, up from399 in April 2015. There were 732 patients waiting forurology surgery in August 2015, which was up from 639in April. Patients waiting for trauma and orthopaedicsurgery in August had increased to 1,786 from 1,660 inApril. The waiting lists for ear, nose and throat,ophthalmic and plastic surgery had, however, fallenoverall by 4.3%.

• The hospital was performing as well for average waitingtimes as others in the local area. Average (median)waiting times for patients for surgery were the same onaverage as those for the South of England NHSCommissioning area. In August 2015, the South ofEngland average waiting time was seven weeks. Theaverage for the six specialties at Salisbury DistrictHospital (in terms of how many patients were waiting tostart treatment) was also seven weeks. There was some

variation in the detail. Oral surgery patients only had a7.7 week wait in Salisbury but 10.3 weeks in the South ofEngland area. The average for the South in trauma andorthopaedic surgery (the largest of the specialties) was7.1 weeks, but eight weeks in Salisbury.

• The number of operations cancelled at the hospital fornon-clinical reasons was below (better than) theEngland average and all eligible patients had beentreated within the next 28 days. In quarter one of 2015/16 (April to June 2015: the most recent available data)the hospital cancelled 95 elective operations (of thoseoperations meeting the NHS non-clinical cancellationcriteria) compared with an average of 134 nationally.When looked at in terms of the number of electiveprocedures, the rate was slightly higher than the NHSEngland average with 1.4% of all elective surgeryadmissions cancelled at Salisbury District Hospital,compared with the national average of 0.9%. Thepercentage of cancelled patients not treated within 28days of a cancellation was, however, exceptional. Therewere no patients in the period from April 2013 to June2015 not being operated on within the next 28 days.

• Although cancelled operations were below average, thenumber cancelled for non-clinical reasons each monthhad increased sharply at one point. Operationscancelled in the period July 2013 to June 2014 werearound 62 on average each month. In the year from July2014 to June 2015 the average had increased to 92 amonth. Staff we asked we not able to tell us why thismight have happened, but did not recall any specificincident or decision taken that would have affected this.

• The trust had links to a number of organisations toprovide additional support to patients and carers. Thisincluded local carers’ support groups, advocacyservices, drug and alcohol support, and links to nationalcharities such as the Alzheimer’s Society and DiabetesUK.

Access and flow

• There were too many patients being discharged homedirectly from the main theatre recovery area followingsurgery, or on to the day surgery unit for eventualdischarge. This was now around 10 patients per week.Staff said this was done with the best intentions in ordernot to cancel surgery, but this was not meeting theneeds of patients. If patients were able to be dischargedhome from the main theatres, this would suggest thesepatients were not being operated on in the right

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location and should be day-case patients. Staff on theday-surgery unit told us there were patients who wereday-case being operated on in the main theatre. Theysaid staff there were not trained or experienced (as theydid not need to be) with getting patients recovered andhome on the same day, and did not have the recoveryfacilities for this. The operating list for the morning of 3December 2015 showed at least five patients who wereprobable day-case patients. The main theatre waslooking to discharge them through the day-surgery unit.We looked back at records and on 17 November 2015there were 11 patients and on 1 December 2015 eightpatients transferred from main theatre to theday-surgery unit for discharge, and this was clearly notuncommon. Similarly there were patients beingoperated on in the day-surgery unit who were notday-case patients and were being planned for anovernight stay. Staff said there was not any useful dataon this being collected but gave us a range of recentexamples from operating lists.

• Occupancy levels were increased by people unable tobe discharged. There were a high number of patientswho were fit for discharge, but remaining in the hospital.The data about delayed transfers of care was for thewhole hospital (so included medical patients) but wouldhave an element of surgery patients. There were around31% of patients in the period April 2013 to August 2015waiting for support to be provided at home before theyleft the hospital. A further 35% were waiting forplacements in a residential or nursing home.

• Although the data is for the whole hospital, there werelimited multiple moves of patients and moves ofpatients at night. In the period from August 2014 toOctober 2015, the highest number of patient movedmore than three times was four patients in December2014 and in May 2015 (0.12% of total admissions) and0.08% of all patients overall. Patients moved more thantwo times affected 0.25% of patients over this period. Interms of the time patients were moved, betweenOctober 2014 and September 2015 there were around150 patients moved between 9pm and midnight (0.5%).This then dropped to around 105 patients (0.3%) movedin the eight hours between midnight and 8am. Evidencesupplied by the trust indicated around two-thirds ofthese patients were medical patients, and theremainder would have therefore been surgical patients.


• The majority of patients complemented the food. ThePatient-Led Assessments of the Care Environment(PLACE) surveys said the hospital had significantlyimproved for food provision. The score had improvedfrom 68/100 in 2013, to 83 in 2014, and was 95 in 2015.This was against the NHS England average of 88 in 2015,and 2015 was the first of these three years where thehospital had been better than the NHS average. In themore direct feedback from patients on the wards,comments were, however, not always favourable. Of 184patient surveys in the musculo-skeletal directorate inMay, June and July 2015, 52 held negative commentsabout food and 78 were positive (the rest did notcomment on the food). Of 58 patient surveys in thesurgical directorate in May and June 2015, 18 hadnegative comments about the food and 14 were positive(the rest not commenting). Having said that, some ofthe positive written comments included: “very tastyfood – feel like I am in a hotel”, “Excellent choice offood”, and “Very pleased with the quality of the food.” Allthe patients we met were complementary about thefood and made comments including: “it’s changed myperception of hospital food for the better”, “reallyimpressed with the food”, and “I like how I can ask for asmall portion as I don’t feel much like eating and that’ssomething they seem to have recognised, which isgreat.” Another patient said how impressed they werewith the vegetarian food options and how there werewell thought-out alternatives each day.

• The trust changed menus each season and ninety-fivepercent of food provided to patients was produced onsite. Wards had pictorial menus to help people makechoices.

• The hospital had significantly improved in patient viewsof the environment and facilities in the PLACE survey.The score had improved from 80/100 in 2013 to 93 in2014 and in 2015 was 95. This was against the NHSEngland average of 90/100 for 2015.

• Most patients had access to entertainment systems,although these were not free to access. Bedsideequipment provided access to television, the internetand radio. There were no entertainment facilities in theday surgery unit, although patients who were stayingovernight were able to watch television in one of thewaiting areas once day surgery had finished for the day,and if they were well enough.

• There were limited facilities for providing the escalatingnumber of patients who were delayed in leaving the

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recovery area with something to eat and drink. Themanager of the recovery team said this was of particularconcern. There were also no toilet facilities for patients,and some were waiting seven or eight hours at times tobe discharged.

• Patients with additional or extra needs were supportedfor their admission to hospital. Advanced arrangementscould be made for a patient with a learning disability tomake their visit to the hospital easier for them and anycarers. Staff on the day-surgery unit said this hadincluded arranging a ‘walk-through’ of the operatingtheatre for a patient and their carers which was found tobe helpful. Patients were also able to use quiet rooms orgiven early appointments so they could be seen first.The trust had a policy for adults with a learningdisability attending hospital. There were links for staff toapproved ‘easy read’ documents at the British Instituteof Learning Disabilities, the University of Birminghamand Bristol University. The hospital did not, however,have a specialist nurse or a team of staff trained tosupport people with learning disabilities and stafflooking after them at the hospital.

• The hospital had produced ‘Care Cards’ for patients withspecific requirements. These yellow credit-card sizecards could be ordered from the hospital and presentedto staff to highlight different needs. There was a leafletavailable to provide to patients or carers to order a card.The card did not contain personal information, butwould direct staff to check the patient’s records to checkwhat specific needs the patient had. The patient mighthave impaired hearing or vision, for example. The cardhad space for or carer to record an emergency contactnumber or a note of the identified need if the patientagreed to record this.

• Patients living with a dementia who came to thehospital were generally well supported, althoughadvance information about their condition was notalways available, and training uptake in dementia carewas poor. In relation to advance information, forexample, staff in the pre-operative assessment clinicsaid they had met with patients who were living with adementia and this was not clear in their notes, or knownabout in advance. In one case, the staff had been able toget advice and support from the patient’s care workersabout how to communicate best. We met with the trustlead for dementia and a consultant in elderly medicineand dementia. One of their main concerns was the pooruptake from staff in ward-based dementia training,

which was offered to staff on the wards in bite-sizedsessions of 30 minutes. The most often offered excusewas staff were too busy. Staff were therefore doing theirbest with stretched resources to support patients livingwith dementia. The surgery wards did not, however,provide any specific prompts or much more thanenhanced signage to assist people living with dementia.There were some places for people to sit other than bytheir bed, but we did not see any patients using theseareas for meals, for example. Patients were not able sittogether at a table to eat, when it has been recognisedthis would often be a trigger to help confused patientsto eat and drink. Communal corridors were very similarand plain with no triggers to help orientation. Therewas, however, plenty of light on the wards to help withreduced vision or light perception.

• Hospital staff had developed a support group forpatients suffering burns or undergoing plastic surgery.The trust facilitated a charitable organisation to providesupport patients who had suffered burns. The BurnsUnit Support Group (BUGS) was founded in 2000 by staffat Salisbury District Hospital and a former patient. Thegroup was run voluntarily and now included a widergroup of patients under the care of a plastic surgeon.The support group provided a range of help includingpractical and professional information, discretionalgrants for research, funding for various projects andevents, and emotional support.

• There was an extensive range of leaflets and informationsheets in many areas of the hospital. This included pre-and post-operative care information, including for totalknee and hip replacements, spinal surgery, skin-flapsurgery; care for injuries such as burns and brokenbones; and how to improve self-care to avoid risks of, forexample, blood clots and pressure ulcers. Informationleaflets extended to more specific conditions, such as‘trauma pain management in the drug dependent’. Theday-surgery unit had an extensive range of informationfor patients to take away following any procedure.Before patients came to the day-surgery unit they weregiven a booklet with information about preparing for anappointment, taking medicines, contacting the unit,what to bring, and what will happen on the day of theoperation. There were helpful maps of the hospital onnotice boards, printed information, and the trustwebsite. The majority of patient information and leafletscould also be obtained from the trust website.

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• The hospital trust provided translation services wherethis was needed. The trust had engaged third-partyservices providing face-to-face and written translationand British Sign Language. These services wereavailable during the week in the daytime. There wasotherwise a telephone translation service available 24hours a day.

• There was excellent use of nursing and healthcare staffin link roles. These were staff on wards and units whowere given roles in certain aspects of care and support.Where possible they were enabled to link with hospitallead nurses or doctors to be part of a network ofsupport. On Downton ward, for example, there wereboth nurses and nursing assistants partnered with linkroles. These included among others, infection control,tissue viability, falls, diabetes, nutrition. Each role hadresponsibilities attached to it, which had been helpfullywritten into a protocol for staff. The responsibilitiesincluded attending link meetings, cascadinginformation to all ward staff, completing and signing-offstaff competence, auditing performance, andchampioning certain care bundles and pathways ofcare. There was a similar process on Britford ward withnursing and healthcare staff partnered in taking the leadon subjects like Deprivation of Liberty, dementia, painand medicines.

• Patients were treated without discrimination throughthe use of staff mandatory training and some, but notall, policies assessed and approved for equality anddiversity. The complaints policy had been ratified forquality and diversity, as had the food and nutritionpolicy, but the consent policy we were given did nothave a written review of any discrimination within thepolicy. Where the policies were reviewed this hadincluded there being no barriers to patients on groundsof sex, race, religion of belief, sexual orientation,marriage or civil partnership, disability, pregnancy andmaternity, gender reassignment, or any additionalcharacteristics important to the policy. From talking withstaff and hearing about the patients who had beenadmitted to the hospital, there was no evidence of anydiscrimination on any of the above protectedcharacteristics. The lack of any discrimination extendedto any visitors to the unit, who were given full accessrights while required also to act in the best interests of

the patient. Staff spoke about respecting people’swishes, rights and beliefs. They were able to describe awide range of different needs and talked about patients’individuality and right to be different.


• The hospital provided a Customer Care Team to dealwith concerns and complaints (and compliments).There were leaflets about the service available in wards,units, and relevant areas for patients or their relatives/friends. This included how to raise a concern, who tocontact and when they were available. Details explainedhow the complaint would be handled and what acomplainant could do if they were not satisfied with theresponse. Patients were also told of their rights, in thatthey were entitled to a copy of any letter written aboutthem. The leaflet was available in different formats andlanguages upon request.

• Customer Care reports were presented in detail to thetrust board each quarter with an annual report eachyear. These reports highlighted how many complaintshad been received, if targets were being met for aresponse, along with the trends in complaint topics. Thereports gave examples of improvements made followingcomplaints. In the most recent published quarterlyreport for April to June 2015, all complaints (which werethose for the whole trust) had been initially respondedto within three working days. The majority of complaints(88%) had a full response within 24 days. Othercomplaints had more complexity or required meetingsto be held before they could be considered as closed.For the musculo-skeletal directorate there were 21complaints, which was much the same as the numberreceived in the previous two quarters. Complaints hadincreased in the surgery directorate, but many of thesewere related to issues with outpatient appointments. Toput the numbers into context, there were 21 complaintsin the musculo-skeletal directorate out of over 18,000patient activities and 22 complaints in the surgerydirectorate out of over 16,000 patient activities.Concerns amounted to 27 and 37 respectively, and therewere 121 and 81 compliments received. In the annualreport some of the actions taken following complaintsincluded the recognition of the use of face-to-facemeeting; staff attitude addressed through appraisal andperformance management; and improvements inresponse to call bells, which was an item on the riskregister.

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• Complaints were discussed in departmental meetingsto look for trends developing in themes or areas.Information was provided at meetings to reviewcomplaints by division or specialty and then at thethemes from the complaints. The information coveredthe last three years, so improvements or deteriorationscould be seen. One of the developing themes in surgeryservices was with appointments and this had beenraised on the directorate risk register.

• We reviewed a complex complaint from a patient inrelation to issues of consent. We reviewed the responseof the trust, which had followed the complaints policyand procedure. There were face-to-face meetings, andan unreserved apology made for some clear areaswhere things could have been done better.

Are surgery services well-led?

Good –––

We have judged the governance of the surgery servicesoverall as good with some areas requiring improvement.There was an effective governance structure, althoughsome of the notes from meetings within divisional teamsneeded improvement. The majority of risks, incidents,audits, complaints and quality performance indicatorswere presented to directorate management, reviewed anddiscussed. There were actions and learning, but this wasnot always demonstrated through minutes. There weresome audits not included as standing agenda items, suchas the surgical safety checklist, and surgical readmissionrates, although most others were presented and discussed.The two surgery divisional teams had recognised andaddressed some of their shortcomings, such as use of thesurgical safety checklist, and acted to bring in best practice.

There did not appear to be a strategic vision for the futureof surgery services. There were some plans, based aroundwhat was required by NHS England and Monitor for 2015/16, but this was individual service development rather thanan overarching strategic plan. The divisional risk registersneeded to define clear actions and demonstrate theirprogress.

There was committed leadership of surgery services. Thiswas at both ward and unit level and with the leadershipteams. All the staff we met showed dedication to theirpatients, the place they worked, their responsibilities, and

one another. There was a strong camaraderie within teams.We were impressed with the loyalty and attitude of the staffwe met. However, despite a dedicated and caringworkforce, the workloads from incorporating high use ofagency staff and many new staff were causing staff stressand anxiety, which had not always been recognised. Therewas a high level of engagement with the staff and public.The hospital valued direct feedback from patients, whichwas more detailed and specific than the NHS Friends andFamily Test. Staff were recognised through awards given bythe trust at the hospital for many things, includingdedication, innovation and being caring.


• From information we were given, we could notdetermine a longer-term vision and strategy for surgeryservices beyond what was requested by NHS Englandthe NHS foundation trust regulator, Monitor. Thesefuture developments were service specificdevelopments over 2015/16. There was no overarchingstrategy looking at innovation, sustainability,improvements and service design for, say, the next fiveyears.


• There were mostly good arrangements for governanceand risk management although some inconsistency inquality of meetings and the notes produced. Manyaudits, incident reports, and other quality informationwas being received and reviewed at clinical governancecommittee meetings, but there were some items notregularly on the agenda. Items not regularly appearingon the relevant directorate agenda included, forexample, the concerns and subsequent progress withthe audit of the surgical safety checklist; theunimproved consent audit; surgical readmission rates,and a report of progress following non-compliance withmany of the assessments of the National EmergencyLaparotomy Audit 2014.

• Clinical governance meeting minutes for thedirectorates demonstrated there was discussion ofincidents, complaints, good practice, resources, safetyand risk. Updates from the divisions within thedirectorate fed into meetings, as did information fromother parts of the governance structure, such asinfection control and risk management. The quality ofthe minutes from the divisional meetings was variable.

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The managers of the directorates agreed there was not aset format for clinical governance meetings within theirdivisions to ensure consistency in what was discussed.Some minutes were good, but others did not recordwho attended, did not appear to have a set agenda, andthere were no actions or review of previous actions orlearning. Examples of this included the minutes of 21April 2015 of what appeared to be the orthopaedicteam, and those of the ophthalmology department from23 January 2015. No names were provided, no record ofwho recorded the minutes, and there were no agreedactions or learning identified.

• There was commendable practice around bringing a‘sense-check’ to directorate meetings. At the regularmonthly specialty meetings, the regular attendees wereable to bring a member of their staff team with themwho would otherwise not attend. This member of theteam was asked to listen to the meeting content, see if itmade sense to them, and whether it described theservice they worked in.

• The directorate divisional risk registers were being wellused, although it recorded only risks and not actionplans for resolving or reducing the risks identified. Risksrated as ‘extreme’ or ‘high’ were escalated to the trustrisk register and allocated to a directorate or team toown, manage and reduce to an agreed level. The trustused SORT: the Salisbury Organisational Trigger Tool, toallow staffhad a self-assessment risk tool to or teams toenable teams to review safety in their department orservice. assess their own risks and escalate issues to thedirectorate manager. This process was carried out twicea year in preparation for mid-year or year-end reports, ormore frequently if there were areas of concern to raisewith the executive team or managers.and there wasgood contribution from both the medical and nursingteams.

• The directorates divided their responsibilities intoseparate forums for discussion. The directorates heldmonthly performance meetings with members of theexecutive team where items such as finance, humanresources and risk management were discussed. Therewas some clinical governance discussed at thesemeetings, but this was in relation to performance andnot high-level matters. There were ‘stocktake’ meetingsheld every quarter chaired by the trust chief executive.two months. These looked at the divisional issues andreceived reports on patient feedback, audit results,

National Institute of Health and Care Excellence (NICE)guidance and quality standard compliance, and reviewsof incidents, complaints and compliments. Performancewith waiting times and referrals were also presented.There was a comprehensive report for each directoratefrom human resources showing staff turnover, appraisalcompliance, update training compliance, and staffabsence levels.

• There was an excellent nursing documentation auditwith an annual report produced. The audit reported onfive sets of random notes collected from each of thesurgery wards (other wards were also covered). Theywere examined by one of the nurse consultants. Actionsfrom the audits were presented at the nursing,midwifery and allied healthcare professional forum.Four areas were assessed:▪ Nursing assessment on admission (29 standards).▪ Record keeping (7 standards).▪ Reassessment during admission (15 standards).▪ Care planning (9 standards).

There was an improvement in the first area, although asmall deterioration since the 2014 audit in the other areas.Nevertheless, results were above 80%, but none actuallymet the targets of 95%.

• There were regular meetings between staff and teams ofvarious roles, although not in all areas. Those takingplace included, for example: theatre staff who met todiscuss their risks and some aspects of performance;senior sisters meetings which were minuted under theCQC questions of safety, effectiveness, caring,responsiveness and leadership; and department leadsand clinical nurse specialists who met and discussedactions from their previous meetings, appraisals andtraining compliance, staffing issues and qualityperformance. Staff on Britford ward said they had nothad a ward meeting for over a year, although said therewere other meetings, including safety briefings threetimes and day and handover meetings.


• There was committed leadership for the surgerydirectorates. Each directorate in surgery services had aclinical director who was a long-serving consultant;directorate managers; and directorate senior nurses.There were lead clinicians for each division sitting underthe directorate, although some vacancies within themusculo-skeletal directorate. The senior staff we met

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were aware of areas of surgery services whereimprovements and innovations could be made, as wellas where pressures and problems existed. Staff withinthe directorates and elsewhere spoke highly of thesupport from the senior managers. They said they wereavailable for discussions, spent time in the departments,and recognised and tackled problems and challenges.

• There was strong and committed leadership at localward and unit level. We were impressed with all theward, team and unit managers. We met most of thesenior sisters and charge nurses on the surgery wardsand the theatre teams and managers. There was anextensive range of experience and commitment fromthe leadership staff with a focus on patient care andteamwork. Staff knew their patients well, and showedan empathy with those who had been in the hospital, assome burns and plastic surgery patients had been, for along time.


• We found the staff to be committed to their patients andtheir wards or units. We were impressed with thepositive culture within the staff we met. In conversationswith staff, the things worrying them were all connectedto patient care. These included delays to patientdischarge, not being able to spend as much time withpatients as they would like, feeling they had to rushpatients out of the day-surgery unit, bed shortages, andsafe staffing levels. However, despite a dedicated andcaring workforce, the workloads from incorporating highuse of agency staff and many new staff were causingstaff stress and anxiety, which had not always beenrecognised. The majority of sStaff were otherwisepositive about giving good care, support of the seniorhospital staff, and supporting each other. This wasexpressed in the hospital by a long-serving workforce,good opportunities to develop new professional skillsand qualifications, and a positive culture within thetrainee doctors and nurses we met.

• Staff were told of compliments about their care andtreatment. We saw thank-you cards on wards for staff toread. Many wards had boxes of chocolates and biscuitsbuilding into small mountains. These were beingcollected to share equally at Christmas among all thestaff, including ancillary staff like cleaners and porters.We saw a high number of compliments including staffbeing singled-out by patients for their kindness andcare. There were staff awards on a regular basis with

staff recommended by their peer group forachievements in small and big areas. In the Striving forExcellence awards for 2015, Chilmark Suite won for theircustomer care. They received a number of nominationsthat described them as “kind, supportive and helpful,with their professionalism standing out.”

• We recognised a good response to areas of staffconcern. One of these was with the surgical assessmentunit. This had been temporarily moved from its usualhome on Britford ward, which was undergoingrefurbishment, to Wilton ward in another part of thehospital. On one of the two days we visited we found theward was under pressure and staff not able to cope wellenough with the number of patients or lack of the usualsupport from Britford ward when it was next door. Thefollowing day we found a different and much improvedatmosphere and the same on our unannounced visit.The ward beds had been reduced from 10 to eight. Theside rooms had been decommissioned to make patientsmore visible. These were going to be used for patientexaminations and any tests, and for staff to work. Stafftold us they were not under pressure to take morepatients than they could safely cope with. The site teamwere therefore aware when they were effectively full.

• Staff spoke highly about their managers. Specificcomments were made to us about the team leader/sister in the pre-operative assessment clinic, the clinicaldirector and lead nurse for surgery services, sisters inthe Burns Centre and on Laverstock ward. MostWithoutexception, staff on all wards and units said they werewell supported by the senior executives, managers andteam leaders.

Public engagement

• Patients were able to give a wide range of feedback.There was monthly more detailed ‘real-time’ feedbackfrom patient on the wards to supplement the Friendsand Family Test. This was analysed and the commentswere put into categories to look for any trends. Anymore specific comments made by the patients were fedback to one of the members of the senior nursing teamwho commented upon how they had addressed anyareas identified as concerns or negative feedback. Inreviews from the musculo-skeletal wards in July 2015, asan example, it was noted however, the feedback from

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the sister was almost identical in each area. This wasrelating to wanting to check if there was furtherclarification available rather than recording any actiontaken following complaints.

• Patients took part in Patient-Led Assessments of theCare Environment (PLACE), although the results did notrelate to named wards or the surgery servicesspecifically. The results, which were mostly comparableto NHS averages, were encouraging for staff, patientsand the trust.

Staff engagement

• There was a lot of internal engagement with staff atboth trust and local levels. There were weeklynewsletters: a general one and one relating to ‘healthnews’. The trust used an email broadcast facility tocascade messages through staff groups from theexecutive team and senior managers. There werenewsletters produced by some wards and units. Forexample, Amesbury ward had produced a staffnewsletter including complaint and complimentmatters, reports from mealtime observations, andraising concerns.

• Staff were enabled to join as members of the trust andwere represented within the governors. Six staff wereappointed by election of the trust staff to the Council ofGovernors.


• There was innovation and improvement sought andencouraged at Salisbury District Hospital. The hospitalwas the first in the Wessex region to carry out lasersurgery for patients with enlarged prostrates. Thisavoided the need for open surgery and enhancedrecovery times. The hospital had a mobile monitoringmachine for anti-coagulation testing. We heard how thiswas a great innovation for patients and staff as pin-pricktests could now be used rather than taking blood in theusual way. The equipment was being used in a one-stopclinic where patients were seen, scanned, assessed andtreated without the need for admission. It was adeveloping service, but staff said it was going really well.

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Responsive Good –––



Information about the serviceCritical care services are located at Salisbury Hospital onthe twelve-bedded unit called Radnor Ward. The unit wasfunded to provide care for nine patients in total comprising;five classified as needing intensive care (level three) andfour requiring high dependency care (level two). RadnorWard underwent significant refurbishment in 2014increasing the number of physical beds from eight totwelve. Since the refurbishment, the unit had around 32patient admissions per month (six months ending June2015).

During this inspection, which took place between 1 and 4December 2015, the inspection team spoke with 27members of staff including consultants, trainee doctors,different grades of nurses, allied health professionals,critical care assistants and support staff. We also spokewith patients and their visiting relatives and friends. Wechecked the clinical environment, observed ward rounds,listened to nursing and medical staff handovers, andassessed patients’ healthcare records.

Summary of findingsCritical care services required improvement to be safeand well led. We found the service good for caring,effective and responsive.

Policies and procedures to prevent patients from therisk of healthcare associated infections were notconsistently adhered to. The use of personal protectiveequipment was inconsistent by bedside nursing staffduring the inspection. A commode was found to be dirtyand a standard cleaning procedure for cleaning thecommodes was not available on the unit.

There were occasions when nurse staffing numbers didnot meet recommended staffing ratios. Medical staffingwas found to be in line with core standards for intensivecare services.

There was sufficient equipment to provide critical careand respond to emergencies. However, the resuscitationtrolley log was not consistently signed to indicate that ithad been checked and was ready for use. The bedspaces did not comply with best practice guidelines forcritical care facilities regarding accessibility and space.

Incidents were reported and appropriate actions weretaken to attempt to prevent recurrence. However,mortality and morbidity meetings had commencedrecently and therefore could not provide assurance ofany improvements or actions taken.

Overall, staff were aware of their responsibilities toreport abuse and how to raise concerns about safety.

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Some online mandatory training rates for trained nurseswere lower than the trust target of 85% and mandatorytraining compliance data for unit based staff was notsupplied, which meant there was a risk that staff werenot up-to-date with current practice.

Records and medicines were found to be stored andmanaged securely. However, documentation in thehealthcare records and charts was not always completeor timely.

Patients’ needs were comprehensively assessed andcare and treatment regularly reviewed on the unit.Information about care and treatment and patientsoutcomes was routinely collected and monitored. Localand national audits were taking place and results werebeing used to improve care, treatment and patients’outcomes. Staff could access the information theyneeded in order to deliver effective care. Patients careand treatment was planned and delivered in line withcurrent evidence based guidance, particular focus wasgiven to rehabilitation. However, we found that therewere some guidance and policies on the unit that wereout of date. In addition, documentation of patients’ painscores could be improved.

There was input into patients care from relevantmembers of the multidisciplinary team in order toprovide effective treatment plans. However, thepharmacist did not attend consultant led ward roundsas recommended in the guidelines for the provision ofintensive care services (GPICS 2015).

Staff were qualified and had the skills to carry out roleseffectively in critical care. This included competencies inblood transfusion and intravenous therapyadministration. However, half of the nursing staff hadnot received an appraisal in the last twelve months,order to identify learning needs. In addition, training inthe use of equipment on the unit required furtherimprovement for both medical and nursing staff.

Discharge from the unit was planned and includedfollow up services after going home from hospital, tosupport patients post critical illness.

Patients we spoke with were positive about the carethey had received. Many kind and caring interactionswere seen during the inspection. Staff were seen tomaintain a high regard for patient’s dignity and privacy.

Relatives expressed that they had been kept up to datewith their loved ones progress and supported by thestaff at the bedside. Not all relatives had received timelycommunication; one family had not been updated bymedical staff. However, this was not a consistent findingamongst all relatives and visitors, and the majority werevery happy with the level of emotional care andtreatment they and their loved ones had received.

The support continued following discharge home fromhospital via the follow up team that supported patientsafter critical illness. The follow up clinic that the teamprovided had recently held a reunion event which hadbeen well attended.

Aspects of the refurbishment and design or the unit hadbeen made in collaboration with staff and local people.The facilities for relatives had been improved with athoughtful inclusion of secure storage of valuables inthe waiting area. However, not all bed spaces werecapable of giving reasonable auditory privacy. Therewere no toilet or shower facilities for patients within theunit. However, patients were able to access thesefacilities in a neighbouring ward without entering ageneral public area.

There were delayed patient discharges due to a bedelsewhere in the hospital not being available. Similar tomost critical care units in England, in the last five yearsbetween 60% and 70% of all discharges were delayed bymore than four hours from the patient being deemedready to leave the unit.

Urgent surgical operations had been cancelled due tothe lack of an available bed in critical care. This wasabove (worse than) the national average. Figures fromNHS England reported 53 cancelled operations at thehospital between July and December 2015. We foundthat there was no limit per day for how many beds couldbe booked on the unit for those patients that requirecritical care after elective operations.

Despite the pressures on bed availability, patients wereadmitted to the unit in a timely fashion and the unit hadnot transferred patients to other units for non-clinicalreasons for over twelve months. Data from the Intensive

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Care National Audit and Research Centre (ICNARC)showed that the unit transferred less patients to thewards out of hours that the England average (performedbetter).

Arrangements for governance of critical care services didnot always operate effectively. For example, the riskregister did not include risks that staff highlightedduring the inspection and the risks had not beenreviewed and updated. The governance structure andprocesses seemed immature and not embedded. Inaddition, it was not always clear how the localgovernance linked with formal trust wide processes.This meant that there was a risk that issues thatrequired escalation were not being raised formally.

Following the refurbishment and recent changes inleadership of both nursing and consultant leads, theteam appeared to be in a period of adjustment.

The team culture was strong within the unit. However,opportunities for staff engagement could be improved,for example unit meetings had been abandoned due topoor attendance.

Are critical care services safe?


Critical care services were found to require improvementregarding safety.

Policies and procedures to prevent patients from the risk ofhealthcare associated information were not consistentlyadhered to. The use of personal protective equipment wasinconsistent by bedside nursing staff during the inspection.One commode was found to be dirty and a standardcleaning procedure for cleaning the commodes was notavailable on the unit.

There were occasions when nurse staffing numbers did notmeet recommended staffing ratios.

The resuscitation trolley log was not consistently signed toindicate that it had been checked and was ready for use.

The bed spaces did not comply with best practiceguidelines for critical care facilities regarding accessibilityand space.

Mortality and morbidity meetings had only commencedrecently and action plans, where written, lacked detail.There was limited assurance of any improvements oractions taken.

Some online mandatory training rates for trained nurseswere lower than the trust target of 85% and mandatorytraining compliance data for unit-based staff was notsupplied, which meant there was a risk that staff were notup-to-date with current practice.

Documentation in the healthcare records and charts wasnot always complete or timely.

However:

Medical staffing was found to be in line with core standardsfor intensive care services.

There was sufficient equipment to provide critical care andrespond to emergencies.

Incidents were reported and appropriate actions weretaken to attempt to prevent recurrence.

Staff were aware of their responsibilities to report abuseand how to raise concerns about safety.

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Critical care


Records and medicines were found to be stored andmanaged securely.

Incidents

• An electronic incident reporting system was used torecord incidents. Radnor Ward staff had reported 59incidents between April 2015 and July 2015. The highestcategory was tissue viability, which included 14 reportsof unit acquired pressure damage. The majority of these(13) related to medical devices such as airway tubes andwere classed as superficial in nature. Evidence was seenthat actions had been taken in response to theseincidents, including for example, different airway tubetapes being used to reduce pressure.

• Staff we spoke with understood their responsibilities toreport incidents or concerns. Staff felt able to raiseconcerns on the unit. They told us the main route theyused were through incident reporting or discussionswith the nurse allocated in charge of a shift.

• Most staff felt they received feedback from incidents.Staff told us that incidents were discussed, at safetybriefings to raise awareness as part of the nurses’handover.

• Meetings had recently started to discuss patients’mortality and morbidity. Mortality and morbiditymeetings did not follow a standard agenda and did notalways include an action plan. An action plan that wasdeveloped lacked timescales and outcome measures.Medical and nursing staff attended them from RadnorWard. However, we were informed that the first meetinghad taken place in October 2015 and there had beentwo meetings so far. This meant that discussions of anyimprovements and learning related to mortality andmorbidity had not been taking place formally untilrecently.

• Regulation 20 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014, is a newregulation which was introduced in November 2014.This Regulation requires the trust to be open andtransparent with a patient when things go wrong inrelation to their care and the patient suffers harm orcould suffer harm which falls into defined thresholds.Staff we spoke with were generally aware of the newregulation to be open, transparent and candid withpatients and relatives when things went wrong, andapologise to them. The minutes of a senior nursemeeting in August 2015 included discussions about howto demonstrate the Duty of Candour had been met. This

included indicating this on the electronic incident reportand documenting conversations in the healthcarerecords. None of the incidents we viewed meet thethresholds required for further action in line with theregulations.

Safety thermometer

• Data on patient harm was required to be reported eachmonth to the NHS Health and Social Care InformationCentre. This was nationally collected data providing asnapshot of patient harms on one specific day eachmonth. It covered hospital-acquired (new) pressureulcers (including stage two, three and four); patient fallswith harm; urinary tract infections; and venousthromboembolisms.

• Safety thermometer data for Radnor Ward for the yearJanuary to December 2016 showed a harm-free carescore of between 62.5% (April 2016) and 100% (August2016). During this timeframe there had been fourpatients with new pressure damage, no patients with anew catheter-associated urinary tract infection, no fallswith harm and one patient with a new venousthromboembolism (VTE). However, the trust informedus the VTE was a recording error and that in fact nopatients had a new VTE during the period.


• In March 2015, a patient acquiredmethicillin-susceptible Staphylococcus aureus (MSSA)bacteraemia (infection in the blood) on Radnor Ward.MSSA is a strain of bacteria that responds well tomedicines used to treat Staphylococcus infections. Aninvestigation report was completed and areas toimprove included documentation of invasive deviceinsertion and ongoing care. Also a central log was to bemaintained for bed space damp dusting, which wenoted to be in place. Data was reported by the unit tothe Intensive Care National Audit and Research Centre(ICNARC: an organisation reporting on performance andoutcomes for around 95% of intensive care units inEngland, Wales and Northern Ireland). This showedthere was also a case of unit-acquired Clostridiumdifficile (a type of bacterial infection that can affect thedigestive system) and a unit-acquired infection in bloodbetween April 2015 and July 2015. However, ICNARC

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data for July 2015 to September 2015 showed that theunit was performing as expected regardingunit-acquired infections (compared to other similarservices).

• At the time of our inspection, the overall environmentand equipment in the unit were visibly clean and tidy.However, one of the commodes was found to be dirty.The critical care assistants (CCA) were responsible fordaily cleaning of the commodes. Charts were found tobe signed consistently to indicate that the commodecleaning had been carried out. Although it wasacknowledged by staff that they did not have a standardway of cleaning the commodes and this did not alwaysinclude taking the commode apart to clean. This issuewas raised with senior nurses and the commodes wereimmediately cleaned. The Director of InfectionPrevention and Control said standards for commodecleaning existed and these should have been availableon Radnor Ward.

• Bed linen was in good condition, visibly clean and freefrom stains.

• Many items on the unit had been labelled to notify whenthey were last cleaned. There was a central cleaning andchecking log that was used by critical care assistantsand other members of the nursing team, to sign whenitems were cleaned and checked. This was consistentlycompleted.

• There were alcohol hand gels and handwashingfacilities available throughout the unit. However, therewas not a hand wash basin for each bed space asrecommended in Department of Health 2013 guidelinesfor critical care facilities (Health Building Note 04-02).There were 11 basins for 12 bed spaces. This was notdocumented on the unit’s risk register.

• Overall, hand sanitising and personal protectiveequipment rules for staff were inconsistently followedon the unit. Most staff followed the policy by washingtheir hands between patient interactions and usinganti-bacterial gel. Staff were bare below the elbow (hadshort sleeves or their sleeves rolled up above theirelbow) when they were within the unit. The majority ofstaff wore disposable gloves and aprons at the bedsidewhen working with a patient or, fluids or wasteproducts. However, staff did not consistently employbest practice; for example, a nurse was observed towear gloves to perform an airway suctioning procedure.The gloves were then not removed until after the nursetouched buttons on two different pieces of equipment

in the bed space. Another nurse was seen emptying aurine catheter bag without wearing gloves or an apron.A senior nurse was informed of this practice and theyrecognised that compliance with this could be better.This was not documented on the unit’s risk register.

• The local handwashing audit results showedcompliance was between 85% and 100% in the sixmonths ending August 2015. The results of anotherhand hygiene audit (included allied health professionalas well as doctors and nurses) carried out in May 2015showed a compliance rate of 67% with the fivemoments of hand hygiene. The World HealthOrganization stated the five key moments when handhygiene should always take place for example, beforetouching a patient. It was also noted during this auditthat all staff were 100% complaint with being barebelow the elbow. Staff were also required to completeinfection and prevention and control (IPC) training.Trained nursing staff had met the compliance target forthis (85%). In addition, staff had to complete an annualpractical hand hygiene assessment. However 34 out of55 (62%) had not completed this update in the previous12 months (as of December 2015).

• There were four side rooms available that could be usedto isolate patients, if required, for infection control andprevention reasons. Three of these had lobbies asrecommended in Department of Health 2013 guidelinesfor critical care facilities (Health Building Note 04-02).

• The equipment storeroom had a sign on it stating‘everything in this room is clean’. This was clarified witha senior nurse who agreed that this did not act as adviceor a barrier to dirty equipment being put in the roomand the poster was taken down.

• Bed space checklists were completed to indicate that itwas cleaned, restocked and ready to be used. We foundthat a bed space had a checklist on it that belonged toanother bed space and therefore could not offerassurance that the bed space was clean and ready. Thiswas brought to a senior nurse’s attention. The followingday the nurse explained that there had been a patientadmitted in an emergency to the bed space temporarily,which had caused the confusion with the checklist.Other checklists were checked during the inspectionand were found to have been completed appropriately.

• There was a dishwasher in the kitchen but it had notbeen plumbed in due to problems with water pressure.This was not documented on the risk register.

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• All disposable equipment was in sealed bags andplaced in drawers or cupboards where possible toprevent damage to packaging. Equipment in storecupboards was on racks to enable the floor areabeneath to be cleaned.


• There was secure access to the front door of the unitwith swipe pass activation and cameras to allow staff tosee who was trying to gain access. However, emergencyexit doors were found to be unlocked, potentially givingaccess to theatres and equipment. This was raised withthe clinical lead consultant who agreed that this was notideal. Action was taken and the doors were securedwhen checked the following day.

• All checked equipment appeared to be well maintained,visibly clean and portable appliance tested. Storagerooms were generally tidy and kept free of clutter. Therewere two part time technicians based on the unit whoalso had responsibilities to theatres. Their role includedmaintaining service logs and ensuring that equipmentwas sent to be maintained as per manufacturers’specifications. They were also involved in training staffin how to use equipment.

• Radnor Ward had appropriate equipment for use in anemergency. All the patients’ beds had emergencyportable oxygen cylinders attached to them to beaccessed, for example, in an evacuation. There wereresuscitation medicines and equipment including adefibrillator. The resuscitation trolley containing theemergency equipment had closed drawers and was fullysecured to prevent or indicate tampering with thecontained medicines or other equipment betweenchecks. However, logs were not always signed toindicate that it had been checked daily. The four monthssheets were checked (July, August, September andNovember 2015) which showed there were betweenseven and 10 days a month where the trolley check hadnot occurred. This meant there was a risk thatresuscitation equipment would not be available in anemergency. There was also a difficult airway trolleyavailable stored in the theatre department, which wasadjacent to Radnor Ward.

• The equipment around the bed spaces was located onceiling-mounted pendants for optimal safety. Therewere also two ceiling hoists and a mobile hoist available

to assist with patient manual handling. There weresufficient oxygen, four-bar air, and vacuum outlets (asrecommended in Department of Health 2013 guidelinesfor critical care facilities, Health Building Note 04-02).

• There was a good level of mobile equipment availableincluding haemodialysis/ haemofiltration machines, anelectrocardiography machine, defibrillator, cardiacoutput monitoring, non-invasive respiratory equipmentand portable ventilators.

• There was a range of disposable equipment available inorder to avoid the need to sterilise equipment andsignificantly reduce the risk of cross-contamination. Wesaw staff using and disposing of single-use equipmentsafely at all times.

• Department of Health guidelines for critical carefacilities (Health Building Notes) gave best practiceguidance on the design and planning of new healthcarebuildings and on the adaptation or extension of existingfacilities. We were informed that following therefurbishment of Radnor Ward none of the bed spacesmet the size specifications as recommended in HealthBuilding Note 04-02. We found that two corner bedspaces were restrictive. These did not provide:▪ an unobstructed circulation space at the foot of each

bed space to maintain the required bed separationfor infection control reasons and aid positioning ofequipment

▪ space to allow staff to manoeuvre the patient,themselves and equipment safely due to the closeproximity of neighbouring bed spaces

▪ space to allow five members of staff to attend to thepatient in an emergency situation

▪ space to accommodate the specialised beds thatwere used for the other critical care patients.

A consultant explained that the two bed spaces in questionwere adequate, especially for level one and two patients.However, during the inspection an intensive care (levelthree) patient was admitted into one of the bed spaces.The operational policy that was in draft for Radnor Warddid not include any restrictions in use for any of the bedspaces. A critical care steering group was establishedduring the planning stages of the project, which includedsenior medical and nursing staff from Radnor Ward. Thegroup were asked to consider the proposed layout of theunit including the bed spaces not meeting sizespecifications as recommended in Health Building Note04-02. They concluded that this was acceptable if ceiling

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pendants were installed for equipment (in place at all bedspaces at the time of inspection) and areas used asescalation only ‘as part of a phased expanded approach’.Initially the unit was to provide care for 10 patients. A riskregister was also developed for the refurbishment.Insufficient space to meet current bed spacerecommendations was included and stated that 12 bedscould be used during periods of escalation if riskassessments were undertaken to reduce risks to patients.However the issue of risk assessments was not included inthe draft operational policy; neither was there adocumented risk assessment for a patient cared for in oneof these beds during the inspection.

Medicines

• Medicines and intravenous fluids were storedappropriately. Medicines were stored in cupboards withstaff only swipe access.

• Medicines required to be refrigerated were kept at thecorrect temperature, and so would be fit for use. Wechecked the refrigeration temperature checklists, whichwere signed to show the temperature had been checkedeach day and these were within the correct range. asrequired. There was also a temperature range decisiontree, to guide staff when to take action. Thethermometer also captured the maximum andminimum temperatures that the fridge had reached inthe previous 24 hours. On occasion, this had been justabove the maximum temperature range and the nursein charge had been informed accordingly.

• Controlled drugs (CDs) were managed in line withlegislation and NHS regulations. The medicines, interms of their booking into stock, administration to apatient, and any destruction, were recorded clearly inthe controlled drug register. Stocks were accurateagainst the records in all those we checked at random.

• Bedside nurses were seen to check all medicineinfusions were running as prescribed as part of theirsafety checks at the start of each shift.

• A ‘safe and secure’ medicines audit carried out in August2015, highlighted the need to ensure daily checking offridge temperatures and secure resuscitation trolley.These items were found to be satisfactory during theinspection.

• We found a patient with a known severe reaction allergywas not wearing a band to indicate this to staff. Theallergy was documented in healthcare records and onthe prescription chart. When an inspector brought this

to the bedside nurse’s attention, they explained thatbecause the source of the allergy was a wasp sting andnot a medicine, the band was not required. Followingdiscussion with the nurse in charge of the unit, anallergy band was put in place. The trust policy for thesafe management of patients with allergy was provided.This was under evaluation as it was past the review dateof December 2014. The policy stated that all patientswith a known allergy must wear red wristbands. Thiswas not reported as an incident initially but wasfollowing the inspector’s recommendation. Followingthe incident, an e-mail was sent to whole senior team toremind them that all allergies with a significant reactionneeded to be recorded in the patients’ healthcarerecords, on the prescription chart, and a red bandshould be worn. Seven prescription charts that werereviewed during the inspection, all had the patients’allergy status documented appropriately.

• Evidence of antibiotic stewardship was seen during theinspection and five antibiotic prescriptions checkedwere in line with the trusts antibiotic policy.

Records

• The observation charts included the patient’s vital signs,fluid balance chart, position changes for patient,ventilator observations and record of specimens sent.All six observational charts we reviewed were completedas required and timed, dated, legible and clear. Chartcovers were used for the observation charts to maintainconfidentiality.

• The patient’s healthcare records were stored securely inpaper-based files. Custom designed bedside trolleysincorporated drawers for healthcare records, whichtrained staff could access via swipe pass. This helpedwith maintaining confidentiality.

• The documentation was noted to be contemporaneous,maintained logically and filed appropriately. Entrieswere signed and dated, however the author did notalways print their name as stated in generic medicalrecord keeping standards (2015).

• Overall, records could have been more complete. Apatient’s healthcare record was checked that had beenon the unit for two days. We found that the reverse ofthe admission chart, which should contain informationregarding social history, family tree, passwords andauthorised visitors, was blank. The communicationrecord where discussions with the patient or relativeswould be documented was also blank. The reverse of

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the observation chart that contained assessment andmanagement plans was not always completed. Apatient’s record that we checked during the afternoondid not have this completed despite ward rounds havingtaken place in the morning. This meant that the staffmight not have had access to the current treatmentdecisions. This was in line with results of nursingdocumentation audit carried out in April 2015 whichshowed non-compliance (target 95%) in the followingareas:▪ nursing assessment on admission (61%)▪ record keeping (57%)▪ re-assessment (84%)▪ care planning (67%)

• We saw completed nurses’ documentation, for examplefor bedrail management, malnutrition screening, fallsrisk, patient manual handling assessment, wound andcommunication charts. Records demonstratedpersonalised care and multidisciplinary input into thecare and treatment provided. However, some of thecharts that were used such as the bed rails assessmentand the admission record were printed or photocopiedlocally. Handwritten prompts were seen for patientsname and hospital number were noted on the bed railsassessment. Review dates for version control of thedocuments used were not always present. This meantthere was a risk that staff were not using the mostup-to-date versions of charts.

• At a recent critical care governance meeting (November2015) it was discussed that a recent audit hadhighlighted documentation of ward round plans in themedical notes required improvement. Following this,the Radnor medical staff implemented a sticker minichecklist. We saw this used each day, following the wardround. This sticker included a date and consultant nameprompt and finished with a reminder to lock notes away.The seven records that we checked had generally agood standard of record keeping by the medical staff.The trust audited record keeping standards annually.However, no audit to monitor local progress had beenplanned. Consultants were seen to document their ownreviews during ward rounds on the unit.

• Physiotherapists completed separate assessment formsevery day for patients who were ventilated. These formswere yellow which meant they were easy to locatewithin the healthcare records.

Safeguarding

• Overall, staff were aware of their responsibilities toreport abuse and how to find any information theyneeded to make a referral. We spoke with a range ofdoctors and nurses who were able to describe thosethings they would see or hear to prompt them toconsider there being some abuse of the patient oranother vulnerable person. Most were aware of theteams within the hospital to contact, and that theinformation could be found on the trust intranet. Therewere also two staff that were named safeguardingchampions for the unit.

• Staff were trained to recognise and appropriatelyrespond in order to safeguard a vulnerable patient, andhad updated their mandatory training by the trustdeadline. Safeguarding training was mandatory andcovered vulnerable adults and children. Data suppliedby the trust showed that 96% of trained nurses hadcompleted safeguarding adults training and 85% hadcompleted the safeguarding children training(November 2015).

• A safety brief was incorporated into the nurse handover.This included whether any of the patients were classedas vulnerable adults. A patient on the unit washighlighted as a vulnerable adult during the inspection.Following the patients admission, the situation hadbeen discussed with the trusts adult safeguarding leadfor advice. An adult safeguarding referral to the localauthority was deemed unnecessary and all appropriateactions appeared to have been taken.

Mandatory training

• Radnor Ward devised and ran their own mandatorytraining study day to ensure that staff had trainingspecific to critical care. This included basic life support,fire evacuation, manual handling and epidural updates.Study days were allocated on the off duty to enable staffto attend.

• Some mandatory training that staff were required tomaintain was accessed online. These included equalityand diversity, infection control and moving andhandling.

• Radnor Ward trained nurses were compliant (85% ormore) with online mandatory training in safeguardingadults and children and infection control andprevention. They were not compliant with:▪ equality and diversity (78%)▪ moving and handing (75%)▪ fire safety (58%)

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▪ information governance (55%)▪ hand hygiene assessment (38%)

Information about compliance with mandatory training forall staff groups and subjects for Radnor Ward specificallyhad been requested but not provided by the trust.


• The nursing team and medical staff assessed andresponded well to patient risk through regular reviews.Consultant led ward rounds in the unit took place twicedaily in the morning and evening. This met corestandards for critical care units. There was input to theward rounds from unit-based staff including the doctorsand the nurses caring for the patient.

• The nurses handover at the beginning of each shiftincluded a safety brief which included patients at risk ofdeveloping pressure ulcers and those not for attemptedcardio pulmonary resuscitation. Patients were closelymonitored so staff could respond to any deterioration.During the site visit patients were nursed byrecommended levels of nursing staff at all times.Patients who were classified as needing intensive care(level three) were nursed by one nurse for each patient.Patients who needed high dependency care (level two)were nursed by one nurse for two patients. However, anumber of nurses informed us that sometimes theseratios were not maintained due to staffing levels. Theelectronic reporting system was used to highlight shiftsthat were short staffed. There were 16 flagged shortstaffed shifts between August 2015 and November 2015.

• There was a standardised approach for detection of thedeteriorating patient. There was an early warningscoring tool that was incorporated in to the wardpatients’ observation chart. If a ward-based patienttriggered a high-risk score from one of a combination ofindicators, staff would follow a number of appropriateroutes. One of the triggers would include a review of thepatient by the critical care outreach team (CCOT). Thisteam consisted of mainly experienced critical carenurses. It had been established to support all aspects ofthe adult critically ill patient, including earlyidentification of patient deterioration. The CCOT and thepatient’s medical team were able to refer the patientdirectly to the consultant for support, advice and review.The CCOT provided 24-hour cover for the hospital asrecommended in the guidelines for the provision ofintensive care services 2015.

• CCOT provided advice to patients that had non-invasiveventilation and tracheostomies throughout the hospital.Specific risk assessment charts had been developed bythe CCOT, to support staff outside of the unit withpatients that required these interventions.

• The CCOT also provided training to ward nurses througha planned annual programme. The subjects coveredincluded sepsis, care of the breathless patient and acuteillness management (AIM). The AIM study dayincorporated competencies and tests, which providedevidence of learning.

• There was a consultant nurse for critical care employedby the trust. The role was mainly regarding the care ofcritically ill or those at risk of deteriorating outside ofRadnor Ward. Professionally they were involved with thecritical care outreach team (CCOT) and clinically workedwith this team twice a week. They were involved inimprovement projects throughout the trust, includingthe electronic observations pilot and surviving sepsis.

Nursing staffing

• The actual and planned staffing levels for each shiftwere seen on display at the entrance to the unit.

• Trained nurses worked a 12.5 hour shift pattern androtated on to night duty.

• There was always a senior nurse for each shift for bothday and nights, which would ensure there wasexperienced support and advise for the staff.

• The rotas were generated and managed via anelectronic system. Eight trained nurses were requiredper shift as a minimum. The rotas were checked duringthe inspection and we found that they did not alwayshave the minimum number of nurses. For example, wechecked nine days at random and compared how thenumbers of staff met the level of care required for thepatients present on the unit at that time. We found thatout of nine shifts, five did not have the requirednumbers of trained staff. The details of these occasionswere not documented. However, the electronicreporting system was used to highlight shifts that wereshort staffed. There were 16 flagged short staffed shiftsbetween August 2015 and November 2015. Based oneight nurses per shift and allowance for annual leavestudy days and sickness 43.73 whole time equivalent(WTE) was required. The actual WTE was 40.28. Also,there was a secondment and staff on maternity leavethat were not covered and two staff on long-term sick

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leave. There had also been a recent turnover of staff and13 band five nurses had been recruited in the last sixmonths. We were told there were plans to go to the trustboard to increase the nursing establishment.

• There was a staffing escalation policy for Radnor Ward,which guided what actions to take if there were notenough nurses. This started with checking if unit staffcould swap shifts or work extra and escalated to theuncovered shift request going out to agency. The reportto the trust board (August 2015) reviewing nurse staffingincluded that the layout of the new unit meant thatwhen the side rooms were all in use there was an extra‘runner’ required overnight. . Data supplied by the trustindicated 1.4% to 0.3% of agency nursing staff wereemployed per month. This included specialist agencystaff for critical care. A member of the managementteam had to agree to request agency staff from certainagencies due to the expense. We were informed that thetrust would prefer to employ agency staff than to closebeds to admissions. During the inspection, we alsonoted staff that had been allocated management timewere caring for patients on the unit. The trust informedus that although this was not ideal in the long run, thiswas part of the escalation to maintain nurse to patientratios during busy periods.

• An agency nurse told us they had received anorientation induction at the start of their shift on theunit. This was because even though she had worked onthe unit before, it had undergone a significantrefurbishment since then. Agency staff inductionchecklists were seen being completed and theyincluded the layout, emergency bleeps, fire procedure,and resuscitation equipment. Five forms were checkedand they were all filled in fully and signed by the agencynurse and the Radnor Ward nurse. Another agency nursewas observed coming on duty and was greeted by thenurse in charge. They went through the orientationprocess and gave the agency nurse a swipe access passto enable them to access medicines. Staff sent feedbackto the agency if nurses had not worked well on the unitor if there were concerns about their practice. This wasseen being done during the inspection.

• Critical care assistants (CCA) were employed by the unit.They were equivalent to care support workers but therole had been specifically adapted to the needs of acritical care unit. Their role included; competency

supported skills such as putting arterial blood gassamples through the bedside analyser, supervision ofconfused patients and assisting with meals. They alsoattended to the daily cleaning schedule for the unit.

• There was a good handover among nurses. Initially abrief handover of all the patients to all of the shift staffoccurred, highlighting the patient’s name, diagnosis andsupport required. This followed a structured style basedon the nurse in charge’s handover sheet. All theoncoming team including the critical care technician,physiotherapist and the CCOT nurse attended it. Theoncoming nurse in charge allocated nurses to patientsto care for, dependant on previous day’s allocation,skill-mix, and developmental needs of staff. Then nurseshad a more detailed handover at the bedside for thepatient /s they had been allocated. The nurse in chargehanded over to the oncoming nurse in charge. The chartthey were using captured basics regarding the patientadmitted and cared for on the unit for a 24-hour period.These were then kept for retrospective review.

Medical staffing

• The level of cover provided by medical staffing on theunit met all professional standards andrecommendations.▪ There was a good consultant to patient ratio because

there was one consultant on duty or on call for anabsolute maximum of twelve beds. This was betterthan the core standards recommended ratio of oneconsultant for a maximum of 15 beds.

▪ Consultants provided a good level of continuity. Aconsultant would spend three or four full daysworking on the unit.

▪ The use of locum junior medical staff was rare (20occasions in the six-month period ending November2015) and there was an induction pack developed, tobe used for any locum doctor that was employed.

▪ There was always an anaesthetist that specialises inintensive care covering the unit. All seven consultantswere fellows of the faculty of intensive care.

▪ Staff told us and we saw evidence in patients’ healthrecords that a consultant conducted a ward roundeach day including at the weekend. However, this didnot meet the core standard for intensive care units,which states that consultants must undertake atleast twice daily ward rounds including weekendsand bank holidays.

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▪ When consultant intensivists were on call, this wasfor critical care only. The core standard states that aconsultant in intensive care medicine must beimmediately available 24 hours a day, seven days aweek. Staff from a variety of disciplines told us andwe saw evidence that the consultant was availableout of hours.

▪ Out of hours cover for the unit was by a registrar whoalso provided cover for maternity, critical carereferrals for the hospital including ED, and wassometimes required to support a more junior traineein theatres. The junior doctor included twilight shift(5-8pm) covered by a registrar with other roles. Whenthe unit was busy during this out-of-hours period, theconsultant would often attend to help. A traineedoctor confirmed that they felt supported and theconsultant was available. However, data provided bythe trust showed that in the three months endingJune 2015, nine beds were occupied 15% of the timeand on occasion the unit had 11 beds in use. Thismeant that the standard of one doctor to eightcritical care patients for the junior critical care doctorwould have been exceeded.

• Despite the medical staffing meeting core standards, theway in which the consultant rota was structured meantthat the consultant for the unit was to be available forthree or four days in a row. This included the nightcover. On two occasions, we found the consultant hadbeen stood down to allow rest due to particularly busynight shifts. This was managed well by calling otherconsultants in and safe cover was maintained at alltimes. A consultant told us that with such a cohesiveteam there had never been an issue covering eachother. There was no formal agreement to cover busyperiods such as, a second on call consultant on the rota.The trust acknowledged that although the consultantrota worked well and provided continuity of care it maybecome necessary to review this if the unit becomesbusier in the future.


• It was noted during an internal patient-led assessmentsof the care environment (PLACE) assessment in January2015 that the emergency exits were classed as not beingfree of obstruction due to items storage. One of thecorridors that had emergency exit doors was also foundto be cluttered on the first day of the inspection. The

doors themselves were clear. However, equipmentwould have needed to be moved from the corridor toenable patient on beds to be evacuated easily. This wasbrought to the immediate attention of the senior nurseand the area was found to be clear the following day.

• There was a fire risk assessment for Radnor Ward and afire emergency plan held locally on the unit. Exit signsand emergency alarms were clearly visible. However,58% of trained staff had completed their fire safetytraining via electronic learning. Practical fire safety wasalso covered during in-house mandatory training days.Information about compliance with this had not beenprovided by the trust.

• There was a major incident policy for the trust, whichwas under review. There were action cards for theconsultant on call and the nurse in charge of the unit.These summarised actions to be taken includingassessment for stepdown of patients from the unit andarranging a satellite critical care unit in theatre recovery.

• Business continuity plans were supplied by the trustdetailing actions to be taken by Radnor staff in the eventor fire, flood or loss of power.

Are critical care services effective?

Good –––

We found critical care services overall to be providingeffective care with some areas requiring improvement.

Patients’ needs were comprehensively assessed and careand treatment regularly reviewed on the unit. Informationabout care and treatment and patients outcomes wasroutinely collected and monitored. Local and nationalaudits were taking place and results were being used toimprove care, treatment and patients’ outcomes. Staffcould access the information they needed in order todeliver effective care. Patients care and treatment wasplanned and delivered in line with current evidence basedguidance, particular focus was given to rehabilitation.However, we found that there were some guidance andpolicies on the unit that were out of date. In addition,documentation of patients’ pain scores could be improved.

There was input into patients care from relevant membersof the multidisciplinary team in order to provide effective

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treatment plans. However, the pharmacist did not attendconsultant led ward rounds as recommended in theguidelines for the provision of intensive care services(GPICS 2015).

Staff were qualified and had the skills to carry out roleseffectively in critical care. This included competencies inblood transfusion and intravenous therapy administration.However, half of the nursing staff had not received anappraisal in the last twelve months, order to identifylearning needs. Although the unit had a comprehensivetraining programme, training in the use of equipment onthe unit required further improvement for both medicaland nursing staff.

Discharge from the unit was planned and included followup services after going home from hospital, to supportpatients post critical illness.

Consent to care and treatment was obtained in line withMental Capacity Act 2005.


• Patients’ care and treatment was assessed during theirstay and delivered along national and best-practiceguidelines. For example, National Institute of Health andCare Excellence (NICE) 83: Rehabilitation after a criticalillness, and NICE 50: Acutely ill patients in hospital.Rehabilitation needs of critical care patients wereclearly a priority. This included:▪ Using target charts on display in every bed space to

plot where a patient is on a day to day basis relatedto eight personal care basics (for example able tobrush hair)

▪ Mobility staircase prompt poster was on display inevery bed space to plot where a patient is on aday-to-day basis.

▪ A therapy assistant was employed on a trial basis forthe unit. This was to dedicate time to patients withrehabilitation needs.

▪ Effectiveness of rehabilitation monthly audits werebeing completed. These showed (May 2015 toOctober 2015) 100% compliance with assessingpatients within 24 hours of admission and 90% of thetime patients had rehabilitation plans in place atdischarge.

• Patients’ length of stay was submitted to the IntensiveCare National Audit and Research Centre (ICNARC: anorganisation reporting on performance and outcomes

for intensive care patients). The mean average length ofstay for all admissions in the unit was between eightand 10 days for the 12 month period ending June 2015which was comparable with the national average.

• Patient care was audited regularly against best practicestandards (care bundles) in the following key areasrelated to critical care and compliance rates for January2015 to September 2015 included:▪ central line (venous access devices) insertion and

care (90-100%)▪ care of ventilated patients (100%)▪ peripheral (access devices) line insertion and care

(50-100%)▪ venous thromboembolism (VTE) prevention (100%)

• Patients were ventilated using recognised specialistequipment and techniques. This included mechanicalinvasive ventilation to assist or replace the patient’sspontaneous breathing using endotracheal tubes(through the mouth or nose into the trachea) ortracheostomies (through the windpipe in the trachea).The unit also used non-invasive ventilation to helppatients with their breathing using usually masks orsimilar devices. Ventilated patients were constantlyreviewed and checks made and recorded hourly.

• Radnor Ward followed NHS guidance when monitoringsedated patients, by using the Richmond AgitationSedation Scale (RASS) scoring tool. This involved theassessment of the patient for different responses, suchas alertness (scored as zero) and then behaviours eitherside of that from levels of agitation (positive scoring) tolevels of sedation (negative scoring). Audits were alsocarried out by the unit regarding diagnosing, preventingand treating delirium in critical care.

• Patients were assessed for risks of developing venousthromboembolism (VTE) such as, deep vein thrombosisfrom spending long periods immobile. There was a dailyreview of patients for risks of developing VTE andpatients were provided with preventative care includingcompression stockings and sequential compressionsdevices in line with NICE83 statement 5. The key qualityindicators for Radnor Ward showed that this assessmentwas carried out 100% of the time (January to September2015).

• Radnor Ward met best practice guidance by promotingand participating in a programme of organ donation, lednationally by NHS Blood and Transplant. As is bestpractice, the critical care unit led on organ-donationwork for the trust. There was a specialist nurse for organ

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donation who was employed by NHS Blood andTransplant and was based at the hospital, to directlysupport the organ donation programme and workalongside the clinical lead. The specialist nurse alsosupported a regional and community programme forpromoting organ donation, which was supported by thetrust organ donation committee. The specialist nursesubmitted data to the national audit regarding potentialorgan donors. We reviewed data about donations fromSalisbury District Hospital for the year from 1 April 2014to 31 March 2015 and the most recent six-month reportfrom April to September 2015. There had been 17patients eligible for organ donation during this18-month period. Of these, there was an approach to sixfamilies to discuss donation. The specialist nurse wasinvolved with five of these families (83%), against anational average of 73% involvement. Evidence hasshown there is a higher success rate for organ donationif a specialist nurse is involved with discussions with thefamily. In the 18-month period, three patients went onto be organ donors and six people became recipients ofthose organs.

• The team were meeting core standards relating toengaging, and participating in a critical care operationaldelivery network. Senior medical and nursing staff wereseen to have attended quarterly meetings.

• There was a local ongoing audit plan in evidence toevaluate policies or effectiveness of treatmentinterventions. For example, a baseline audit had beenrecently completed assessing both patients opinion andstaff perception of good sleep. This was in preparationfor a planned launch in December 2015 of a new ‘sleepcare bundle’ (best practice care plan). A patient told usthey had experienced difficulty sleeping on the unit, dueto the alarms and bells waking them up. Nurses alsoinformed us that patients who were sedated andventilated, would routinely be washed between 6 and7am. This meant patients’ sleep may have beendisturbed by this practice.

• A daily checklist sticker was being used to supporteffective ward rounds. This was placed in the healthcarerecords after the review of the patient and includedreminders including bowel management, blood tests,and VTE prevention.

• We found guidance and policies that were available onthe unit, including bedside reference guides were out ofdate. For example, the insulin protocol was dated 2005.This was highlighted to a senior nurse who informed us

staff usually accessed a computer for the latest policies.However, they acknowledged that they was a risk thatstaff may access information that was not up to dateand would ensure that this was addressed.

• It was decided following a ward round review that apatient required nursing in a ‘prone position’. The policyregarding this procedure was provided. This was withindate and explained that current evidence suggestedthat early turning of patients onto their fronts improvedchances of survival in acute respiratory distresssyndrome.

Pain relief

• Staff carried out assessments of the severity of apatient’s pain and it was given a score. Pain scores werelogged on the observation chart and the managementplans embedded on the reverse of this chart included aquestion about whether the patient’s pain wascontrolled. However, we found that this documentationof patient’s pain scores could be improved. We checkedseven patients’ current observation charts for presenceof pain scores and five out of seven had beencompleted. In addition, a patient that we spoke withsaid that they had experienced pain occasionally. Wefound that there were no pain scores documented ontheir observation chart.


• Patient nutrition and hydration needs were assessedand effectively responded to. Nutritional planning wasconsidered daily and supported by documentationincluding a section of the daily assessment sheets. Fluidintake and output was measured hourly, recorded andanalysed for the appropriate balance and anyadjustments necessary were recorded and delivered.The method of nutritional intake was recorded andevaluated each day. Any feeding through tubes orintravenous lines was evaluated, prescribed andrecorded.

• The unit had guidance and support for specialistfeeding plans. A dietitian attended the unit everyweekday to provide advice. There was also a nutritionsupport team who supported parenteral feeding such,total parenteral nutrition (nutrients suppliedintravenously through a central venous access devices).There were approved protocols for nursing staff tocommence enteral feeding, including clear flowcharts.

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• Meals for specific dietary requirements were availableon request including gluten free, low allergen, soft dietand for religious needs.

• Patients on Radnor Ward who were able to eat anddrink, were given choices every day regarding what theywould like for their meals and assistance provided asnecessary, to enable the food to be eaten. A patient toldus that the food was excellent.

• A patient who was waiting to be transferred to a wardbed was seen to have access to water to drink, placedwithin reach.

• At the time of the inspection, 94% of trained nursingstaff were deemed competent to administer intravenousfluids and medicines. Newly qualified staff could beginto obtain their training and competencies to administerintravenous (IV) fluids after three months (truststandard). An algorithm was used to determine if newlyemployed staff needed to undergo further IV training.However, following the initial IV training there was norequirement by the trust for any updates regardingintravenous administration. This did not meet NICEguidelines that stated that hospital should establishsystems that reassess staff at regular intervals todemonstrate competence (NICE guidelines CG174). Thismeant that there was a risk that staff may not be up todate with best practice.

Patient outcomes

• Around 95% of adult, general critical care units inEngland, Wales and Northern Ireland participate inICNARC the national clinical audit for adult critical care;the case mix programme (CMP). Following rigorous datavalidation, all participating units received regular,quarterly comparative reports for local performancemanagement and quality improvement. There was anadministration assistant employed by the unit whoserole included the input of data for ICNARC.

• The unit was performing as expected (compared toother similar services) in all CMP indicators used in theICNARC Annual Quality Report (2013/2014) and theseareas were:▪ Hospital mortality▪ Out of hours discharges to the ward▪ Non clinical transfers (out)▪ Unit acquired MRSA▪ Unit acquired infection in the blood▪ Delayed discharges▪ Unplanned readmission within 48 hours

Competent staff

• Staff were required to be assessed each year for theircompetency, skills and development. All staff knew whowas responsible for their appraisal and staff in lead rolesknew who was in their team and due an appraisal. Thenurses were divided into teams each led by a seniornurse to facilitate team working and organise appraisalcompletion. However, we were informed that 50% of thenursing staff had been given an annual review of theircompetence and performance. One reason that wasoffered to explain the low nurse appraisal rate was lackof management time, due to the busy nature of the unit.

• There was good support to trainee doctors. A traineedoctor explained that they received a localdepartmental induction and good supervision in role onthe unit. They had an educational supervisor andregular meetings. They enjoyed working on the unit andwould recommend the placement to colleagues. Wewere informed that medical staff appraisal rates andrevalidation was 100%.

• An experienced critical care nurse was employed in aneducation role for the nursing staff. This was in line withcore standards, which stated that each unit was to havea dedicated clinical nurse educator responsible forcoordinating the education, training framework fornursing staff and pre-registration student allocation.They were also involved in delivering lectures on thepost registration critical care course and the coursedesign. The role was not included in the number of staffallocated to care for patients. However, the clinicaleducator was allocated patients occasionally to ensuresafe staffing levels. Although not ideal, it did provide anopportunity to educate staff during the shift anddemonstrated a flexible approach to maintainingpatient safety.

• Each month the clinical educator submitted the statusof trained nurse competency and training regardingblood transfusions. The training rates for June 2015show that rates were between 86% and 97% (for thefour competencies).

• Two trained nurses were funded to attend the postregistration critical care course each year. There hadbeen a training needs analysis and whichrecommended this number to increase to three nurses a

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year in the future. 62% of trained staff held a postregistration award in critical care, which exceeded theminimum set by core standards for critical care services(50%).

• We were told, and we saw evidence, that new nursingstaff to the unit had a period of time where they weresupernumerary (extra to the clinical numbers) in linewith core standards. Generally, it was four weeks.However, this was also the case for three newly qualifiednurses who joined the team recently. This did not meetcore standards of a minimum of six weekssupernumerary time for newly qualified staff. Two of therecent starters (including one newly qualified nurse) hadbeen given further supernumerary time after supportand training needs were identified by their mentors andthe practice education team. These staff hadindividually assigned short-term objectives set withregular scheduled reviews and were supervised andsupported by key members of the team.

• Clear induction processes were available for newnursing staff supported by documentation, which wesaw during the inspection. This included a checklist thatwas completed in this period. Critical care worksheetsand competencies were also used for key skillsincluding; tracheostomy care, arterial lines andvenepuncture. We observed informal bedside teachingtaking place between nurses at the bedside.

• The newly qualified staff were included in the trustspreceptorship programme, which supported their firstyear as a qualified nurse. This ran alongside the localinduction to Radnor Ward.

• Nurses completed a medicines administrationcompetency when they first started working at the trust,but no updates were required. This meant there was arisk that staff were not kept up to date with bestpractice.

• Training in the use of equipment required improvement.There had been a recent focus to improve this fornursing staff, as gaps in training had been identified. Theclinical educator had arranged specific study days forthe nurses covering key equipment, which startedNovember 2015, and further dates were planned. Aspreadsheet was also being maintained electronicallyso that compliance could be reviewed. However, wewere told that equipment training for medical staff was

provided but not captured formally. As primaryresponsibility for use of the equipment rests withnursing and technical staff, medical staff do not operateunfamiliar equipment without supervision.


• The unit had input into patient care and treatment fromthe physiotherapists, dietitians, microbiologist (ahealthcare scientist concerned with the detection,isolation and identification of microorganisms thatcause infections) and other specialist consultants andteams as required. We witnessed members of themultidisciplinary team (MDT) contributing to patientscare and treatment. For example, a physiotherapist toldus they felt integral to the team on Radnor Ward. All themembers of the MDT did not routinely attend the wardrounds on the unit. However, the nurse in charge of theunit did and would collate advice and help tocommunicate effectively plans made by otherdisciplines.

• Discharge from the unit was supported by documentsthat were jointly completed by medical and nursingstaff. This included rehabilitation information, infectioncontrol issues, psychological and emotional needs andchecklist of prompts and reminders. This was to provideward staff with relevant at a glance information in orderto care for the patient.

• The critical care outreach team (CCOT) reviewedpatients discharged from the unit. Patients would thenbe visited once they had settled into the new ward.There was no limit to the reviews and these would bedone as often or as little as required.

Seven-day services

• The CCOT provided a 24-hour, seven day a week servicecovering the whole trust. Out of hours they workedalongside the hospital at night practitioner.

• Occupational therapist input and advice could beobtained if required. However, staff felt that this supportcould be increased.

• The pharmacist was not dedicated to Radnor Ward,however they did attend the unit every day Monday toFriday and this provision met the recommended level.The pharmacist did not attend consultant-led wardrounds as recommended by the core standards forcritical care units (GPICS 2015).

• Physiotherapists covered the unit every weekdaymorning and reviewed all new patients for rehabilitation

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needs and planning. They attended a safety round onthe unit to receive handover with the nurse in chargeand lead consultant each weekday morning.Physiotherapists were available at the weekends andovernight, via an on call system. Frequent physiotherapyreviews were seen documented in health care records;including daily reviews of patients at the weekend.

• Staff told us that at the weekend, the consultantattended the unit and was available. We saw evidencein-patient records of consultant led ward rounds beingdocumented. Medical and nursing staff maintained thatthe unit was consultant led and they were available outof hours, were easy to reach, and would come in ifrequired.

• The dietitian provision was not a dedicated service forcritical care, but available Monday to Friday. The trustinformed us that dietetic services were delivered fromtheir community provider according to a service levelagreement. In practice, there was five to six hours ofsenior cover per week for the unit. The service met thecore standards for critical care(GPICS 2015).

• Speech and language therapists were available onrequest, Monday to Friday.


• Staff had access to relevant information to assist themto provide effective care to patients during their stay. Allsubstantive staff had access to email accounts.Healthcare records at the trust were paper based andwere available at the patient’s bedside. Someinformation including results from patient investigationsand guidance was available via the trusts intranet. Forexample, during the consultant-led ward round, aportable computer on wheels accompanied the staff.This allowed patients diagnostic results to be accessed,as well as guidance and policies. Although, staff told usthat the search engine for finding policies was notalways successful. This was not a consistent complaintfrom staff we spoke with.

• We met a ward clerk on the unit who was based at theworkstation. This role clearly supported effectivecommunication with visitors and staff throughout theunit.

• The trust intranet was open and available to allsubstantive staff. The staff had good levels of access to

their own information. We were told that all nursing staffhad a general password to access information on thecomputer and all had access to a shared drive to accessdocumentation and information.

Consent and Mental Capacity Act

• Patients gave their consent when they were mentallyand physically able. The staff demonstrated a goodawareness of the Mental Capacity Act 2005. A doctorworking on the unit told us that patient’s mentalcapacity was regularly discussed on the ward round.

• Senior staff admitted that initially following theSupreme Court judgement they had beenover-reporting and had been requesting Deprivation ofLiberty Safeguards (DoLS) authorisation on all patientsthat were sedated and ventilated on the unit. There hadbeen clarification received via the lead for the trust andthe policy updated to support that this was not alwaysrequired and should be on an individual case basis. Alog of patients that required DoLS consideration wasmaintained at the unit’s workstation. There were notany DoLS authorisations in place at the time of theinspection.

Are critical care services caring?

Good –––

Critical care services were providing good, compassionatecare.

Patients were positive about the care they had received.Many kind and caring interactions were seen during theinspection. Staff were seen to maintain a high regard forpatient’s dignity and privacy.

Relatives expressed that they had been kept up to datewith their loved ones progress and supported by the staff atthe bedside. We identified one family who had not beenupdated by medical staff. However, this was not aconsistent finding amongst all relatives and visitors, andthe majority were very happy with the level of emotionalcare and treatment they and their loved ones had received.

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The support continued following discharge home fromhospital via the follow up team that supported patientsafter critical illness. The follow up clinic that the teamprovided had recently held a reunion event which hadbeen well attended.

Compassionate care

• All the patients and relatives we met spoke highly of thecare they received. Due to the nature of critical care, wecould not talk to as many patients as we might in othersettings. However, patients we were able to speak withsaid they had found the staff caring and compassionate.Patients said they felt safe and supported. A patient wespoke with had found all the staff polite and caring.

• There was a calm atmosphere on the unit and the staffwere seen to introduce themselves to patients andrelatives, offer explanations and provide opportunity toask any questions.

• We observed good attention from all staff to protectpatient privacy and dignity. Curtains were drawn aroundpatients and doors closed when necessary. Voices werelowered to avoid confidential or private informationbeing overheard. The nature of most critical care unitsmeant there was often limited opportunity to providesingle-sex areas. However, staff said they wouldendeavour to place patients as sensitively as possible inrelation to privacy and dignity. The unit were very awareof this issue and reported mixed sex breaches whenpatient transfers to the ward were delayed.

• The NHS Friends and Family Tests (FFT) asked patients ifthey would recommend the ward to their family andfriends. These questions were usually asked when thepatient was discharged from the hospital. As few of thepatients were discharged from critical care (they usuallywent to a ward before ultimate discharge), they werenot participating in the test. The unit had a form thatprovided a route for feedback to the staff about theirexperience particularly from patients’ relatives andvisitors. The forms were on display in the waiting roomand included the following prompts:▪ What was good?▪ What could we have done better?▪ Is there anything would have improved your

experience?

Completed forms were placed in a comments box in thewaiting room and staff emptied this every week. We saw 11cards that had been completed (between March 2014 and

November 2015) and they were all complimentary exceptone. This requested that the entrance to the unit via buzzercould be manned (March 2014). We were told that therewere plans to increase the unit receptionist cover. However,this had not been achieved yet. The compliments included“cannot fault the care and expertise” and “myhusband…received the best care we could have wished”.

• We spoke with a family that were visiting a patient onthe unit. They described the care as exemplary and thepatient had been on the unit for a long time on aprevious admission. They had been so impressed withthe care that they had written to the local paper to sayhow fabulous the unit had been. Also a substantial sumof money had been donated by another ex-patient,which had been put towards the cost of therefurbishment of the unit.


• Staff communicated with patients and those close tothem so they understood their care, treatment andcondition. Patients were involved with their care anddecisions taken. Patients who were able to talk with ussaid they were informed as to how they wereprogressing. They said they were encouraged to talkabout anything worrying them. They told uscommunication was good, and this had extended totalking with their families. We observed staff, bothdoctors and nurses talking inclusively with patients andtheir relatives. Patients that were sedated and unable tocommunicate were also spoken to by staff, for exampleexplaining what they were about to do.

• The views of relatives and carers were listened to andrespected. However, a relative that we spoke with saidthat since admission to Radnor Ward, which wasapproximately two days previous, they had not beenspoken with by any of the critical care doctors. Thepatient’s communication record was blank. We reviewedfive patient healthcare records and found thatdocumentation regarding communication between theRadnor Ward team and relatives and visitors, waspresent in four cases.

Emotional support

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• The team on the unit demonstrated that theyappreciated the emotional turmoil that patients andrelatives experienced due to critical illness andadmission may cause. They provided a supportive, kindand unrushed approach.

• There was a specialist nurse for organ donation whowas employed by NHS Blood and Transplant and wasbased at the hospital, to directly support the organdonation programme and work alongside the clinicalteam.

• The unit had a well-established follow up service andclinics were provided for patients and their relatives toattend. A clinical psychologist was available as part ofthe follow up team that supported patients after theirdischarge from critical care, in addition to beingavailable for in-patients, their relatives and staff, andattending multidisciplinary team meetings. The staffhad also arranged a successful event recently, wherepatients that had previously been to the clinic wereinvited to a reunion. We were told that over twentypeople had attended.

• The unit supported the completion of patient diaries.These would be completed to capture the story of thepatients stay on Radnor while they were too ill to beaware. When the patient recovered this could be sharedwith them.

• Chaplaincy support was available to the unit for anyonewho required it. They often visited but could becontacted 24-hours a day in between these times.

Are critical care services responsive?

Good –––

Critical care services were found to be good forresponsiveness.

Aspects of the refurbishment and design of the unit hadbeen made in collaboration with staff and local people. Thefacilities for relatives had been improved with a thoughtfulinclusion of secure storage of valuables in the waiting area.

There was a well-established follow-up clinic for patientsthat had been discharged home after a critical careadmission.

Despite the pressures on bed availability, patients wereadmitted to the unit in a timely fashion and the unit had

not transferred patients to other units for non-clinicalreasons for over twelve months. Data from the IntensiveCare National Audit and Research Centre (ICNARC) showedthat the unit transferred less patients to the wards out ofhours that the England average (performed better).

However:

Urgent surgical operations had been cancelled due to thelack of an available bed in critical care. This was above(worse than) the national average. Figures from NHSEngland reported 53 cancelled operations at the hospitalbetween July and December 2015. However, none of theoperations were cancelled more than once. We found therewas no limit per day for how many beds could be bookedon the unit for those patients that required critical careafter elective operations.

There were delayed patient discharges due to a bedelsewhere in the hospital not being available. In the last fiveyears between 60-70% of patients had their discharge fromthe unit delayed by more than four hours. This was broadlyin line with the national average.

Not all bed spaces were capable of giving reasonableauditory privacy. There were no toilet or shower facilitiesfor patients within the unit. However, patients were able toaccess these facilities in a neighbouring ward withoutentering a general public area.


• The unit did not meet all the recommendations of theDepartment of Health guidelines for intensive care unitsas they related to meeting patient needs and those oftheir visitors. These included:▪ not all bed spaces were capable of giving reasonable

auditory privacy,▪ there were no facilities for patients who were well

enough to have a shower or use a toilet. Patientswere able to access shower and toilet facilities in aneighbouring ward, which could be accessed withoutentering a general public area.

However, there were areas that did meet the guidelinesincluding:

• the main work base on the unit had a glazed screen tocontrol noise transfer,

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• there was intercom-controlled entry to the unit.Entrances were locked and could only be opened byauthorised hospital staff.

• The refurbishment had been designed to reducedelirium and anxiety with calming pastel colours anduse of natural light. Families, doctors, nurses and alliedhealth professionals were all actively involved in thedesign. Beautiful photographs taken by one of theconsultants had been enlarged and used to decoratethe unit.

• Relatives and visitors of patients being cared for on theunit had access to a waiting room with comfortablechairs. A new quiet room had also been created so thatrelatives and carers could spend time away from thebedside for reflection. There was also a kitchen, wherevisitors could make themselves hot drinks. There weresome facilities available for relatives to stay overnight ifrequired. Lockers had been installed to secure personalvaluables such as handbags, while visiting patients onthe unit.

• Visiting times were between midday and 8pm each day.However, they could be flexible to meet the needs of thepatient and their loved ones. The policy was for only twovisitors per bed space unless the patient was extremelypoorly. There was limited space in the unit and visitorswere asked to restrict numbers where possible. Visitingtimes prioritised the needs of the patient, while beingsupportive to relatives.

• Patients discharged from the unit had access to a followup clinic. This was recommended by National Instituteof Health and Care Excellence (NICE) guidance. Theclinic was run by one of the units’ consultants and waswell established. A reunion event for patients that hadpreviously been to the clinic had recently taken place.


• Every day a core plan for patients was completed bynursing staff. These were individualised to meetpatient’s needs. Patients were seen to have access to aclock with date to help with orientation and a televisionset if required. A patient who was waiting to betransferred to a ward had been provided with a nursecall buzzer within reach, which could be used to requestassistance.

• Translation services were obtainable and staff wereaware of this and knew how to access them. They alsohad access to ‘no verbal’ cards which could be used toassist with communication.

• While some staff were able to describe the specialistsupport available at the trust for patients with learningdisabilities, this was not universal. ‘This is me’ bookletswere mentioned by staff. These booklets offered apractical way of informing staff about the needs,preferences, likes, dislikes and interests of a person.These can be particularly useful when caring forsomeone living with dementia. The booklets were notbeing used yet as there were plans to adapt it for use inthe unit.

• A variety of information leaflets were available on theunit including about what to expect on intensive care forpatients and relatives. These were printed in English.Some leaflets indicated how to get the information inanother language or, for example, in braille. This servicewas accessed through a customer care free-phonenumber or email address.

• Patients on Radnor Ward who were able to eat and drinkwere given choices every day regarding what they wouldlike for their meals and assistance provided asnecessary, to enable the food to be eaten. A patient toldus that the food was excellent.

Access and flow

• The unit had 12 physical beds, nine of which werefunded and staffed, comprising five for intensive carepatients (level three) and four for high dependency care(level two). Radnor Ward underwent significantrefurbishment in 2014 increasing the number of physicalbeds from eight to 12. A draft operational policydescribing elective and emergency admissionprocedures was provided by the trust.

• There was a process for booking elective beds followingsurgery. However, there did not seem to be a limit tohow many elective beds could be booked each day. Abed booking sticker was completed and placed into adiary at the nurses’ station. It included prompts to helpreview of the outcome for example, surgery cancelled.The last 11 stickers were checked and eight of them hadbeen fully completed. This meant that the outcome ofthe booking was not always documented.

• Urgent surgical operations had been cancelled due tothe lack of an available bed in critical care. This wasabove (worse than) the national average. Figures from

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NHS England reported 53 cancelled operations at thehospital between July and December 2015. Thisrepresented an average of just below 9 cancellations permonth against an England average of just over 3 permonth. However, none of these operations werecancelled for a second time.

• In the three months ending March 2015, 11 electivesurgery cases were cancelled due to lack of availabilityof a post-operative critical care bed. This performancewas much worse compared with other acute NHS trustfigures. Performance had not significantly improvedsince the expansion of the unit to twelve beds, therewere 20 patients cancelled between January 2015 andNovember 2015. Compared with the same number ofcancellations on the eight bedded unit between April2014 and December 2014 (nine months).

• Since the reopening in January 2015, the unit hadaround 32 patient admissions per month (six monthsending June 2015). Just under half of the patients wereventilated (level three) on admission. The occupancyfluctuated between 50% and 100% howeverpredominantly it had been around the national averageof 80% (NHS England data from May 2013 and June2015).

• There were many patient discharges delayed due to abed elsewhere in the hospital not being available.Similar to most critical care units in England, data fromthe Intensive Care National Audit and Research Centre(ICNARC) reported a high level of delayed dischargesfrom critical care. In the last five years between 60% and70% of all discharges were delayed by more than fourhours from the patient being deemed ready to leave theunit. This was broadly in line with the national average.Transfer within four hours was the standardrecommended by the Faculty of Intensive Care MedicineCore Standards. Although patients remained well caredfor in critical care when they were medically fit fordischarge, the unit was not the best place for them. Italso could delay access for patients who needed to beadmitted, or meant the unit was at a higher occupancythan recommended. The delays were mostly less than24 hours although some were longer. The rate ofdelayed discharges had been high for the last five yearsand at no point had been better than the national orsimilar-unit average in the last five years.

• Due to the delays experienced in accessing ward bedswhen required, there were patients that weretransferred out during the night. The core standards for

intensive care units stated, discharge from should occurbetween 7am and 10pm.Three patients were transferredto the wards out of hours between July 2015 andSeptember 2015 (according to ICNARC data). However,this was better than the national average (compared toother similar services). The bed manager visited the unitevery weekday morning to find out if there were anypatients ready to go to a ward bed.

• Despite the pressure of transferring patients out of theunit when ready for the ward, patients were admitted tothe unit in a timely fashion. For example there had beenno patients transferred to other hospitals to access acritical care bed due to non-clinical reasons in the year2015. A patient requiring critical care should beadmitted within four hours of the decision to complywith core standards for intensive care. Seven patients’healthcare records were checked and all had beenadmitted within four hours of the decision to admit timeand had been reviewed by a consultant within 12 hoursof that admission. One of the reasons for therefurbishment of Radnor Ward was the inability to nurseall the patients that required critical care on the eightbedded unit. Prior to increasing the number of bedsavailable, patients waiting to be admitted weresometimes cared for by the Radnor Ward staff in theatrerecovery. The trust informed us that since theexpansion, no patients have been ventilated outside theunit owing to bed pressures. The number of beds in usefor the unit was increasing. Between January 2015 andMarch 2015, seven beds were occupied 45% of the timeand up to nine patients 4% of the time. Compared to thethree months ending September 2015 where 90% of thetime the unit had between four and eight beds occupiedand on occasion had 11 beds in use (2%). At one pointduring the inspection, 12 patients were being cared foron Radnor Ward (three more than commissioned for).This demonstrated the unit’s responsiveness to ensurecritically ill patients were cared for in the unit andprevented the need for transferring patients (fornon-clinical reasons) to another hospital to receive thiscare.


• In the nine month period ending September 2015, theunit had received one formal complaint. Staff said thatthey had low numbers of complaints because theyasked for early support and advice from seniormanagers in the division to attempt local reconciliation.

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• The formal complaint was from a patient that had aparticular visitor without their consent. Due to theirclinical condition, critically ill patients are often unableto inform staff about who they are happy to visit themduring their stay on the unit. In response to thecomplaint practice was changed. In order to preventpeople being allowed to visit whom the patient wouldnot have wanted to; the patient (if possible) or thepatient’s next of kin were asked about this. The namesof acceptable visitors were recorded in the healthcarerecords. Passwords were also set up to support thispractice, which we observed in use during theinspection.

• In March 2014, a relative had completed a negativefeedback form. This requested that the entrance to theunit via buzzer could be manned. There were plans toincrease the unit receptionist cover however; this hadnot yet been achieved.

Are critical care services well-led?


The governance and leadership of critical care services didnot always support the delivery of high quality personcentred care.

Arrangements for governance of critical care services didnot always operate effectively. For example, the risk registerdid not include risks that staff highlighted during theinspection and the risks had not been reviewed andupdated. The governance structure and processes seemedimmature and not embedded. In addition, it was notalways clear how the local governance linked with formaltrust wide processes. This meant that there was a risk thatissues that required escalation were not being raisedformally.

Following the refurbishment and recent changes inleadership of both nursing and consultant leads, the teamseemed to be in a period of adjustment. The team culturewas strong within the unit and the well-establishedfollow-up clinic was used to actively seek the views of thepublic regarding critical care services. However,opportunities for staff engagement could be improved. Forexample, there were no unit meetings taking place.


• The unit had been through lots of changes in the lasteighteen months. Whilst the extensive refurbishmentwas being carried out, the whole unit was moved toanother ward on a temporary basis. When they returnedto the refurbished unit the staff told us that new ways ofworking had to be evolved related to their newsurroundings. The refurbishment was the culmination ofthe vision and strategy for the unit for some time andthey now seemed to be in a period of adjustment.

• The unit had twelve physical beds and the funding andstaffing to provide care for nine patients. Senior stafftold us that the plans were to increase the funding forunit to provide six intensive care (level three) patientsand four high dependency (level two) patients andincrease staffing accordingly.


• When refurbishing an existing facility, best practice is tocomply fully with Health Building Notes (HBN 04-02).Critical care should be delivered in facilities designed forthat purpose. However, if this was not possible, thereasons should be formally documented through theprovider organisation’s clinical governance process. Arisk register for the planned refurbishment wasdeveloped. However, non-compliance with HBN orissues related to the new layout does not feature on theunits current risk register.

• The governance structure and processes within criticalcare services seemed to be immature and notembedded. For example, the morbidity and mortalitymeetings started in October 2015. In addition, it was notalways clear how the local governance linked withformal trust wide processes.

• There was no lead role for governance or policies andguidelines on the unit.

• The risk register for the unit required significant reviewand improvement. There were items that were past thereview date. Some risks had not been updated followingimprovements, which significantly reduced risks. Forexample, the unit had changed to the use of radiopaque(opaque to X-rays) naso-gastric tubes to reduce the riskof incorrect placement. The risk had not been updatedwith this information. There were many risks that seniorstaff highlighted to us during the inspection, which had

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not been documented on the risk register, such as thelack of usable dishwasher. This meant that risks werenot formally being monitored, mitigated and escalatedthrough the risk register process.

• The critical care outreach team (CCOT) on the otherhand, had a risk register specifically for them, which wasup to date.


• Critical care services provided on Radnor Ward weremanaged under the umbrella of the surgical division inthe trust.

• The leadership of the critical care service was in atransitional period. The unit met critical care standardsby having a lead band eight nurse and a consultant in aclinical lead post. The long-term lead nurse for the unithad recently retired. The new senior lead nurse hadstarted in their role on the same week as the inspection.The unit had also developed a deputy lead nurse role.This was initially a rotational post but now was to bepermanent. The clinical lead consultant was also new intheir role (since June 2015). The clinical lead consultanthad been offered a management course to supportthem in their role, but they had declined.

• Clinical leadership of the patient’s treatment and carewas good from senior nurses and medical staff. Duringsite visits, the nurse in charge of the unit was alwayssupernumerary (did not have a patient allocated to carefor) leaving them free to co-ordinate the shift. The nursein charge also wore a badge, which alerted visitors tothe unit who was managing the shift. According to corestandards for critical care units there should always be asupernumerary nurse available (GPICS 2015) and wesaw evidence on rotas that this was the case for themajority of the time . However, staff told us occasionallythe nurse in charge had taken care of a patient. Thefrequency that this occurred was not documented. Anadditional recommendation is that units with more than10 beds should have a further additional supernumerarynurse (GPICS 2015). On 4th December during theinspection there were 12 patients on the unit with onesupernumerary nurse in charge. However, ICNARC datashowed this did not happen often. For example, in the 3months ending September 2015, the unit had 11 beds inuse 2% of the time.

• According to core standards for critical care units thereshould always be a supernumerary nurse available.Radnor Ward was funded to provide critical care for nine

patients although they had twelve physical bed spaces.Intensive Care National Audit and Research Centre(ICNARC) showed that in the three months ending June2015 the unit sometimes had 11 beds in use. As aminimum requirement, those units that have more than10 beds, must have a further additional supernumerarynurse (core standards for intensive care). This standardwas not being met. On 4 December 2015 during theinspection, there were 12 patients on the unit with onesupernumerary nurse.

• Band 6 nursing staff had access to a local leadershipdevelopment programme for Radnor Ward only. Thiscomprised of four study days, shadowing site teamleads and attending trust wide level meetings. This waswell received by staff that we spoke with.

• There was a consultant nurse for critical care. This rolewas dedicated to critical care issues outside of RadnorWard. The consultant nurse professionally supportedthe CCOT and was involved in strategic level plans forthe trust including risk assessment for vulnerablepatients, for example those with tracheostomy.

• We were told CCOT nurse were usually employed onband six and follow a development programme whereprogression is rewarded by promotion to band seven,based on merit.


• A strong supportive teamwork culture was evidentwithin the service. This was clear from the medical staffparticularly. They supported each other to ensure theunit was always covered despite the workload affectingthe consultant’s ability to cover.

• New nurses that joined the team told us that it was apositive supportive environment for learners.

• Staff described a respectful relationship on the unitbetween doctors and nurses. A nurse told us that theywere really proud of the good care that was given by theunit to patients and their relatives.

• A trainee doctor we spoke with described the unit as akind and friendly place.

Public engagement

• There was an established follow-up clinic providingsupport for patients and relatives that had been throughcritical illness. This service actively sought patients’ and

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relatives’ views of the service, which were used to informgroups, such as the rehabilitation teams, in order tomonitor service quality and identify improvementopportunities.

• Families were actively engaged regarding therefurbishment of the unit. This directly resulted inchanges to the design of the unit including lights, colourscheme, and relatives’ facilities (including lockers fortheir use). Relatives could also feedback to staff viacomment slips that were in the relatives’ waiting room.However, these did not appear to be used very often.

Staff engagement

• Doctors, nurses and allied health professionals were allactively involved in the design and refurbishment of theunit. Ideas on how it was to look and function wereobtained before. After the refurbishment staff wereasked for their views on the unit and most commentswere complimentary.

• Staff unit meetings had recently been abandoned dueto poor attendance. Instead, emails and staff noticeshave been used for communication. A text messagesystem enabled staff on the unit to contact all thenursing team through the computer. It was often used tosee if anyone wanted to cover short-staffed shifts.Therefore there were limited formal opportunities forstaff engagement.

• There was a structured approach to nursing teamswithin the unit. This meant that a senior nurse had ateam of nurse allocated to them to support. Theseteams were also to be used for appraisals. However, wewere told that 50% of staff had not received an appraisalin the last 12 months. Link roles were allocated tonurses and used by the unit to cascade information.There was a list on view in the coffee room.

• There had been an executive led quality and safety walkround on Radnor Ward in August 2015. This gave nursingstaff and other support staff, the opportunity to raiseissues directly to senior trust managers.


• The trust had an award ceremony and Radnor Wardteam won the ‘Service Improvement Sponsored ProjectAward 2015’. This award was for the unit redevelopment.

• The unit had developed an innovative video for trainingstaff about how to turn and care for patients in theprone position. It was a collaborative project withmanual handling advisors, physiotherapists and nursingstaff. This was available on the shared drive, which wasaccessible by all substantive unit staff.

• The unit had a rehabilitation and follow up team whichincluded the appointment of a therapy assistant tosupport compliance with NICE guidance (CG 83).Specifically focussing on continuity following dischargeto the wards.

• Implementation of critical care assistants posts andtraining programme

• Following refurbishment, the CCOT was based withinthe critical care unit to encourage collaborative workingwithin the department and wider hospital, with CCOTattending MDT handover daily.

• Three members of the Radnor team plus the nurseconsultant for critical care were on the faculty for theBournemouth University critical care course, Ongoingclinical projects were linked to Bournemouth University,enabling individual members of the Radnor team togain academic credit as part of the evidencingprofessional learning programme

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Information about the serviceSalisbury Hospital provided a range antenatal, perinataland postnatal maternity services in the hospital and withinlocal community settings. The provision of maternity andgynaecology were managed within the clinical support andfamily services directorate of the trust. Choice of place ofbirth was limited to the hospital or patients home as thetrust did not have a midwifery led birthing unit (plans werein place to develop this). The delivery suite at the hospitalwas consultant led and was able to provide care for womenwith low and high risk pregnancies and/or complex healthproblems. The community midwives were split into fiveteams covering a broad geographic area which borderedthe Somerset, Dorset and Hampshire clinicalcommissioning areas.

There were nine delivery rooms, two rooms had a birthingpool and all the rooms had en suite showers. There wasone triage room with an assessment couch and a fourbedded antenatal bay which was used by patientsuring theday if increased observations and monitoring wererequired for short periods or on an inpatient basis. Therewas one dedicated maternity theatre with adjacentanaesthetic and recovery rooms. The anaesthetic roomwas further fully equipped to transform into a seconddelivery room in the event of escalation or emergency.

During the period April 2014 to March 2015, 2,446 babieswere born, and 2,936 women received or planned toreceive ante or postnatal care by the community midwives.This included women who chose to deliver at a differenthospital. The majority of deliveries (2,360) were on theconsultant led unit, and the remainder (86) were home

births. The average percentage of home births per monthwas 4%. During the period 1 April 2015 to 31 August 2015there had been a further 954 births of which between sixand nine per month were home births.

There was an early pregnancy unit with an ultrasoundservice which enabled pregnancies to be monitored,screening tests to be completed and potential problemsdiagnosed. These services were accessed on an outpatientbasis. Antenatal patients who required increasedmonitoring were admitted to the delivery suite. Postnatalcare for women needing to stay longer in the hospital wasprovided on Beatrice ward which had a seven beddedbaywith shared bathroom facilities. There were an additionalfour single en suite rooms and a four bedded area forwomen who required a higher level of monitoring (total 15beds).

A range of gynaecological investigations and treatmentswere provided. These included general and emergencygynaecology, and treatment for gynaecological cancer andabnormal bleeding. The majority of gynaecology patientsreceived their treatment and care on an outpatient basis..During the past three years there had been approximately650 emergency gynaecology admissions. Of these, 90% ofpatients length of stay was less than 24 hours and themajority (80%) were treated during week days. There wasno dedicated gynaecology ward patients were admitted toa surgical ward. A termination of pregnancy service wasprovided. This was for medical terminations for fetalabnormalities up to 12 weeks of pregnancy. Women whorequired a medical termination for fetal abnormalities


Maternity and gynaecology


beyond this date referred to a specialist fetal medicineservice for diagnosis, with the option of returning to theBenson suite for the termination. All surgical terminationswere referred to a specialist service..

During our inspection we spoke with 13 patients, fiverelatives and a range of staff working throughout thegynaecology and maternity services. These included;consultant obstetricians, gynaecologists and anaesthetists,registrars, senior house officers, sonographers, the head ofmidwifery, lead midwives for community, screening,safeguarding and risk, labour ward coordinators, operatingdepartment practitioners, the specialist nurse forgynaecology, midwives, nurses, health care supportworkers, maternity support workers and ward clerks. Weheld a number of focus groups and meetings. Two wereeach attended by seven band five and band six midwives.We observed a staff handover on the delivery suite. Wereviewed nine sets of patient records. Before, during, andafter our inspection we reviewed the trust’s performanceinformation.

Summary of findingsOverall, we have judged the maternity and gynaecologyservices to be good for responsive, effective, caring andwell-led services. Overall, we have judged safety in thematernity service requires improvement.

Care in both the gynaecology and maternity wards anddelivery suite was consultant led. Patients had riskassessments completed and reviewed regularly.Incidents were reported and thoroughly interrogated forlearning and safety improvements. Good safeguardingprocesses were in place, which included establishedlinks with the lead local authority. Staff demonstratedunderstanding of duty of candour regulations andcompliance with this was also evidenced in records.

Safety improvements were required to the maternityservices. The midwifery staffing levels did not meet theRoyal College of Obstetricians and Gynaecologists(RCOG, 2007) Safer Childbirth Minimum Standards forthe Organisation and Delivery of Care in Labour. Themidwife to patient ratio exceeded (was worse than)recommended levels and one to one care for women inestablished labour was not evidenced to have beenachieved 100% of the time. There was a lack of regularaudit of the World Health Organisation surgicalchecklist. Retrospective audits completed used smallsamples (numbers of cases reviewed) and identifiedpoor compliance levels.

The maternity services were responsive to the needs oflocal women. Positive feedback was consistentlyprovided. This showed the majority of patients werehighly satisfied with their treatment and care and wouldrecommend services. We saw records documentingpatient’s choices and preferences. The maternityservices had achieved full accreditation with UNICEF UKbreast feeding standards. The gynaecology service hadlinks with other specialists and treatment centres. Thissupported the provision of effective care and treatmentplans for patients. Annual audit plans were in placewhich enabled clinical standards of practice to bechecked and improvements made. Policies andprocedures were provided in line with national guidanceand policy.




There were thorough risk management and quality andgovernance structures in place. These linkeddepartmental with trust risk and governance meetings.This ensured an effective flow of information from wardto board and vice versa. Incidents, audits and other riskand quality measures were scrutinised for serviceimprovements and appropriate actions taken. Systemswere in place to effectively share information andlearning. Staff were proud of the patient care theyprovided and a learning culture was evident. Leadershipwas described as good. Junior staff told us they werewell supported and senior managers were visible andapproachable. The trust board had approved a capitalinvestment in the maternity services. This included theprovision of a new midwifery led birth unit.

Are maternity and gynaecology servicessafe?


Overall we have judged safety as requires improvement.This applied to the maternity services as midwifery staffinglevels did not comply with the Royal College ofObstetricians and Gynaecologists (RCOG, 2007) SaferChildbirth Minimum Standards for the Organisation andDelivery of Care in Labour.. The midwife to patient ratioexceeded (was worse than) recommended levels. It was notpossible to confirm if one to one care was provided 100% ofthe time for all women in established labour. There was anapparent lack of regular audit of the World HealthOrganisation surgical checklist. Retrospective auditsreviewed small samples fo clinical records and identifiedpoor compliance levels.

Records contained clear plans of care, and appropriatereferrals to other professions or services. Women hadindividual risks assessed and these were regularlyreviewed. There was evidence of thorough investigatingand learning from incidents. There was good evidence ofstaff understanding and following the Duty of Candourregulations. Staff were knowledgeable about safeguardingprocess and understood their responsibilities. There wereestablished relationships with other safeguarding leadagencies. There was a safe level of consultant supportavailable 24 hours a day, seven days per week across thegynaecology and maternity services to respond toemergencies and maintain oversight of women with highrisks and/or complex health.

Incidents

• The number of incidents in the maternity services hadincreased. From April 2013 to March 2014, 477 incidentshad been reported. Between April 2014 to March 2015,the number of incidents reported was 530 (an increaseof 53; 11%). Senior staff had monitored and analysedthe types and severity of incidents reported. Staff wereconfident the rise was a consequence of reporting beingcompleted more efficiently rather than an actualincrease in incidents. This was supported by discussionswith midwives. All of those we spoke with emphasisedthe need to report and learn from incidents in order toimprove safety and outcomes for patients.




• Between April 2015 and June 2015, 180 incidents hadbeen reported by the maternity service. Analysis of thisinformation revealed more than half of the incidentsoccurred during labour when care was least predictable.The types of labour incidents included, shoulderdystocia, post-partum haemorrhage and perineal tears.

• All the staff we spoke with demonstrated a clearunderstanding of the types of issues that should berecorded as incidents and told us they were activelyencouraged to report incidents. All staff said theyreceived feedback from incidents they had reported.This was completed on a one to one basis and throughservice wide emails and meetings. We looked at aselection of meeting minutes. These reported incidentsas standard agenda items. This included the rates andtypes of incidents, changes to policy and specificlearning.

• The gynaecology service referred to a trigger list ofissues to be reported as incidents. These included arange of patient issues or harms such as delayed ormissed diagnosis, anaesthesia complications,unplanned readmissions, unsuccessful procedures andfailed equipment. The gynaecology staff demonstratedan understanding of incident processes. Investigations,outcomes and learning was evident in records.

• The trust followed the serious incident frameworkguidance from the Department of Health (March, 2015).This states an incident must be considered on acase-by-case basis against a revised description ofserious issues. There were clear investigations andlearning at departmental levels which was evidenced inroot cause analysis (RCA) investigations and risk andgovernance meeting minutes. In addition, since January2015 serious incidents were logged onto the nationalquality improvement programme ‘Each Baby Counts’(2015) Royal College of Obstetricians andGynaecologists.

• Records showed serious incidents had been robustlyanalysed and interrogated. Between May 2014 and April2015 six serious incidents had been reported related tothe maternity services. We reviewed the RCAinvestigations for four of these incidents. One incidentwas referred to the coroner’s court who determinednatural causes and the case was closed. At this point thematernity department could have concluded their owninternal investigation. Senior managers continued withthe intention of learning all that was possible from thisserious and unexpected incident. The deep and probing

analysis revealed the possibility of other contributingfactors. This information was passed back to the coronerwho subsequently reopened the case for furtherinvestigation.

• We saw records which showed where recommendationshad been made as a result of investigating seriousincidents, action plans had been put in place. Theseincluded identifying responsible persons, timescales forcompletion of actions and what further evidence wasrequired to show how learning had been shared widelywithin the department or with others as necessary.

• Perinatal mortality and morbidity (M&M) meetings andgynaecology M&M meetings were held every month. Welooked at meeting minutes which detailed individualcase reviews. Discussions were recorded betweenclinical staff regarding improvements to practice andprocedures..

• The quality of the M&M meeting minutes wasinconsistent. We observed the perinatal minutes werewell organised. They included embedded PDFdocuments which provided clinical details of the patientcase for discussion. A typed pro forma was completedwhich clearly documented discussions, learning points,and any necessary actions to be taken. The gynaecologyminutes we were shown were hand written and lackedthe same level of detail and discussion. Attendees werenot consistently recorded. It was therefore difficult toreview and establish how information (also limited)related to learning and outcomes had been agreed.

Duty of Candour

• During November 2014, a new regulation wasintroduced to providers of NHS services. They arerequired to comply with the Duty of Candour Regulation20 of the Health and Social Care Act 2008 (RegulatedActivities) Regulations 2014. This related to incidentstermed as ‘notifiable safety incidents’. These were anyunintended or unexpected incidents occurring to apatient leading to death, severe, moderate or prolongedpsychological harm. This regulation requires staff to beopen, transparent and candid with patients andrelatives when things had gone wrong.

• Staff throughout the maternity and gynaecologyservices demonstrated an understanding of Duty ofCandour. We asked a range of maternity andgynaecology staff, including the 14 midwives who




attended the focus groups about Duty of Candour. Allstaff were clear regarding their roles and responsibilitieswhen patient treatment or care had gone wrong or hadnot been satisfactory.

• Records evidenced Duty of Candour regulations werefollowed. In the four serious incident records wereviewed, all documented how patients and theirrelatives had been informed of and included ininvestigations. We observed if patients or relatives hadparticular questions that these had been asked andanswered within the investigation reports.

Safety thermometer

• The inpatient maternity wards (Beatrice) participated inthe NHS safety thermometer. This was a process tocollect patient safety information in relation to falls,catheter associated infections, venousthromboembolism (VTE), urinary tract infections, andpressure sores. Information provided by the trustconfirmed from January 2014 to 30 November 2015there were no recorded patient harms under thesecategories.


• All ward and clinical areas in the maternity andgynaecology services appeared clean. We observedstickers were used on some equipment when it hadbeen cleaned and was ready for use.

• Monthly hand hygiene audits were completed. Auditresults were provided by the trust for July and August2015. These covered the labour suite and dayassessment unit, Beatrice postnatal ward and thegynaecology clinic areas. The compliance levels rangedfrom 89% to 100%. We saw a hand hygiene action planwas in place to improve and maintain compliance. Thisincluded use of a light box to ensure correct handhygiene procedures were being used and a review of thetraining methods.

• The patients we spoke with had no concerns regardingthe cleanliness of the environment. Patients confirmedthey observed staff washed their hands and worepersonal protective clothing such as gloves and apronsbefore providing treatment or care. Antibacterial handcleaner was available throughout clinical areas. Weobserved staff washed their hands before and afterproviding care or treatment to patients.

• Cleaning staff had responsibility for floors, bathroomsand communal areas. Staff confirmed tasks werecompleted to a satisfactory standard.

• Equipment used on the delivery suite was visibly clean.The midwifery care assistants and midwives hadresponsibility for this and cleaned equipmentin-between admissions. The two birthing pools lookedvisibly clean. These were decontaminated by staff aftereach use in order to be available for the next personusing the room.

• There was evidence that processes were in place andfollowed to minimise infection control risks in thematernity service. The labour suite, ante and postnatalareas participated in the annual patient led assessmentof the care environment assessment (PLACE). Thisexternal audit reviewed staff practices and theappropriate provision and maintenance of facilities andequipment used by patients. We reviewed the PLACEreport dated January 2015. Clinical areas were assessedas clean and well maintained, with no visible dirt ordebris evident. Staff were observed to be appropriatelydressed and bare below the elbows. This reduced therisks of cross contamination and enabled effective handhygiene to be completed.


• The delivery suite environment was well organised, withequipment stored appropriately. All areas on thedelivery suite were appropriate for use.

• The maternity and gynaecology wards were accessiblewith a swipe card for staff and controlled by a buzzer forpatients and visitors. CCTV was used by ward clerks,clinical staff and security to staff to monitor forunauthorised access to the delivery suite and wards.

• There was an extensive bereavement suite in a separatecorridor to the labour suite; this had a kitchen area andsitting room and three bedrooms, two of which were ensuite.

• The antenatal day assessment and gynaecologyoutpatients’ areas had all required and necessaryequipment and was appropriate for use.

• The central delivery suite had adult and babyemergency resuscitation equipment. Cardiotochographequipment for fetal heart monitoring were available foreach delivery room. However there were only two babyresuscitaires for all nine patient rooms. We discussed




this with senior staff who told us there had not been anoccasion when this had impacted on the care needs ofnew born babies. Daily safety checks of this equipmentwere documented.

• There was adult and baby emergency resuscitationequipment and a baby resuscitaire on the postnatalward (Beatrice). The adult resuscitation trolley had thenecessary medicines and equipment was stored safely.Daily safety checks of the resuscitaire on Beatrice wardhad not been fully completed. We looked at the recordsdated from the 30 October 2015 to the last entry dated29 November 2015. There were gaps in the safety checksthroughout this period of between one and four days.

• We observed there were limited computer on wheels(CoWs) within the delivery suite. These enabled clinicaland other information to be reviewed and updated inthe delivery rooms. For example; registering the baby foran NHS number. The midwives we spoke with told usthey were often required to remain with patients. Thelack of CoWs often delayed information beingcompleted in a timely way when it was necessary toremain in the delivery room.

• We saw some equipment did not have in datemaintenance checks. This included baby scales anddelivery beds used by patients on the delivery suite.

• There was a lack of understanding regarding theprocesses for the maintenance of equipment within thematernity services. We discussed this with senior staff.There was reference to a central database. However,there was lack of clarity regarding when equipment hadbeen serviced or if maintenance checks were in dateand who had responsibility for oversight of this.

Medicines

• Most medicines and controlled drugs were stored safely.We observed medicines stored in appropriately lockedcupboards, and within the resuscitation trolleys, in thematernity theatres and other clinical areas. However, wefound medicines on two separate occasions left ininsecurely in rooms on the delivery suite. We alertedstaff to this during our inspection. Midwives and nursestold us they had adequate stocks of medicines and noissues with the pharmacy services.

• Oxygen and nitrous oxide (used for pain relief) waspiped into delivery rooms. Stronger analgesia wasavailable for patients in labour if they required it.

• A protocol was followed for the safe storage of cylindersof oxygen and nitrous oxide at a patient’s home. Recordsshowed this was discussed with women prior to birthwho signed to say they understood the conditions andinstructions to be adhered to.

Records

• Gynaecology and midwifery medical records and otherconfidential patient information was stored safely inlockable records trolleys. When records were notrequired they were stored in a central office which waslocked when not staffed. The trolleys and office wereaccessible to all staff who required access to them. Stafftold us they always had medical records in a timely wayfor clinical interactions with patients.

• We reviewed nine maternity patient records and thematernity safeguarding files. These recordsdemonstrated clear plans of care. Documentationsshowed referrals to other professions or services hadbeen made where necessary and information sharedappropriately. There were no gynaecology inpatients atthe time of our inspection, we therefore did not reviewgynaecology medical records.

• Midwifery record keeping was compliant with local andnational standards. Between March 2015 and April 2015an audit of midwives record keeping had beencompleted. A supervisor of midwives had reviewed 14care records against standards set by the NationalHealth Service Litigation Authority (NHSLA, 2012) andNational Institute for Health and care Excellence (NICE,Quality Standards 22, 2012). The midwifery entries’ were100% compliant with standards.

• Records were not always completed in a timely manner.The maternity services regularly used the escalationprocess (redeploying clinical staff from other areas tothe delivery suite) in order to safely meet the clinicalneeds of patients. Midwives told us patient care andtreatment were prioritised and as such records were notalways completed in a timely way. Senior staff wereaware of these issues and in the process of recruitingadditional midwives.

• The way the records were used and organised enabledclinicians to access relevant information to review care.Pregnant women had hand held records which wereprovided at their initial booking of ante natal care.These were maintained through to completion of




post-natal care by community midwives. We saw allnecessary risk assessments were completed andregularly reviewed. Risks were recorded as having beendiscussed with patients.

• Midwives took positive actions if hand held records werenot available. We saw in one set of records that thepatient had forgotten to bring with them to an antenatalappointment. The midwife wrote a clear summary of theappointment, discussion and actions to be taken. Inaddition the patients NHS number and date of birthwere included. The summary was clear, factual, signedand dated by the midwife. This information had beenadded to the hand held records at the next consultation.This had ensured consistent records of clinical care weremaintained.

• Systems were in place which ensured the legalrequirements of a termination of pregnancy werepursued and documented in records. Processes werefollowed which ensured records were properlycompleted and forwarded as required to theDepartment of Health in a timely way. Stickers wereused on records to indicate when specific parts of theprocess had been completed. This followed goodpractice guidance recommended by the Royal Collegeof Obstetricians and Gynaecologists (2011).

Safeguarding

• Staff we spoke with were knowledgeable about thetrust’s safeguarding process and were clear about theirresponsibilities. Staff demonstrated an understanding ofwhat kind of issues might alert them to considersafeguarding issues, and what they could do to respondto the patient in a safe and supportive manner. Welooked at records which showed when concerns hadbeen identified, appropriate referrals had been madeand these were fully documented. Records werediscretely marked and IT information tagged in orderthat all clinicians involved in care were alerted tovulnerabilities. Detailed information was held securelyby the lead safeguarding midwife

• Women were assessed for mental health issues as partof antenatal, perinatal and post-natal care. There was amidwife who specialised in working with vulnerableadults which included those with mental health needs.If issues were identified records showed, appropriatesupport was provided. Patients consent was sought tomake referrals and share information with otherprofessionals involved with their care.

• A revised perinatal and infant mental health pathwaywas in the processes of being implemented bymaternity services. The first phase of this revisedprogramme began during September 2015. Thismultiagency/multidisciplinary policy clarified theresponsibilities and roles of the maternity service (andothers) to prevent, detect and manage perinatal mentalillness and infant mental health problems. This includedclear and detailed ante natal and postnatal mentalhealth pathways for women and young women underthe age of 18 years. The lead midwife for safeguardingtold us it was anticipated that all obstetricians andmidwives would have completed update training by theend of January 2016. Other midwives we spokedemonstrated a clear awareness and understanding ofthe new policy roll out.

• The lead midwife for safeguarding was trained to theadvanced level four in safeguarding and protectingvulnerable adults. This person provided advice andsupport to other staff when required. This includedspecific safeguarding supervision which was provided tomidwives who were involved in safeguardingprocedures.

• The safeguarding midwife had good links with the leadlocal authority safeguarding services. This midwife wasa member of the strategic local authority children’sboard. We looked at the last meeting minutes datedNovember 2015. This documented the results andactions taken from a maternity vulnerable adultpathway audit. The minutes also documented how firmlinks with other local maternity services had beenestablished. This ensured a consistent approach andresponse to safeguarding across all local services.

• There was no data available to confirm the level ofcompliance medical staff had with safeguardingchildren’s training. Medical staff attended a whole dayslevel three children’s safeguarding training. This wasfacilitated by the trusts safeguarding lead nurse. Thetrusts data did not provide the levels of compliance withthis training specifically for obstetric and gynaecologymedical staff.

• There was no data available to confirm the level ofcompliance by obstetric and gynaecology staff forsafeguarding vulnerable adults. This training wascompleted every two years as part of the trusts




mandatory training programme. The trust providedinformation of an overall compliance rate for allmandatory training by all staff groups. This figure was76% against an overall compliance target of 85%.

• The lead midwife for safeguarding facilitated a rollingprogramme of level three safeguarding children updatetraining for midwives. During 2015, six, two and half hoursessions had been planned. Midwives were rostered toattend this training and only did not attend if absentfrom work. The lead midwife for safeguarding told us bythe end of December 2015, 90% of midwives wereexpected to have completed the safeguarding update.

Mandatory training

• The trust provided a range of statutory and mandatorytraining for staff which were allocated based on roles.This included training on dementia, equality anddiversity, moving and handling, safeguarding adultswhich included mental capacity and deprivation ofliberty safeguards, and infection control. The trustprovided information of an overall compliance rate forall mandatory training by all staff groups. This figure was76% against an overall trust compliance target of 85%.

• Maternity staff attended an additional day’s mandatoryskills and drills prompt training (practical emergencyobstetric training). This was a multidisciplinary,evidence based and accredited training packagePROMPT (RCOG and RCM, 2013). This included the use ofa simulation model which was used to recreateemergency scenarios. Records showed 95% of midwivesand 100% of consultants were compliant with thistraining. Midwives spoke extremely positively about thequality of this training, stating it enhanced teamworking, learning and confidence.

• The midwives attended further mandatory training inNeonatal Advanced Life Support as required by the UKResuscitation Council and attended annual updatetraining. The compliance rate during November 2015was 74%. We spoke to senior staff about this. We weretold at times of escalation on the delivery suite; staff hadbeen redeployed from training. Additional midwiveswere being recruited at the time of our inspection.


• All pregnant women had comprehensive riskassessments which were started at the first bookingappointment. We spoke with community midwives whotold us they provided an extended booking time. This

was to ensure issues or risks were identified and actionsto mitigate these were initiated. Risk assessments andaction plans were reviewed with every subsequentcontact with a doctor or midwife. This includedscreening for pre-eclampsia, gestational diabetes,venous thromboembolism, and other medicalconditions. Other risk factors were assessed anddiscussed with women including; previous obstetrichistory, family medical history, social issues, andscreening for domestic abuse and mental health.

• Clinical leads maintained regular review of thecomplexity of patients on the delivery suite. TheBirthrate Plus acuity tool was used by senior staff everyfour hours to risk assess the needs of patients againststaffing levels. Birthrate Plus is a nationally recognisedtool (reflected in DH and NICE guidance) used to provideassurance that staffing levels safely meet service needs.The acuity tool was used as evidence for invoking theescalation policy. This policy enabled staff roles andresponsibilities to be reorganised and redeployed toreduce risks and meet patients’ needs. This included thecommunity and ward midwives, and if required, thespecialist midwives and the head of midwifery.

• The central delivery suite was consultant led and able tosupport women with high risk pregnancies and/orcomplex health. Women assessed as having low riskswho chose a home birth and developed unexpectedcomplications were transferred immediately to deliverysuite at the hospital. Between April 2015 and October2015 there had been 22 (average; two per month)intrapartum or postpartum transfers of women fromhome to the hospital.

• Systems were in place to respond to acute, severe andunpredictable obstetric emergencies. Anaesthetic andobstetric medical staff were available 24 hours a day,seven days per week. We observed on call contactinformation was available to staff.

• The anaesthetists from the hospitals surgicaldepartment who covered on call received regularobstetric updates to maintain their skills. These weremonitored and reviewed through their annualappraisals.

• On call consultant obstetricians and anaesthetists werecontractually obliged to be on site within 30 minutes ofthe call. We observed daily safety briefings wereconducted twice per day on the labour suite andpostnatal ward (Beatrice). We looked at records whichshowed a range of issues were reviewed and actions




taken. For example, patient acuity (level of need),staffing levels, equipment and security issues,safeguarding issues, theatre activity and cover andavailability of the neonatal unit.

• Consultants and midwives were familiar with guidelinesfor the management of conditions such as cordprolapse and post-partum haemorrhage. We sawrecords which showed emergency skills’ training wascompleted annually by medical and maternity staff.

• The paediatric medical staff reviewed care on a dailybasis. The paediatricians were in regular contact withthe delivery suite and visited the antenatal ward(Beatrice) each day. This ensured the neonatal intensivecare unit were aware of any potential issues. Recordswere maintained on Beatrice which documentedpaediatric clinical reviews had been completed in atimely manner.

• On the delivery suite there was adult and babyresuscitation equipment and sufficientcardiotochograph equipment for fetal heart monitoring.We observed ‘fresh eyes’ stickers had been signed toconfirm trace readings had been double checked by asecond midwife. These actions ensured any additionalconcerns or actions could be promptly responded to.

• There were processes and equipment in place for thesafe transfer of newborns requiring additional orspecialist support. The neonatal intensive care unit(NICU) was situated next to the delivery suite.Paediatricians were available within minutes if required.There was a baby transporter incubatorresuscitationunit. This was used if a newborn required transfer to analternative service for specialist treatment.

• Safe practice guidance was followed before obstetricsurgery commenced. We observed the World HealthOrganisation (WHO) surgical safety checklist being usedin theatre. The guidance prompted actions for safeclinical practice before anaesthesia, before incisions,and before the patient left the operating room. Theatrestaff appeared familiar with processes and participatedappropriately. The safety checklist also formed part ofthe obstetric theatre team brief. This gave cliniciansadditional opportunities to discuss and plan for anyissues relating to the safety of patients. We spoke tomedical and theatre staff regarding the use of the safetychecklist and theatre team brief. Staff told uscompliance with both was well established andembedded in practice.

• There appeared to be a lack of regular audit of the WHOchecklist to evidence compliance levels. We reviewed aretrospective audit of women’s maternity records datedSeptember 2015. The sample size was small; with only10 records reviewed. Compliance with the reguiredactions were poor ranging between 33% and 83%.Actions were put in place including raising staffawareness and adding a signature box to more clearlyidentify who was responsible for completing thechecklist. A second small audit was repeated duringDecember 2015. This was an observational, real timeaudit of eight patients. The compliance rate wasrecorded as between 87% and 100%. We were told theaction plans were being developed

• Obstetric risk management guidance tools wereavailable, used and appropriately referenced to othernational standards and guidance. For example; we sawrecords of risk assessments completed for venousthromboembolism, safe induction of labour, and forwomen who had had previous caesarean section.

• Staff demonstrated an understanding of gynaecologyemergency risk management guidelines, and knew howto access these for reference. We observed guidelineswere based on national best practice standards andguidance. For example, National Institute for Heath andCare Excellence (NICE) clinical guidance 154 on themanagement of ectopic pregnancy and miscarriage.

Midwifery staffing

• There were 78 whole time equivalent (WTE) midwivessupporting the provision of maternity and obstetricservices within the trust and local community. Thisincluded a head of midwifery, a safeguarding midwifefor children, a midwifery advisor for vulnerable women,an antenatal screening coordinator, a specialistnewborn hearing screening midwife, an infant feedingspecialist, a deputy head of midwifery and practicedevelopment midwife, and an audit and complaintslead midwife.

• There were inadequate numbers of midwives to meetthe Royal College of Obstetricians and Gynaecologists(RCOG, 2007) Safer Childbirth Minimum Standards forthe Organisation and Delivery of Care in Labour. Thisrecommends a midwife to patient ratio of 1:28 for safecapacity to achieve one-to-one care in labour. Duringthe period May 2015 to October 2015 the midwife tobirth ratio ranged between 1:33 and 1:41, with theaverage being 1:37.5. No audit or analysis information




was collated to establish if one to one care was achievedfor all women during established labour. We discussedthis with the head of midwifery who told us they wereconfident this was provided through the use of theescalation process. However, it was not possible toestablish theses facts.

• Shortfalls in midwifery staffing were covered fromsubstantive midwives temporarily increasing theirhours. If staffing issues were not resolved this way, thematernity escalation policy was followed. This requiredthe community and ward midwives, and if required, thespecialist midwives and head of midwifery to beredeployed to fill any staffing gaps. Senior midwivesconfirmed the escalation policy had to be used mostdays, and staffing issues were a concern. We sawrecords which showed this had been entered on the riskregister.

• During 2014/15 the trust commissioned Birthrate Plus(Royal College of Midwives, 2006) to review the fundedestablishment of midwives within the maternityservices. Data was collected during a four month periodand the findings indicated a shortfall of 10 WTEmidwives. In response, the trust committed to theimmediate employment of five band five midwives andfive band six midwives. At the time of our inspection, thedepartment had recruited the band five midwives(included in the 78 WTE figure) and had advertised forthe band six midwives. Once all vacancies had beenfilled, the funded establishment would have increasedto 83 (WTE). The head of midwifery told us this wouldtake the birth to midwife ratio to 1:32. We were told thisratio was agreeable with the local clinicalcommissioning group.

Medical staffing

• There were safe levels of medical staffing. The trust had19 whole time equivalent medical staff who workedacross the gynaecology and obstetric services. Therewere six (WTE) consultants who provided 40 hours ofobstectric cover per week. This met therecommendations of the RCOG Safer Childbirth, TheFuture Workforce (2007).

• There were sufficient anaesthetic, obstetric andgynaecology medical staff to provide surgical andclinical support to at all times. This was managedthrough an on call rota. However, the registrars were oncall one night in every six. The local medical deanerywas concerned as this rate had been impacting on the

programme of educational and clinical teaching. Theseissues had been presented to the trust board who hadapproved the appointment of two resident consultants.Once in post it was anticipated the on callresponsibilities would reduce to once every eight days.

Other staffing

• Senior staff said there were sufficient staff employed inroles which supported the midwifery and gynaecologyservices such as sonographers and ward clerks.

• The theatre staff from the hospitals surgical departmentwere rostered to work in the obstectric theatre.

• There was one WTE specialist gynaecology nurse, a parttime band five nurse, (0.32 WTE) and band three healthcare support workers (1.85 WTE).

• There were 17.07 WTE band two midwifery careassistants and four WTE band three posts.

• There was a low use of bank staff in the maternity unit.Between April 2014 and March 2015 the use of bank staffremained consistently below 1%. No maternity agencystaff had been used.


• Senior staff demonstrated an awareness of the trustsmajor incident plan and how to access this, but had notbeen included in training.

Are maternity and gynaecology serviceseffective?

Good –––

Overall, we have judged effectiveness as good in thematernity and gynaecology services. Policies andguidelines had been developed in line with national policy.These were available on the trusts intranet and staffdemonstrated they knew how to access them. A range ofequipment and medicines were available to provide painrelief in labour. The midwifery services had achieved fullaccreditation with UNICEF UK breast feeding standards.The gynaecology service had good processes in place topromote and maintain effective care and treatment. Therewere opportunities to improve some midwiferycompetencies and obstetric multidisciplinary teamworking.





• We observed policies and guidelines in the maternityand gynaecology services had been developed in linewith national policy. These included a range of NationalInstitute for Heath and Care Excellence (NICE)guidelines, the Royal College of Obstetricians andGynaecologist; Safer Childbirth (RCOG, 2007), The Careof Women Requesting Induced Abortion (RCOG, 2011)and the Termination of Pregnancy for Fetal Abnormality(DoH, 2010) guidance. Patient’s received care in line withNICE quality standards 22 (for routine antenatal care), 32(for caesarean section) and 37 (for postnatal care).

• Policies and procedures were available on the trustsintranet and staff demonstrated they knew how toaccess them. However, the intranet system was slow toload up and delayed prompt access by staff.Gynaecology staff told us they had printed manypolicies and procedures in order to be assured the teamhad easy access to information when required. The leadgynaecology nurse took responsibility for ensuring thesewere kept up to date.

• The gynaecology and maternity services had auditprogrammes in place. This included local clinical auditsand participation in national clinical audit. Theseenabled the services to evaluate if treatment and carewas being provided in line with national standards andto identify improvement actions.

• The maternity audit plan was extensive and includedaudits completed in previous years and others plannedto take place during 2017. There was a range (22) ofaudits dated from 2014 to 2016 at various stages ofprogress, planning and completion. We reviewed oneaudit report dated April 2015. This had analysed howinformation was recorded on cardiotocographyprintouts (monitoring of the fetal heart). This providedan overview of standards and staff practice. Furtheractions and learning from this audit had been presentedat the maternity governance meeting and shared withstaff.

• We observed an audit tracking system for 12 obstetricrelated NICE guidelines. This identified how practice wasbeing delivered to patients in accordance with NICE.This had been established through baseline auditscomparing current practice to that recommended.Where required, action plans had been put in place andre-audit planned.

• New or updated national or trust guidance wascommunicated to staff via meetings and email. Weobserved policy and procedure updates were includedin meeting minutes and the weekly maternity staffupdate emails.

• The termination of pregnancy service was provide inline with RCOG (2011) evidence based clinical guidanceand standards. These included a pathway ofassessment, treatment and support before, during andafter procedures.

• All gynaecology cancer patients received appropriatecare which followed national standards and guidance.This included NICE improvement outcomes guidance,2003 (for ovarian cancer) and 2004 (for gynaecologycancer), and The Cancer Reform Strategy, 2007. Beforepatients started treatment plans, they were discussedand signed off by a regional specialist cancer centre.

Pain relief

• Patients we spoke with told us they regularly had theirpain assessed by staff and were given medicinespromptly. We looked at patient care records and sawpain and comfort needs had been assessed.

• A range of pain relief was provided on demand in thedelivery unit. Each room had an electronic delivery bedwhich could be adjusted to support different positionsand ease pain. Nitrous oxide gas (Entonox) and oxygenwere piped into each delivery room. Epidurals and otherpain relieving medicines were available for patients inlabour 24 hours a day, seven days a week. Midwivesconfirmed anaesthetist’s responded promptly.

• Additional resources were available to relieve pain andsupport a natural delivery. Water was used to alleviatepain and birthing pools were available in two of thedelivery rooms. A range of equipment was availableincluding; a birthing couch, bean bags, birthing stoolsand mats and large sit on balls. Approximately half of allmidwives had been trained to use aromatherapy as anoption available to reduce and alleviate stress andanxiety.

• Pain relief options were planned in advance and withpatients on the delivery suite and birth centre. Weobserved birthing plans had been completed betweenpatients and clinical staff in advance of delivery. Thisincluded discussions regarding pain management.

• Midwives told us pain management options and choiceswere regularly reviewed during labour. We saw this wasdocumented in care records.





• The maternity services had full accreditation (level 3)with the UNICEF UK Baby Friendly Initiative. This meantstaff had fully implemented breast feeding standardswhich had been externally assessed. This involvedinterviewing mothers about the care they had receivedand reviewing policies, guidance and internal audits.

• On the postnatal ward (Beatrice) there was a dedicatedbaby feed fridge. We observed ample stocks of breastpumps which were available for use by patients ifrequired.

Patient outcomes

• The majority of deliveries (2,360) were on the consultantled unit, and the remainder (86) were home births. Therate of home births was the highest in the south westregion. The average percentage of home births permonth was 4%, significantly higher than the averagenational average of 2.3% (Office of National Statistics,2014). During the period 1 April 2015 to 31 August 2015there had been a further 954 births of which between sixand nine per month were home births.

• Women were encouraged to breastfeed following bestpractice guidance. The uptake of breastfeeding at thehospital exceeded (was better than) the nationalaverage which was 74.35% (NHS England, July, 2015).Records showed between July 2014 and June 2015 theaverage percentage uptake of breastfeeding by womensupported by the maternity services was 81%.

• Treatment and care was provided in a timely care. Allbabies were required to have a neonatal examinationwithin 72 hours of birth. These were performed bypaediatricians. We saw records on the postnatal wardconfirming the majority were completed the same daythey were requested by midwives. In addition we weretold approximately half of all midwives had completedspecialist training to provide the newborn checks. Thissupported the prevention of discharge delays.

• A range of effective and timely gynaecologicalinvestigations and treatments were provided. Theseincluded general and emergency gynaecology, andtreatment for gynaecological cancer and abnormalbleeding. The colposcopy service (treatment followingpositive cervical smear tests) provided a prompt andeffective service. The hospitals referral to treatmenttimes were exceeding (were better than) the nationalaverage rates. We looked at audit information dated

April 2014 to March 2015. Standards were set for urgent,moderate and routine appointments. Nationalguidelines recommend 90% of patients should have hadan appointment within set time frames based onurgency (NHS Cancer Screening Programmes, 2010). Thetarget times achieved at Salisbury hospital werebetween 95.5% and 100%. In addition, test results andtreatment plans were provided to patients in a timelymanner. The percentage shared within four weeks ofattendance was 97%. This exceeded (was better than)the national target of 90%. The percentage sharedwithin eight weeks was 99.5%, against a national targetof 100%.

• The rate of unexpected admissions of full termnewborns to the neonatal intensive care unit (NICU) wasmonitored and investigated for learning and safetyimprovements. Staff said it was difficult to establish thethreshold for unexpected admissions to NICU as theyincluded those transferred there for safeguardingreasons. From April 2014 to March 2015 the percentageranged between 2% and 5%. Between April 2015 andAugust 2015 the transfer percentages ranged between1% and 4%.

• Between April 2014 to March 2015 there had been oneunplanned maternal admission to the intensive careunit (ICU). We saw records which showed this had beensubject to both an in depth internal and coroner’sinvestigations. Between April 2015 and August 2015there had been no unplanned maternal admissions tothe ICU.

• The maternity services maintained a red, amber, green(RAG) rated dashboard of clinical outcomes. This relatedto birth figures and complications during perinatal care.The parameters were based on RCOGrecommendations. Some of this clinical data had beenadjusted further. This was based on analysis of SalisburyHospital’s data during a three year (minimum) period.For example, the national average home birth rate was2.4% (Office for National Statistic’s, 2014). The averagehomebirth rate for Salisbury hospital had been higher.Therefore the threshold for home births was adjusted to4% to reflect this.

• We reviewed the clinical dashboards for the period April2014 to March 2015 and April 2015 to August 2015. Therate of elective and emergency caesarean sections was24% which was below (better than) the national averageof 26%. The rates of third and fourth degree perinealtears were measured together using the RCOG guidance.




This recommends rates should account for less than 5%of deliveries. During 2013/14 the rate was 3.9. From April2014 to March 2015 the rate had decreased to 3.4%.Records showed all incidents of this type had beenreviewed. Analysis had not identified any significantcontributing factors other than the body mass index ofpatients at Salisbury hospital (a recognised indicator,RCOG). The national average rate for postpartumhaemorrhage (PPH) was between 1% and 5% of allbirths. The rate of PPH at Salisbury maternity serviceswas hospital was 1.8%.

• The maternity service participated in the Maternal,Newborn and Infant Clinical Outcome ReviewProgramme (MBBRACE). We reviewed the most recentreport dated November 2015, reviewing data from 2013.This analysed the rates of stillbirths based on acalculation of percentage per 1000 births. During 2013,this was 3.6% (nine stillbirths). Between April 2014 andMarch 2015 the rate was 4% (10 stillbirths). Whilst thesefigures were higher compared to other similar sizedtrusts. The rates were slightly below the south westregional average of 4.1% and the national average of4.7%.

• All stillbirths were fully investigated as part of seriousincident reviews and reported onto the national qualityimprovement programme ‘Each Baby Counts’ (RCOG,2015). In addition Salisbury maternity services hadcompleted two reviews to interrogate for themes ortrends, and make any necessary changes to practice.The most recent report included all stillbirths which hadoccurred between January 2012 and December 2014. Arange of data was scrutinised using a validatedproforma (British Journal of Obstetrics andGynaecology, 2011). This included analyses ofdemographics, previous pregnancy history, obstetricrisk factors, social issues, antenatal and intrapartumcare. Overall, no new trends were identified and anaction plan was put in place and shared with staff toreinforce areas of good clinical practice.

Competent staff

• Clinical expertise and support was available to juniormedical staff and midwives. Junior staff said they feltsupported. For example one doctor explained how theyhad performed a complex procedure. We were told theconsultant had sat outside the theatre while this wascompleted. The doctor said this had provided a goodbalance of learning with immediate support available if

required. There was experienced labourmanagercoordinator and a community midwiferymanager. These roles provided additional clinicalexpertise to more junior staff.

• There were good processes in place to maintain theskills and competencies of gynaecology staff. Theconsultants met every month to present their owngynaecology cases. This formed part of a peer reviewprocess which positively promoted the developmentand clinical skills.

• The gynaecology lead nurse took responsibility forensuring the health care support workers and band 5nurses had the necessary competencies and skills toeffectively support patients. This included providingskills training sessions, supervision and support andensuring policy updates were understood.

• The gynaecologists had processes in place to developskills and clinical practice. The team had establishedworking relationships with other specialists external tothe service. Each week at least one of the seniorclinicians joined a large multidisciplinary meeting takingplace at another hospital via video conference. This wasattended by a number of gynaecology specialties whoworked within the south west region. The purpose ofthese meetings was to review clinical work, get adviceand support, discuss potential referrals to others andshare good practice.

• Not all staff were being supported to have an annualappraisal. Records dated November 2015 showed 64%of midwives had a trust annual appraisal in date. Thisdid not been the trusts target compliance target of 85%.Senior staff told us frequent use of the escalation policyand prioritising safe patient care had impacted on thecompletion of appraisals in a timely manner. Staffassured us appraisals were being scheduled.

• The ratio of supervisors to midwives (SoM) metrecommended guidelines. The regulation of midwivesincludes an additional layer of investigative andsupervisory responsibilities provided by a supervisor ofmidwives (SoM). By law midwives must have a namedSoM with whom they meet once a year to consider theirpractice. The recommended ratio of SoM to midwiveswas 1:15 (Midwifery Rules and Standards, rule 12,Nursing and Midwifery Council, 2014). There were tenSoM which gave a ratio at was 1:12. Records showed the




percentage of completed SoM reviews was between78% and 100%. Staff told assured us SoM appraisalswere scheduled for those midwives who still requiredthem.

• There was a SoM available on call 24 hours a day, sevendays per week to support midwives with clinical practiceissues. Midwives confirmed supervisors were responsivewhen contacted for advice.

• There were a number of experienced specialistmidwives who had completed additional training andhad enhanced skills. This included midwives for:safeguarding children, vulnerable women, antenatalscreening, newborn hearing screening, infant feeding,practice development, audit and complaints andbereavement. These midwives had lead roles for theirspecialties, providing clinical updates, auditinformation, advice and support.

• The senior gynaecology nurse was skilled andexperienced. This person ran their own colposcopyclinic once per week. This involved taking patients fromreferral through to discharge and independentlyproviding diagnostics and treatment.

• Systems were in place to ensure junior midwives hadthe required skills for practice. Newly qualified band fivemidwives completed a preceptorship programmeduring the first year in post. This was to enhanceconfidence and competence in order to provide safe,effective care to patients. Once competencies had beenfully reviewed and signed off, these midwivesprogressed to band six posts with increasedindependent working and responsibilities. This practicefollowed the recommendations in the PreceptorshipFramework (Department of Health, 2010). We spoke witha junior midwives. We were told the training andsupport provided was of a highest standard. Whenjunior midwives reported for duty the most seniormidwife identified themselves and ensured anyadditional clinical support was provided. We were toldthe practice development midwife was approachable,was a good listener and had an open door policy. Thisperson supported junior midwives to find or create theirown action plans to move forward with issues andprofessional development.

• Not all midwives felt confident to practice in all areas ofcare. There was no planned midwifery rotationalworking programme (between community, deliverysuite, ante and postnatal care). The band six midwivesonly rotated from their main place of work if this was

requested and, if there was the capacity toaccommodate this. Therefore some midwives, who haddeveloped skills in specialist areas, remained in theirroles long term. However, during busy periods when theescalation policy was used, all midwives wereconsidered for redeployment to other clinical areas tomeet service demands.


• Maternity staff reported good multidisciplinary workingwhen delivering direct patient treatment and care.However, there were missed opportunities formultidisciplinary working on the delivery suite. Themidwifery and medical handovers were held at differenttimes. In addition, we observed when medicalhandovers took place, these were completed bymedical staff privately (in closed rooms; unit meetingminutes dated July 2015 and September 2015).Therefore, the whole multidisciplinary team was notable to benefit from each other’s handover. This mayhave reduced the potential for developing staffknowledge and skills, and for effective patientcommunication and coordination of treatment andcare.

• Whilst all staff confirmed they worked cohesively todeliver patient care, we were told this did not alwaysextend to other working practice within the department.Many maternity staff felt there was a hierarchicalapproach between medical and midwifery staff whichwas felt to have a negative impact on whole teamworking.

• We observed a morning medical handover meeting.This was attended by the labour ward coordinator,medical and anaesthetic staff. During the meeting theclinical needs of patients booked for induction and /orelective caesarean sections were reviewed. All staffengaged and participated in discussions, which wereproductive and well managed.

• Information was shared appropriately with otherprofessionals and services for the benefit of patient care.Some of the records we reviewed showed clear anddetailed communication with other external services.For example, we saw information shared by thesafeguarding midwife with the local authority.

• The gynaecology team worked cohesively. Teammembers told us there were effective systems ofcommunication and respect shown between all staff




which benefited patient care. For example, the nursingassistants joined and contributed to clinical meetings. Inaddition they were competent and confident toquestion and raise concerns or issues with consultants.

• The e weekly elective caesarean section lists wereaccommodated by a dedicated surgical team. The teamworked effectively with maternity staff to coordinate andmanage obstetric surgical procedures. For example,when emergency sections had to be accommodatedand the surgical lists had to be revised.

• The midwives worked effectively with services in thecommunity. Antenatal and postnatal care was offered inthe woman’s home, at a children’s centre or GP surgery.Information was shared in order to improve outcomesand ensure consistency of care.

• Postnatal care in the community was coordinatedeffectively. The community administrator had systemsin place to keep the community midwives updated.These processes ensured clinical information wasshared in a timely way. For example, sonography andother test results and delivery and dischargeinformation. This supported a seamless transition ofcare from the acute to the community setting.

Seven-day services

• The central delivery suite was staffed 24 hours a day,seven days per week. The maternity services had notclosed from January 2014 to November 2015.

• Obstetric and gynaecology services were consultantlead and provided 24 hour emergency clinical andsurgical care, seven days per week. A middle gradedoctor was on site 24 hours a day and had responsibilityfor emergency admissions to the labour suite and anygynaecology inpatients. Overnight the duty consultantcould be contacted at home and was available to comeinto the hospital. All of the obstetric consultants livedwithin a 20 minute travel time to the hospital.

• The maternity day assessment and ultrasound unit wereopen during week days. Out of hours imaging wasprovided by the hospitals main imaging department.


• Medical records were accessible and available for bothgynaecology and maternity clinics. Reception staff toldus previous medical records were requested and weresupplied and checked before clinics. This ensured staffhad relevant information required.

• Pregnant women carried their own records which wereprovided during the initial booking appointment. Thesewere used by all clinicians involved with care during thepregnancy. After delivery, new records were made whichincluded relevant information regarding the pregnancy,birth and baby. These records were carried by womenand used for post-natal care.


• Staff followed the correct processes to gain consent. Thepatients we spoke with confirmed that staff had askedfor permission before proceeding with any care ortreatment.

• Procedures to gain consent were documented. The ninecare records we reviewed clearly documenteddiscussions regarding consent before carrying out anyexamination or procedure.

• Not all staff were in date with trusts mandatory trainingon the Mental Capacity Act 2005 and Deprivation ofLiberty safeguards. This formed part of the safeguardingvulnerable adults training. The trust providedinformation of an overall compliance rate for mandatorytraining by staff groups. This figure was 76% (November2015) against an overall compliance target of 85%.

Are maternity and gynaecology servicescaring?

Good –––

Overall, we have judged caring in the maternity andgynaecology services as good. Staff cared for pregnantwomen before, during and after birth with kindness,compassion, dignity and respect. Patients told us they feltinvolved with their care, had their wishes respected andunderstood. The support provided to patients and familieswas person centred, compassionate and sensitive.Feedback from patients and relatives regarding the care,treatment and support received was consistently positive.

Compassionate care

• The monthly Friends and Family Test results wereconsistently positive. Feedback was sought from thosepatients using; gynaecology outpatients, antenatalclinics, the delivery suite, care provided for home births,the postnatal ward (Beatrice), and postnatal care




provided in the community. We looked at records datedNovember 2014 to October 2015. The average responserated during this time was 13.9% and the averagepercentage of patients who were satisfied with their careand would recommend the service was 97%.

• Five of the patients we spoke with had chosen to havesubsequent births at Salisbury hospital because theirprevious experiences had been so positive.

• Compassionate and sensitive care was provided tofamilies who had experienced the loss of a baby,including women who used the termination ofpregnancy service.

• Many of the patients we spoke with commented thatwhen they arrived for maternity appointments,reception staff were welcoming, friendly, helpful andkind.

• We observed compassionate and person-centred careprovided to patients. We saw staff knocked on doorsbefore entering rooms and spoke kindly andappropriately with patients.

• We saw recent letters and cards from patientsexpressing grateful thanks for the care received.

• There were opportunities for patient privacy to beimproved. On the delivery suite and postnatal ward(Beatrice) we observed that no indicators or signs wereused to show when patient rooms on the delivery suiteor Beatrice ward (postnatal) were occupied. Staff told usthey had to continually check for updates.

Understanding and involvement of patients and thoseclose to them.

• Most of the patients within the maternity services wespoke with told us they felt involved in their care, andthat information had been presented in meaningful andunderstandable ways. One patient told us theirappointments with the consultants and midwives werenever rushed and they were given written information,encouraged to ask questions and told to go away andthink about choices and options before makingdecisions.

• We spoke with five partners of women who said they feltincluded and had been given explanations of care as itwas occurring which they had found helpful andreassuring.

• We looked at nine patients’ records and saw discussionsand treatment plans were documented as discussedwith patients and where appropriate, with those closeto them.

• Ward and clinical areas were relaxed and we observedstaff had friendly but respectful interactions with bothpatients and relatives.

Emotional support

• The majority of patients were satisfied with how theywere supported in the maternity services. We spoke with13 patients and five partners. Comments included thatstaff had been friendly, supportive and helpful. Partnerstold us they were included and supported to participatewith the birth process. One patient told us they had afear of hospitals, but staff had been extremelyreassuring and helpful. This patient said theysubsequently felt sufficiently relaxed and comfortable tobe able to have achieved their preferred birth plan.

• The Benson bereavement suite was staffed by midwives.There was one lead identified midwife with specialistinterest and skills to support with bereavement andloss. This midwife, together with thethe chaplaincyservices and three other midwives with specialistinterest in grief and loss provided direct support topatients or advice and support to other midwives asrequired.

• A range of caring and thoughtful mementos wereavailable to patients and their relatives to support withbereavement and loss. Staff provided personalisedmemory boxes and specific blends of aromatherapy oilsfor patients to take home when they left the Bensonsuite. A camera was available and patients wereprovided with the camera’s memory card. In addition, amedical photographer was available 9am to 5pmMonday to Friday. Staff told us this person workedsensitively, producing beautiful photographs inresponse to patients’ personal requirements. One of themortuary technicians was also able to provide plasterfoot casts.

• The specialist midwives provided counselling andsupport to women undergoing antenatal screening.Women who attended for termination of pregnancy forfetal abnormalities were provided emotional care andsupport by midwives on the Benson suite.

• We observed midwives and medical staff supportingwomen on the telephone, within the obstetric theatreand in other clinical areas. Individual concerns werepromptly identified and responded to in reassuring andpositive ways. Patients were spoken with in anunhurried manner and staff checked information was




understood. When speaking on the telephone, womenwere encouraged to call back at any time if theycontinued to have concerns, however minor theyperceived them to be.

Are maternity and gynaecology servicesresponsive?

Good –––

Overall, we have judged responsive as good for thematernity and gynaecology services. Refurbishments to thematernity services had been completed based on patientand staff feedback. This included the provision of a newmidwife led birth unit which would provide local women arange of birth options to choose from. The bereavementfacilities for maternity and gynaecology patients whoexperienced loss were outstanding. Sensitive,individualised care was provided to patients and theirrelatives. There was good flow through the maternity carepathway; however there was concern that the escalationpolicy was not always used to its full effect.


• The current and planned environmental refurbishmentsof the maternity services were based on patient andstaff feedback. This had included refurbishment of thelabour suite and parts of the ante and post-natalservices.

• Systems were in place to plan maternity care to meetthe needs of local people. Senior midwifery staffattended the south west strategic clinical networkmaternity working group. Meetings were held every twomonths and were attended by clinicians and managersof acute trusts in the south west region, commissionersof maternity services, patient representatives and PublicHealth England. The purpose of the group was todevelop quality standards and benchmarking tools thattook account of the needs of the local population.

• The community midwives worked with other services onlocal health promotion initiatives. For example, thecommunity midwives had been trained in carbonmonoxide monitoring. This was used as part of aprogramme to support and enable women to stopsmoking during pregnancy.

• The community midwives (employed by the trust)provided care in community venues to suit individualneeds. This included at patient’s homes, at children’scentres or at their GP practice. The delivery of care in GPsurgeries provided additional opportunities to engagewith local people.

Access and flow

• The maternity services responded to the needs ofpregnant women living in the locality who required care,treatment and support before, during and after birth.Between April 2014 and March 2015, 2,446 babies weredelivered supported by the maternity services atSalisbury hospital. From the 1 April 2015 to 30September 2015 there had been 954 births. Of thesethere were between six and nine home births permonth. Between April 2014 and March 2015 2,936women received or planned to receive ante or postnatalcare by the community midwives. Some of thesewomen chose to deliver at different hospitals.

• A range of gynaecological investigations and treatmentswere provided. The majority of gynaecology patientsreceived their treatment and care on an outpatientbasis. During the past three years (2013 to 2015) therehad been approximately 650 emergency gynaecologyadmissions. Of these, 90% of patients’ length of stay inthe hospital was less than 24 hours. The majority (80%)of patients were treated during week days.

• A maternity triage service was provided through thematernity day assessment unit and central delivery suite24 hours a day, all year round. This enabled pregnantwomen to call or visit with concerns or queries. Thisservice supported effective flow through to the differentmaternity services.

• Between January 2014 and November 2015, thematernity services had not closed and were responsiveto the needs of women. However, there had beenoccasions when the midwife to birth ratio had beenexcessively high. For example during September andOctober 2014 the ratio was 1:44, during September2015; 1:41 and October 2015; 1:39. The Royal College ofObstetricians and Gynaecologists (RCOG, 2007)recommended a ratio of 1:28 for safe care. We reviewedthe trusts maternity escalation policy. Whilst theredeploying staff to the delivery suites was used at timesof high patient numbers, there was an option to close




the delivery suite. Midwives were proud services had notever closed. However, we were concerned as to howhigh the midwife to birth ratio would have to becomebefore a decision was made to close.


• The Benson bereavement suite had been establishedand designed in partnership with two previous patientsand their partners. These extensive facilities had beendeveloped from charitable funds for use by patients andtheir relatives who were experiencing loss. This includedpatients who used the termination of pregnancyservices. The suite was located in a separate wing off thelabour suite, accessible to patients and relativesthrough a private entrance. This enabled other areas ofthe delivery suite to be avoided. The emphasis of thesuite was to provide compassionate care in a homefrom home environment. There were three bedrooms,one with a double bed. Staff told us this enabledpartners and patients to remain close and comfort eachother. Other facilities included a lounge and quiet room,a private garden and kitchen area. Staff told us theseadditional facilities allowed extended family to visit foras long as required, including overnight.

• The maternity staff were responsive to individual needs.Patients told us staff provided personalised care andtreatment. We spoke with thirteen patients and fivepartners. We were told staff checked with patients howthey preferred to receive their care.

• Women were limited to two choices for place of delivery.Options included a home birth, or at the consultant leddelivery suite (the provision of midwifery led unit was indevelopment). Choices were dependent upon acomprehensive risk assessment of individual needs,which was regularly reviewed

• Midwives explained how they supported women withlearning disabilities or women with complex or specificneeds at all stages of the maternity pathway. Staff saidwith the woman’s permission they worked closely withpartners or carers and gave extended appointmenttimes. Consideration was taken to ensure informationwas provided in a format the patient understood and attheir own pace. This supported a reduction in anxieties.

• Each of the delivery rooms was equipped with moodlighting and a MP3 player and speakers. In additiontThere was a television and telephone in each room forhire.(both free). Patients’ personal music choices could

be played if they wished in the obstetric theatre. Thisenabled patients to personalise their birth experience.Each room had a recliner chair for partners to staycomfortably for extended periods. There was an infantfeeding specialist who provided advice and support topatients and staff with all aspects of baby feeding.Patients were complimentary about the hospital foodand told us they were offered plenty of hot and colddrinks. We observed water jugs were frequentlyrefreshed.

• In-between set meal times, snacks and drinks wereavailable to purchase 24 hours a day. On the postnatalward (Beatrice) and the bereavement suite (Benson)there were kitchenette areas where women and theirpartners could access hot and cold drinks and snackswhen required.

• Thoughtful resources were available to gynaecologypatients. A large round painting, in four sections hadbeen privately commissioned. This had been mountedon the ceiling, surrounding the main angle poised lampand examination chair used during procedures. Seniorgynaecology staff said patient feedback regarding thiswas consistently positive, as the painting providedcomfort and distraction.

• Adaptations to the maternity environment had beencompleted which promoted patients’ privacy anddignity. The facilities had been part of the trusts ongoingrefurbishment plans. We observed windows and glassareas of doors had been covered with a patternedstencil. This blocked vision whilst maintaining light. Thishad been used throughout the different maternitydepartments.

• Translation services were available. For women whosefirst language was not English; information wasprovided in other languages. Staff said an interpretingtelephone system was used regularly to support womenin the hospital and community

• The senior gynaecology nurse assured us gynaecologypatients’ were offered, and provided with a chaperonefor appointments if required.

• The trust provided a termination of pregnancy service.Information was provided on choices for fetal remainsand counselling was provided as or when required.

• A range of leaflets, pictures and other information andresources were available for patients and relatives.These were related to conditions, treatments and




medicines. These were available throughout thematernity and gynaecology departments and on thetrusts website. These were also available in alternativelanguages.


• Systems were in place for patients to register complaintsand concerns. The patients we spoke with understoodhow to raise issues if they had concerns. Most patientstold us they would raise issues directly with staff. Thetrust also provided a customer care service which wasaccessible in person, by telephone or email. We sawthere was clear guidance on information leaflets and thetrusts website. This included a suggested lettertemplate and anticipated time scales for responses.

• Systems were in place to evaluate complaints in order tomake service improvements. We looked at recordswhich showed between January 2015 and 16 December2015 there had been 23 concerns and complaints for thematernity service. These were reviewed by thecomplaints midwife and head of midwifery. We sawcomplaints were investigated, actions recorded andlearning identified as part of clinical governancemeeting minutes. Learning points were disseminatedmore widely during departmental meetings and theweekly staff newsletter.

• The maternity services had looked for ways to learn andmake improvements from other maternity services.Senior staff were in the process of completing a servicegap analysis in response to the five key learning pointsidentified in Morecambe Bay maternity servicesinvestigation (DoH, 2015).

Are maternity and gynaecology serviceswell-led?

Good –––

Overall we considered well led as good for the maternityand gynaecology services. Thorough risk management andgovernance structures and processes were in place. Theselinked departmental and trust risk and governancemeetings. This ensured an effective flow of informationfrom ward to board and vice versa. There was evidence to

show incidents and other risk and quality measures wereinterrogated for service improvements and responsiveactions were taken. Significant investment in the maternityservices had been agreed.

Systems were in place to share information and learning.Staff were proud of the care they provided and reportedsenior staff as approachable and supportive. There wasevidence of using patient feedback as the basis for servicedevelopments.


• There were no specific gynaecology and maternityservice line strategies in place. Midwives demonstrateda broad understanding of the trusts vison and corevalues. All the midwives we spoke with stated their goalwas to provide high quality, person centre midwiferycare.

• Systems were in place to develop a unified vision andapproach to maternity care across the south westregion. Senior midwives attended the south weststrategic clinical network, maternity working group.Meetings were facilitated every two months. The aim ofthese groups was to develop a cohesive approach tomaternity practice across the south west area. Meetingminutes documented discussions regarding nationalinitiatives and polices, and subsequent actions toincorporate new practice and policies at a local level.


• Thorough risk management and governance structuresand processes were in place. These linked departmentalwith trust risk and governance meetings. This ensuredan effective flow of information from ward to board andvice versa. We looked at a range of departmentalmeeting minutes. These included the monthly maternityrisk management and clinical governance meetings,and the combined maternity and paediatric riskmanagement annual report (April 2014 to March 2015).We saw governance, risk management and qualityinformation was recorded and subsequent actionstaken. For example, following one serious incident, theactions included training for midwives and obstetricianson a new fetal surveillance programme (Perinatal




Institutes Growth Assessment Protocol; GROW). We sawthis information was shared within the maternitydepartment, and the trusts clinical risk group though tothe trust board. P

• Patient risk management and quality issues wereescalated to the appropriate trust committees. Abusiness case had been made to the finance committeefor the appointment of two additional consultant posts.This was to ensure there were sufficient numbers ofconsultants available to provide clinical care to patientson the labour ward, and an appropriate quantity oftraining and supportfor junior medical staff.

• The supervisor of midwives (SoM) were establishedwithin the governance framework. Part of the SoMs roleincluded investigating and challenging poor midwiferypractice. We reviewed the annual audit report ofstandards of supervision and practice dated June 2015.This evidenced how governance systems were effective.For example, the SoMs had noted an increase in thirddegree perineal tears. This prompted a review of allrelevant clinical cases. No themes were identified. Thisinvestigation was shared within the relevant maternityrisk and governance meetings and the trusts clinical riskgroup.

• Effective systems and processes were in place to makequality measurements of clinical treatment and care.New audits were triggered as a consequence of enquiryor learning from incidents and complaints, and whennew or updated national clinical guidance was released.The process included the completion of a baseline auditto assess the current standard. This was red, amber orgreen (RAG) rated. Subsequent action plans were put inplace and further audit completed to measureimprovements in standards. We looked at the currentaudit plan dated November 2015. This evidenced anumber of baseline audits had been completed andidentified what actions needed to be taken to improvestandards. For example, compliance with NICE guidancefor women with multiple pregnancy; evaluation showed100% compliance with two of three standards. An actionplan had been put in place to increase compliance withthe third standard. This was kept under review andfurther audit was planned.

• Different systems and recording processes were used tomaintain audit information which was complex.Detailed actions (including times, dates, personresponsible) were recorded on the trusts governanceaction tracker spreadsheets. These were not readily

accessible. Summarised information was recorded atdepartmental levels. The risk and complaints midwiveswere familiar with the different systems in place.However in their absence, information was difficult tofind and fully interpret.


• The consultants provided good leadership and supportto junior medical staff. We spoke with junior doctorswho said they had excellent support and workingrelationships with the consultants. The doctors told usthey got the right balance of training opportunities andresponsibility and they felt encouraged and nurtured bysenior staff.

• Midwives told us senior staff had open door policies andwere approachable and supportive. Senior midwiferyand gynaecology staff were visible and present inclinical areas and demonstrated a good understandingof current clinical activity and priorities on the days ofour inspection.

• The head of midwifery told us she visited othermaternity services when possible. This was to review forpotential service improvements. These reviews werediscussed with other senior staff to assess for newservice improvements at Salisbury hospital.


• All the gynaecology and maternity staff we spoke withoverwhelmingly enjoyed working with their colleaguesand were proud of the care they provided. Staff at alllevels demonstrated a keenness for continued learningand improvement for the benefit of patient care. Thiswas evident in how positively staff spoke regardingfeedback from incidents and near misses.

• Many maternity staff felt there was a hierarchicalapproach between medical and midwifery staff. Whilstall staff confirmed they worked cohesively to deliverpatient care, we were told this did not always extend toother working practice within the department.

Public engagement

• Patients were encouraged to provide feedback and tocomplete the Friends and Family (F&F) test. Patients wespoke with told us they had been provided forms tocomplete prior to leaving the hospital. From October2013 to March 2015, 1,333 maternity patients completedthe F&F test. Patient feedback was consistently positive,with 1,193 ‘extremely likely’ and 111 ‘likely’ to




recommend the maternity services (total 98%). The ninepatients (1%) who gave negative feedback said a lack ofmidwifery availability was the main reason fordissatisfaction. Between April 2015 and June 2015, afurther 202 F&F responses were received. The majority ofthese (167) stated they would be ‘extremely likely’ torecommend the service.

• The trusts customer care team provided a service forpatient and relatives to give any feedback on carereceived. The ante postnatal ward (Beatrice) had beenincluded in the trusts real time patient survey. BetweenApril 2015 and June 2015, 472 inpatients were surveyed.When analysed, the feedback was equally dividedbetween positive (staff attitudes) and negativecomments (for maternity; how and what informationwas provided). We reviewed records dated September2015 which showed action plans had been put in placeto address all of this feedback. For example, one patientfelt towards the end of pregnancy there was insufficientinformation to make a birth plan. In response all staffhad been reminded of the importance of emphasisingindividualised care and documenting this.

• Patient feedback was used to design and develop thematernity and gynaecology services. The Bensonbereavement suite was designed with full participationof previous patients and their partners. Senior staff toldus the recent maternity refurbishments and design ofthe new department was based on patient and stafffeedback. For example, the services would be based inone block in a manner to facilitate patient flow throughthe different services.

• The supervisors of midwives (SoMs) provided a monthlylistening clinic service. This provided patients anopportunity to discuss a previous or current pregnancyif care was not provided according to birth plans. Themidwives said the clinic received positive feedback andthey were reviewing ways in which to provide a formalevaluation

Staff engagement

• Systems and processes were in place to keep staffinformed regarding maternity and trust updates. Staffreceived a weekly email update. We looked at a range ofthese sent to staff during August 2015 to September2015. We observed information shared included trustand maternity specific clinical update reminders and

professional development update information from theRoyal College of Midwifery. Other information relating tothe trust or gynaecology and maternity services weredisseminated in departmental emails and staffmeetings.

• The maternity and neonatal unit staff held a jointmeeting every two months. We looked at meetingminutes dated July 2015 and September 2015. Thesedocumented discussions and sharing of informationrelated to departmental, staffing and clinical updates.


• A community midwife won a Pinder award duringNovember 2014 (Nursing Times) for her mentorship ofstudent nurses in practice.

• There was a lack of defined future succession planningwithin the maternity and gynaecology services. Seniorstaff had expressed concern regarding service impacts inthe event that key personnel retired or left their currentposts. Formal succession planning was not fullyestablished to enable new or current staff to undertakenew roles and responsibility in advance of futurevacancies. Formal succession planning would haveminimised potential impacts of senior staff vacancies onpatient treatment and care.

• The trust board had approved a capital investment inthe maternity services (trust board meeting minutesdated January 2015). This was agreed based on changesto the local population as a result of army personnelbased abroad returning to the local area. It wasestimated this would result in an additional 100 birthsper year. These new developments included a midwifeled birth centre. This would increase local women’schoice of how and where their babies could bedelivered. The work was expected to have beencompleted during 2016.

• The gynaecology service had identified ways to providea more effective and responsive service to patients. Thiswas based on analysis of emergency admissions andpatient feedback. Proposals had been submitted as partof the maternity service review business case submittedto, and agreed by the board during November 2015.These included the provision of an additional nurse ledscanning and assessment outpatient clinic. The aim ofthis was to be able to provide more timely care andenhanced patient experience.










Information about the serviceSalisbury District Hospital provides service forapproximately 45,000 children and young people living inand around Salisbury. Services for children are provided fora variety of clinical needs including, surgical, orthopaedic,ophthalmology, cleft palate surgery, general paediatrics,oncology, cystic fibrosis and ear, nose and throat. Surgeonsemployed by the trust treated adults and children withintheir field of specialty such as orthopaedics. Children andyoung people also receive medical support frompaediatricians where it is appropriate.

The service is arranged on two floors of the hospital inclose proximity and consists of a children and youngpeople’s unit including a ward area (Sarum Ward), a dayassessment unit and a children and young people’soutpatient department. The local neonatal unit is situatedin a separate part of the hospital, close to the maternityunit.

Children and young people up to the age of 19 years arecared for on Sarum Ward, day assessment unit and inchildren’s outpatients. Sarum Ward is commissioned toprovide care for 16 children and young people but canaccommodate up to 18 children at time of high demand inone of the ten side rooms or three bays. There is provisionfor a parent or carer to stay with their child. Parents areable to use the parent’s kitchen, toilet facilities, shower andanother larger bedroom if needed. There is a dining roomfor children which has a dual purpose as a school roomoutside of meal times.

The day assessment unit, adjacent to Sarum Ward consistsof waiting areas for children and young people, a clinicalroom and four rooms that can be used for assessment of achild or young person’s condition. The children and youngperson’s outpatients department is on the floor below theward area with waiting areas for children and families and avariety of rooms used by therapists, doctors and nurses.Each of the two floors has a secure outside play space thatis accessible to patients and their families.

Neonatal Unit (NNU) has four bays that canaccommodate14 babies. Parents can use the single anddouble rooms as well as the toileting facilities and parentskitchen and lounge areas on the unit.

There are other hospital departments that care for adultsas well as children and young people. These includeradiology, sexual health, day surgery unit, bereavementsuite, burns unit, theatres and general outpatients.

Day surgery unit is in a separate part of the hospital. It isarranged in three bays with one side room and is used foradults and children with curtains to screen children fromviewing adult care if needed. The unit has its own surgicaltheatres and recovery areas arranged on two floors.

Sexual health offers clinic appointments offering advice,testing and treatment to young people and adults. Theclinic area is within the hospital grounds. The service alsoruns ten clinics outside of the hospital, across the county ofWiltshire.

During our visit we spoke with 64 staff members whichincluded consultants, medical staff, nurses, managers andsupport staff. We also spoke with 18 parents, nine children

Servicesforchildrenandyoungpeople

Services for children and young people


and young people. We visited the paediatric areas as wellas facilities which children and young people shared withadult services. In all areas we observed care and reviewedcare records and other documents.

Salisbury Hospital admitted 1,819 children and youngpeople to the children’s unit between January andDecember 2014. Of these 2% were day cases, 19% wereelective and 79% were emergency admissions.

Summary of findingsOverall we found the services for children and youngpeople to require improvement.

Staff were clear they wanted to provide the best carethey could for children and young people but there wasno clear vision for how the service wanted to beperforming in the coming years. The recent successfultender for children and young people's communityservices by another provider was having an effect onforward planning in the acute service.

Staffing levels for both medical and nursing staff did notmeet the nationally recommended guidelines for theacuity of children cared for in the hospital. Risks topatient safety regarding nurse staffing levels had beenraised as a concern but no permanent arrangement hadbeen put into place to maintain safe staffing levels. Highdependency patients were nursed on the ward but therewas no funding available within the baseline budget forthe extra nursing staff needed to care for these patients.

Safeguarding training did not meet national guidelinesat the time of our visit but we were shown a plan was inplace to provide this training and a timeline for meetingthe guidelines.

There were times when children and young people werecared for in areas used for adults such as someoutpatient appointments, main theatre and day surgeryunit. Some provision had been made to protect childrenfrom adults in these shared areas. We found the screensto protect a child were not always used.

Learning from examples of past practice wasencouraged and medical staff felt well supported bytheir senior colleagues. Staff were able to access trainingthat would add to their skills and the majority of nursesin the neonatal unit were trained in their specialty.Children and young people’s needs were cared for andresponded to by competent staff. Policies and protocolswere based on national guidelines ensuring that bestpractise was observed. Audit programmes werecontributed to both internally and nationally todemonstrate how well the department performedagainst other trusts.




All staff worked flexibly to support the needs of children,young people and their families. Staff worked togetherand shared information appropriately with communitystaff to ensure the safety and wellbeing of children whowere being discharged home.

Staff were compassionate in their treatment of patientsand their families and privacy and dignity was respectedat all times. Children and young people’s views werelistened to and their consent was always sought in away they could understand. Facilities were provided andused flexibly for parents to spend time with theirchildren and at times included the accommodation forthe patient’s whole family.

Staff had developed methods of gaining feedback fromchildren of all ages and had made changes to facilitiesin response. Patient and parent feedback we saw waspositive with comments including “unconditionalsupport and care”, “cheerful, even at the end of a longshift” and “patience and honesty”.

Staff from the children’s unit were supporting thoseareas where adults were also nursed with projectsdesigned to improve a child or young person’sexperience when they visited that area.

Are services for children and youngpeople safe?


We rated services for children and young people asrequiring improvement for safety.

All areas were aware of the 2013 RCN guidance for saferstaffing but these were not always observed to be followed.Areas did not all use an established method of calculatinghow many staff were required to care for their patients.Where this was used the indicated staffing requirementswere not always in place which left children at risk. On oneoccasion, after we raised a concern with the seniormanagement team about inadequate staff numberspresenting a risk to the safety of children, extra staff wereprovided.

Medical staffing did not comply with guidelines from theBritish Association for Perinatal Medicine. To mitigate thelower numbers of junior medical staff, consultants provideda greater level of cover out of hours.

Not all areas we visited used a tool for early recognition ofwhen a baby’s condition was deteriorating. As mitigationthe majority of nursing staff in the neonatal unit hadadditional qualifications in their specialty providing themwith knowledge and skills to recognise what action wasneeded when a patient’s condition was deteriorating.

Staff compliance with mandatory training was variable anddid not always meet the trust target of 85%. Level threesafeguarding children training had not been completed byall staff working with children. There was a programme inplace to provide more opportunities for staff to access thistraining.

Not all areas of the hospital had rigorous, documentedcleaning systems for toys held in their department.Neonatal unit (NNU) had equipment that had been cleanedbut nothing attached to identify how long ago it had beencleaned. We were subsequently told there was a dailycleaning log which included equipment in use and instorage. The areas we visited looked clean and auditsshowed there were no concerns regarding hygiene. If aninfection was identified appropriate actions were taken.




Staff followed the trust policy for transferring children inneed of alternative care and kept children safe.

Senior medical staff were always available to support thecare of children and advise more junior colleagues.

Incidents

• Staff understand their responsibilities to raise concerns,to record safety incidents, concerns and near misses,and to report them.

• Never events are largely preventable patient safetyincidents that should not occur if preventative measuresare taken. There was one recorded never event involvinga child which occurred in September 2014. This eventwas fully investigated by the trust and an action plan ofchanges to procedures in surgical theatres wasidentified. There had been no further untoward eventsor incidents recorded between that time and December2015.

• Staff in all areas of the children and young people’sservice were confident in using the electronic reportingsystem. We were told of occasions it had been used toreport concerns, risks or near misses. Two of the staff wespoke with told us of how they could access feedbackregarding the outcomes from their reporting. Howeveranother two staff informed us they had received nofeedback from incidents they had reported althoughthey were aware feedback was available.

• Mortality and morbidity meetings were held for babiesin the perinatal period to review circumstances andlearning points of serious illness and death in neonates.The records we saw of these meetings showeddiscussions between a range of professionals about theoutcomes of clinical interventions. Concerns aroundserious illness and death in older children werediscussed at the multi-agency child death and overviewpanel meetings. These meetings were attended by apaediatrician from the trust and learning was shared atstaff meetings. There were also ‘sick kids’ meetingswhich had been developed by a paediatric consultant todiscuss and share learning on treating medicalconditions in children and young people moreeffectively. Minutes from the November 2015 meetingshowed attendance of medical staff from intensive care,anaesthetists and registrars. Information from thesemeetings was shared with staff at team meetings.

• Duty of Candour legislation has been in place sinceNovember 2014 and requires an organisation to disclose

and investigate mistakes and offer an apology if themistake results in a death, severe or moderate level ofharm. We saw records where families had beeninformed about a mistake that had been made and anapology offered. Staff we spoke with were aware of theterm duty of candour, told us that training was availableand described how they were open and honest withpatients and families.


• Infection prevention and control procedures were inplace and seemed to be practised by all staff weobserved.

• Hand sanitiser, with instructions for use, was availablefor staff, patients and visitors to use on entry to the wardand at other strategic points on any unit we visited. Weobserved staff complying with the trust infectionprevention and control policy by ensuring they werebare below the elbow, hands were sanitised on entry toa ward area and before and after patient contact. Whereit was necessary to protect patients from the spread ofinfection, protective equipment such as gloves andaprons was available and used appropriately.

• Audits were undertaken monthly to measure how wellthe children and young people’s service were managingthe prevention and control of infection. For the periodbetween April and August 2015, the monthly handhygiene audit reported compliance to be between 92%and 100% on Sarum Ward and at 100% for outpatients,sexual health and neonatal unit. The trust had a targetof 95% compliance. The results identified compliance ofeach professional group; nurses, doctors, allied healthprofessionals and other. The August result showed thatout of two people observed in ‘other’ group, one wasnot compliant with hand hygiene procedures and couldnot be identified from the documentation to remindthem of good practice. Sarum Ward, children’soutpatients and day assessment unit achieved 100%compliance in the hand hygiene audit for July andAugust 2015.

• Information about safety of the patients on Sarum Wardwas displayed for visitors to see. It displayedinformation about the number of infections on the wardand hand hygiene audit results

• There was no recorded incidence of Clostridium difficileon any of the children’s units for the period betweenJune and December 2015. Blood cultures results hadshown the presence of methicillin-resistant




staphylococcus aureus (MRSA) in a child admitted toSarum Ward in August 2015. Appropriate action hadbeen taken to reduce the spread of infection andinvestigate any additional actions required by the trust.This included keeping the child in a single room withprivate washing facilities and staff wearing protectiveequipment when they entered the room. NNU reportedan incidence of Staphylococcus aureus following whichall staff used a course of antibacterial lotions on theirskin to reduce the risk of spreading infection.

• Equipment we saw on Sarum Ward looked clean andhad ‘I am clean’ stickers identifying when it had lastbeen cleaned and that it was ready for use. Theneonatal unit had covers over equipment that had beencleaned but no date identifying when the cleaning hadtaken place. Cleaning of toys in the children’s ward andoutpatients department were included in thehousekeepers’ task list and the senior nurse on dutywould sign a record to confirm the cleaning had takenplace. Cleaning of toys that were in other areas of thehospital where children might visit were theresponsibility of that area. For example, theatres had asmall box of toys for young children which we wereinformed were cleaned with a sanitising liquid on aweekly basis. There was no record of when this cleaninghad taken place and therefore no evidence that the toyshad been cleaned.

• Mothers were able to express breast milk and store itsafely in a fridge or freezer for future use. Both NNU andSarum Ward had a process of checking the correct milkwas being used. NNU’s process was for mother to labelthe breast milk with babies name and date expressedand stored on a tray dedicated to that baby. Before useit was checked by two nurses. Sarum Ward would storebreast milk labelled with the child’s first name, date ofbirth and date milk was expressed. Before use it waschecked by mother and a nurse.

• Salisbury hospital scored higher than other hospitals inEngland in the CQC children and young people’s survey2014 which asked adults how clean they thought thehospital area was that their child was in. Results fromthe 2015 survey were not available at the time of ourinspection.


• The environment was suitable to care for children andyoung people. Processes were in place to maintainsafety of equipment and action taken when faults werefound.

• Sarum Ward had ten side rooms, five of which hadprivate toileting facilities, two bays of two beds each andone bay of four beds. Each of the bays had access totheir own toilet and shower. There were additionalwashing facilities and equipment to help patients withmobility difficulties. A room was dedicated for parents toprepare bottle feeds and store expressed breast milksafely. The milk fridge had a process for checking that asafe temperature was maintained and guidelines wereattached to the fridge. We saw two occasions where thetemperature had not been documented as having beenchecked. Staff were made aware of the lack ofdocumentation

• Sarum Ward, day assessment unit and NNU wereaccessible by a system where staff released the door forvisitors to enter. When leaving Sarum Ward area visitorswould press a door release button placed too high foryoung children to reach. Visitors leaving NNU wouldneed the door to be released by a member of staff. Themain doors were monitored by closed circuit televisionwhich also monitored children’s outpatient departmenton the floor below. Children’s outpatients’ main doorhad no locking system but the reception desk adjacentto the door was staffed when the department was inoperation.

• NNU was arranged in four bays with accommodation for14 cots which were all visible to nursing staff throughglass panels. A fridge and freezer were available forstoring expressed breast milk. The temperature checkswere completed and documented appropriately.

• Paediatric resuscitation equipment was available to usein all areas where children and young people were caredfor. There was a system to record that appropriateregular checks were made to ensure it was available andsafe to use. The burns unit had an incidence of twodates in November 2015 when the record had not beensigned to verify the resuscitation equipment had beenchecked. This was brought to the attention of staff onthe unit at the time of our visit.

• In all areas we visited equipment had been serviced toensure it was safe and ready to use. The date of therecommended next service date was attached to theequipment.




• Storage areas for clinical waste were uncluttered andwaste was removed regularly without risk to children oryoung people.

• There was a vacuum system of sending specimens tothe laboratory for testing. Staff placed the specimen in atube on the ward and did not need to leave the ward.

• Fridges were available for medicine storage on SarumWard and NNU. There were systems in place to checkthat temperatures were maintained at a safe level andprocedures for reporting when temperatures werenoted to be outside of the safe level.

Medicines

• Processes were in place to ensure medicines werestored and administered safely.

• A pharmacist with paediatric knowledge visited SarumWard, NNU and burns unit daily from Monday to Friday.We saw charts had been signed by the pharmacist asbeing compliant with trust policy. Staff also told us theregular visits from the pharmacist meant advice wasavailable around prescribing issues or other medicinequeries reducing the incidence of prescribing errors.

• In all the areas we visited we found medicines werestored securely in locked rooms. Controlled medicineswere stored in a separate locked cabinet in a lockedroom. They were checked daily by two qualified staffmembers who signed a log to verify the check had beencompleted. Stock levels were also checked by amember of the pharmacy team.

• Intravenous fluids, medicines and oral medicines werestored and prepared in an area away from access bychildren young people and visitors.

• Sarum Ward had reported a fridge not workingadequately for medicine storage. As a result they hadrelocated the medicines to another fridge in theintravenous preparation room and were waiting fordelivery of a replacement fridge.

• Pharmacy staff undertook audits of storage facilities andtheir correct use on each area. We saw the audit for NNUin August 2015, identifying action needed to maintain amedicines storage room at a lower temperature.Recommendations were recorded and followed up bybeing reported on the electronic reporting system andongoing monitoring of temperatures.

• Compliance with the trust antibiotic prescribingprotocol was audited on Sarum Ward in August 2015.The result was 93% compliance which exceeded thetrust target of above 80%.

• Paper medicine charts were being used and were clearlywritten with allergies, child’s weight and agedocumented. Of 14 charts we examined two had nodocumentation of a prescribed intravenous saline flushand the remaining 12 were completed accurately.

• There were three incidents regarding medicine errors onSarum Ward for July and August 2015. These had beenreported, investigations held actions taken to reducethe risk of repeating the error.

Records

• There were systems and processes in place to ensurethe confidentiality of patients’ records. Paper patientrecords were stored in locked trolleys with a key onSarum Ward which was stored at the nurse’s station forstaff to access. NNU used a number combination lockfor staff to access the notes storage trolley.

• Charts used for monitoring a child or young person’scondition and nursing needs such as fluid recording andobservation charts were kept at the end of each bed orcot and outside the single rooms. This meant they wereavailable immediately for staff to view the needs of thepatient.

• Clinical records which reviewed a patient’s conditionand held test results were kept in the locked trolley onthe ward. These records were updated by all staffinvolved with the child including nurses, allied healthprofessionals and doctors. All records we saw had arecord of the history of the child or young person, socialcircumstances and clinical condition on admission tothe hospital. They were reviewed by senior cliniciansand had a plan for ongoing care needs.

Safeguarding

• The trust had a team with responsibility for safeguardingchildren consisting of named professionals. This teamincluded representation to the trust board, a medicallead, a named nurse and nurses in areas such as sexualhealth, paediatric ward and maternity unit who acted aschampions for safeguarding children

• The trust had a system of finding out if there were anysafeguarding concerns about any children in thehospital and placing an alert on the child’s electronicrecord for staff to see. Staff confirmed they were alertedto concerns in this way. Trust staff we spoke withinformed us they followed the safeguarding childrenprotocol about reporting safeguarding concerns tosocial services. Paediatricians would refer any child




protection concerns as they would undertake a medicalexamination as part of the referral process but if theywere not available nursing staff would log a concern. Wewere told of a time within the last month, when nurseshad contacted social services to check whether a familywere known to them.

• Trust policy stated “To be compliant with the ChildrenAct: Section 11, all staff should receive suitable training,commensurate with their needs as identified in WorkingTogether to Safeguard Children (2015)” The namednurse for safeguarding had completed a training needsanalysis in May 2015 which identified staff compliancewith different levels of safeguarding training. We wereunable to isolate the compliance figures for staff incontact with children but results for the trust as a whole,in September 2015 showed:▪ 83% compliance for level one training▪ 75% compliance for level two training.▪ 21% compliance for level three training (this figure

had risen to 41% compliance in November 2015)

Compliance with level three safeguarding training wascalculated for those staff groups needing to complete it.The intercollegiate document - Safeguarding children andyoung people: roles and competences for health care staff,March 2014 states “All clinical staff working with children,young people and/or their parents/carers and who couldpotentially contribute to assessing, planning, interveningand evaluating the needs of a child or young person andparenting capacity where there are safeguarding/childprotection concerns”. This training needs analysisdemonstrated a strategy for increasing staff compliancewith level three safeguarding training to 90% by 31 March2017. This trajectory had been agreed with the clinicalcommissioning group for the trust.

All the staff we spoke with told us they had completed levelone and two safeguarding training. The training packagewe saw had been approved by Swindon and Wiltshire LocalSafeguarding Board and included information on femalegenital mutilation with supporting guidance available fromthe trust’s sexual health department.

The ward manager of Sarum Ward kept a record of whichstaff had completed level three safeguarding childrentraining which at the time of our visit was at 80%. Therewas a system of cascading safeguarding supervision. Leadnurses would attend a two day supervision course afterwhich they would be able to offer safeguarding children

supervision to their teams. The named nurse forsafeguarding would supervise these lead nurses. All staffwe spoke with said the named nurse for safeguarding wasavailable and supportive and were able to contact her ifthey had any concerns.

• Staff with the sexual health department undertooktraining for their specialty, such as child sexualexploitation and domestic abuse. Since October 2015this had included training on female genital mutilation.

• Security in children’s areas complied with the trustabduction policy. Main doors to NNU were operated bystaff for both entry and exit. On Sarum Ward main doorswere operated by staff on entry only and visitors couldlet themselves out by using a door release button. Thiswas placed too high for a small child to operate and thearea was overseen by closed circuit television screenson the ward. Between 8am and 6.30pm a receptionistwas present at a desk with clear view of the doors.

• All patient records we saw had the section aboutinvolvement of other services including social worker,completed appropriately. Nurses on day surgery unitand paediatrics had a system to inform communitypublic health nurses of any concerns that may needfollowing up after the patient was discharged. Anexample of this was when children had dentalextractions which may have been indicative of neglect.

Mandatory training

• The trust had a programme of training that all staffneeded to attend identified on a mandatory trainingmatrix which included the required frequency ofupdating knowledge. This included training in movingand handling, fire safety, infection prevention andcontrol and fire safety. Other programmes wereidentified for specific staff roles that needed completionand included paediatric immediate life support whichneeded to be completed by doctors, operatingdepartment practitioners, registered nurses, registerednurses for children and midwives. Staff told us they weremade aware of the training that was due to becompleted on receipt of an e mail generated by theelectronic learning system.

• Levels of staff compliance with mandatory training weremeasured by the trust but were presented asdirectorates. Children and young people’s services werepart of the clinical support and family servicesdirectorate. Other areas that were part of this directorate




were maternity and gynaecology, neonatal unit andchildren’s therapy services. The trust target forcompliance with mandatory training was 85%. Staffcompliance within the directorate ranged between 66%for mental capacity training and 88% having completedhealth and safety training. Ward managers informed usthat all staff working with children had undertakenpaediatric life support training appropriate for the age ofchild in their care.


• Each child or young person had a paediatric nursingassessment completed on admission. It included riskassessments based on the condition and medicalhistory of the patient with any special needs orsafeguarding issues documented. Burns unit had a riskassessment tool which was specific to the degree ofburns experienced by the child. Sarum Ward and burnsunit used age specific Paediatric Early Warning Score(PEWS) charts which were kept at the end of the child oryoung person’s bed or outside their single room.Escalation advice was included on the PEWS for theactions that nursing staff should take if a child’scondition deteriorated. The observation charts hadbeen completed consistently. Staff compliance withcompleting the PEWS had not been audited for theprevious 12 months. Senior staff told us this wasbecause the tool was being reviewed and developed inconjunction with the regional Paediatric Critical CareNetwork and would be audited once the revised toolwas in place. We saw records where a paediatric sepsisscreening tool was used. This included advice for therisk a child or young person may be suffering aninfection and appropriate actions health professionalsshould take.

• Nurses on NNU used other charts to record risk.Theiradditional training in their specialty gave them theknowledge and skills to recognise when to escalate achild’s deteriorating condition. We were told of plans tointroduce an early warning score chart for neonates inthe near future but this was not in place at the time ofour visit. These early warning score charts were beingtrialled for babies identified as at risk but not routinelyfor all babies in NNU. An example given was a baby maybe identified as at a greater risk of acquiring a group Bstreptococcal infection. Other babies had their clinicalobservations recorded on a special care observation

chart which were completed appropriately recordingwhen a possible deteriorating condition neededescalating. We did not observe any early warning scorecharts being used at the time of our visit.

• Should a child or young person have needed to beventilated to support breathing for more than 48 hourspolicy was that arrangements would be made totransfer the child to a more specialised unit. We saw thetransfer procedure taking place when a poorly child wastransferred by a specialist team to a unit providing morespecialist intensive care. The paediatrician had arrangedthe transfer soon after the child had been admitted tothe ward. A full history of treatment was communicatedto the specialist team and parents were kept informed.

• Side rooms near the Sarum Ward nurses station wereused for patients with high clinical dependency. Wewere told by paediatricians there was potential for threehigh dependency children to be cared for on the wardalthough this level of service had not been funded bycommissioners. We saw an occasion when the lack ofnursing staff had resulted in a child who needed highdependency level care had no direct nurse observationleaving the parent to observe and call for help if needed.

• Where children and young people had surgery we sawthe World Health Organisation surgical safety checklistcompleted appropriately. Audits of compliance withusing this checklist were undertaken for all ages ofpatients attending for surgery. It was not possible toseparate the data that applied to children and youngpeople.

Nursing staffing

• A lack of nursing staff compromised patient safety whenchildren and young people needed a higher level ofnursing input.

• Planned and actual staffing levels for Sarum and NNUwere monitored by the trust and bank nurses were usedto fill any unexpected staff absences or extra needs ofhigher dependency patients. Nursing staff told us that ifbank nurses could not be found, nurses may beredeployed from another area such as NNU or staff fromthe ward would work extra hours. There was areluctance to use staff supplied by other agencies asthey would be unfamiliar with the ward andperception by staff that it would incur additionalfinancial expense. The average rate of actual staffinglevels meeting the planned staffing levels on all shifts inNovember 2015 was;




▪ Registered nursing staff◦ Between 93% and 97% for NNU◦ Between 96.8% and 103% for Sarum Ward

▪ Healthcare assistants or nursery nurses◦ Between 13% and 52.5% for NNU◦ Between 87% and 175% for Sarum Ward

These planned staffing levels did not always meet thoserecommended by the 2013 RCN guidance on safer staffingfor paediatrics. This resulted in the planned staffing levelsbeing met but paediatric areas remaining understaffed forthe acuity of patients they were caring for.

• NNU had no acuity tool in place to plan required staffinglevels but used the British Association of PerinatalMedicine (BAPM) standards as a guideline. Staffinformed us the cots were rarely occupied to fullcapacity but that a workforce review was in progressusing a benchmark of 70% occupancy of the cots. Thishad indicated a need for four registered nurses (child)and a health care assistant or nursery nurse to be oneach shift to comply with (BAPM) standards. The staffingrota for the previous four weeks had shown staffinglevels to range between two and four registered nursesper shift. A recent concern about staffing had beenraised using the electronic reporting system. Seniornursing staff told us that by the end of January 2016,they anticipated having three registered nurses and onehealth care assistant rostered on each shift. Theincreased staffing levels followed recent recruitment ofstaff who were working their notice period and awaitingtheir disclosure and barring system checks.

• The Sarum Ward manager had responsibility forensuring that day assessment unit, Sarum Ward andchildren’s outpatients were staffed with appropriatelytrained nurses. Skill mix reviews were carried out by theward manager six monthly. Staffing risks for Sarum Wardwere raised at the trust board meeting in August 2015.An acuity tool was being trialled by Sarum Wardmanager and risks highlighted to senior managers asthey occurred. Insufficient staffing had been an item onthe trust risk register in January 2015 and again in June2015 and reported to clinical governance meetings in2014 and 2015. Each registered nurse on the day shiftwould be caring for five patients as an average withfluctuations during the day as children were admittedand discharged. These children could be of any age. The2013 RCN guidance on safer staffing for paediatricsrecommends a minimum ratio of one registered nurse

to three patients who are under two years of age, onenurse to four patients over two years of age and for highdependency patients, one nurse to two patients. Inaddition there should be a band seven registered nurseto work on a supervisory level. There was potential andcapacity for three high dependency patients and 15other patients needing to be cared for on the ward. Thesenior nursing staff told us they most often workedclinically when their role should have been supervisory.The night nursing complement had been re arrangedusing the existing ward budget, from two registerednurses with a health care assistant to three registerednurses with no health care assistant. This was reportedto the trust board as increasing safety for patients atnight. Staff told us the flexibility of having an extraregistered nurse at night had improved patient safety.

• At the time of our visit we saw a high dependencypatient in a side room with no direct registered nursingsupervision as the nurse had been called away to attendto other patients, leaving the parent to use theemergency buzzer if there were any deterioration in thechild’s condition. When this was raised with thedirectorate manager as a risk to patient safety, aregistered nurse (child branch) was redeployed from theNNU to work on Sarum Ward. No acuity tool wasformally in place to assess staffing needs but the wardmanager had researched and was trialling an acuity toolto provide this information. For the period between 09November and 30 November 2015 using this acuity tool,the staffing hours provided had not reached the hoursthat had been assessed as needed. The understaffingranged from a period of 20 minutes to over five hoursper day for that period. At an unannounced visit on 13December 2015, Sarum Ward staff told us there hadbeen a risk meeting the previous week resulting in anextra registered nurse on duty for each day shift and ifrequired, there had been another registered nurseallocated for the night shift. There was no extraregistered nurse at the time of this visit but all avenueshad been explored to provide the extra nurse with nosuccess. Ward staff told us they were managing theneeds of the patients on the ward at this time.

• Day assessment unit was staffed with two registerednurses (child branch). Sarum Ward and day assessmentunit would support each other when they were able.

• We observed staff handover where clinical needs ofpatients were discussed and nurses consulted andupdated parents at the bedside




• Children’s outpatients was staffed by a health careassistant and reception staff. Consultants, registerednurses and therapists were in attendance when theywere holding their clinics.

• There was one registered nurse (adult and child branch)on the burns unit who would prioritise the care ofchildren when they were admitted to the ward. Stafffrom Sarum Ward also supported care of children whowere patients on the burns unit. If neither of theseoptions were possible children would have a registerednurse (adult) who had completed additionalcompetencies with children, assigned to their care. Thesenior ward staff of burns and Sarum were workingtogether investigating methods of ensuring RCNguidelines for staffing were met and that children werecared for by appropriately trained nurses.

• Day surgery unit was an area used for adults andchildren. Due to staff turnover the number of paediatrictrained nurses on the unit would be reducing in the nearfuture. The paediatric nurses were unaware of anyaction plan to address concerns that remainingpaediatric nursing staff would be unable to cover everyshift children were in the department. However, this hadonly been raised with managers within the previousweek.

Medical staffing

• Sufficient numbers of medical staff were not alwaysavailable within the hospital but an on call system wasdeveloped to mitigate any risk to patients. In September2014 the proportion of paediatric consultants employedby the trust was was15% higher than the Englandaverage with 6% fewer registrars and 2% fewer juniordoctors. Day time shifts were adequately covered withall grades of medical staff. The weekend and night timeon call rota was provided by a consultant being on call,a registrar or consultant resident in the hospital and onejunior doctor present in the hospital. This providedmedical care for children in two areas of the hospital atany one time such as, Sarum Ward and NNU. Ifpaediatric medical assistance was needed elsewhere inthe hospital such as the emergency department ormaternity unit the on call consultant would attend. TheBritish Association of Perinatal Medicine (BAPM)guidelines state that in a hospital where there is a LocalNeonatal Unit, there should be two junior doctorspresent at all times. The trust were aware they did notmeet these guidelines at evenings and weekends and

had developed a system where consultants wereavailable to cover any shortfall. Use of locum medicalstaff for children and young people services was verylow. The highest rate we saw was 0.7% for the month ofSeptember.

• There was a daily consultant round on Sarum and NNUand handovers involved all grades of medical staff anddiscussed needs of the children. This was followed by avisit to each child on the ward and discussion withparents. Patient records showed compliance with TheRoyal College of Paediatrics and Child Health (RCPCH)guidelines with no child admitted having waited longerthan 24 hours to see a consultant.


• Plans had been made to cope with an increaseddemand in the winter by increasing Sarum Ward bedcapacity to 18 and opening day assessment unit atweekends.

• Staff we spoke with were aware of their roles in theevent of a major incident and knew how to access thepolicy. One member of staff we spoke with said they didnot know of a major incident policy and would expect tobe informed of expected actions by managers.

Are services for children and youngpeople effective?

Good –––

We rated services for children and young people as goodfor delivering effective services.

Staff took measures to make sure that children and youngpeople were cared for appropriately. They complied withtrust recommendations and guidelines wherever theycould and contributed to local and national auditprogrammes.

Policies and procedures were based on nationallydeveloped guidelines and were accessible for staff.

Staff involved specialists to support effective care forchildren and young people. Dieticians were available tosupport nutrition and hydration, psychological and mentalhealth services worked with all areas we visited. Regionalnetworks were used to support specialist practice such asburns and neonatal services.




There was communication between staff internally andoutside the hospital to support the ongoing care ofchildren and young people. Patients living with long termconditions were supported to learn about how to managetheir conditions using a variety of methods andorganisations outside of the trust.

Pain that children and young people were experiencingwas well controlled with regular pain relief given where itwas needed.

Staff competency was monitored with opportunitiesoffered to continue their learning and obtain additionalskills.

Children, young people and their parents or carers wereencouraged to be involved in decisions about their carewith people of all abilities being communicated with in away they could understand.


• The children and young people’s service promotedgood quality care based on available evidence.

• Policies, procedures and guidelines were available tostaff on the trust’s intranet such as for the managementof acute asthma, sepsis and bronchiolitis. These werebased on guidelines developed by specialist bodies forthese conditions including those from National Institutefor Health and Care Excellence (NICE). Some of the morecommonly used policies were also available in papercopy which posed a risk that staff may not be referringto the most up to date guidance. We saw an occasionwhere the electronic held guidelines from the BritishSociety of Paediatrics Endocrinology and Diabetes wasfrom 2013 and the paper version was from 2009.

• Specialist nurses were supported in their practice bylinking with specialist centres for conditions such ascystic fibrosis, oncology and palliative care. A transitionprogramme was provided for young people with longterm conditions moving into adult care. Thisprogramme which followed NICE guidelines had beenshown to be effective in other areas.

• NNU actively encouraged skin to skin care betweenbabies and parents (an established method ofpromoting bonding, lowering stress levels andoptimising brain development in babies) with leaflets

and physical support where needed. There were singlebedded rooms designed for this purpose called‘kangaroo rooms’. We saw staff supporting parents whowere engaging with skin to skin care with their baby.

• The sexual health department had policies in placebased on national guidelines and audits wereundertaken to assess compliance with standards, suchas compliance with NICE guidance on standards foradministering long acting reversible contraception.

• Children and young people had care plans available foruse and records we saw were completed according totrust policy.

Pain relief

• Nurses assessed children’s pain by using ageappropriate assessment tools such as smiley faces andnumbers to grade pain. These assessment tools helpedchildren of all abilities to communicate how much painthey were in and were included in every child’s nursingrecord. Children and young people we spoke with toldus they had been offered pain relief.

• The CQC children and young people’s survey 2014showed that parents thought Salisbury hospital staffwere better than other hospitals in England for doingeverything they could to ease their child’s pain.


• Suitable and sufficient food and drinks were available tomaintain patients’ nutrition and hydration. Staff hadaccess to dietician advice if they needed it and wereable to offer mid-morning and mid-afternoon snacks forchildren who preferred to eat smaller portions morefrequently. A children’s menu offered a variety of foodsto encourage children to maintain their nutrition suchas pizzas, smaller snacks and pureed food for thoseundergoing surgery to the mouth. Food was checkedbefore serving to ensure it was at the appropriatetemperature to be safe for consumption.

• Drinks such as cordial and fruit juices were alwaysavailable for children on Sarum Ward.

• Breast feeding mothers were able to store expressedbreast milk and store it safely for future use.

• Patient records we reviewed showed that any fluid ordietary intake was monitored and recorded wherenecessary.

Patient outcomes




• Between February 2014 and January 2015 the numberof emergency readmissions following elective surgery atSalisbury hospital was 2.8% which was below ( betterthan) the England average of 3.8% for children less thanone year old. Readmissions for children between oneyear and 17 years of age following elective surgery was1.4% which was also below the England average of 2.7%Readmissions following emergency treatment for thesame period were very low with actual numbers notbeing reported to protect confidentiality of the patient.

• Paediatric diabetes audit performance for 2013/14published October 2014 indicated the trust performedat a similar level to the average for England.

• NNU contributed to the National Neonatal Audit Report.The results for 2014 which were published in November2015 showed the trust met or exceeded the nationalstandard for three of the measures:▪ A documented consultation with parents by a senior

member of the neonatal team within 24 hours ofadmission

▪ Retinopathy of prematurity screening in babies witha gestational age of less than 32+0 weeks or greaterthan1501g at birth

▪ All babies above or below 28+6 weeks gestation hadtheir temperature taken within the first hour afterbirth

▪ The trust had not reported on the data at the time ofour visit but had shown improvement in two of themeasures compared with the previous year’s results.

• The sexual health department audited their serviceaccording to the standards set by The BritishAssociation for HIV and Sexual Health (BASHH) andMedical Standards for the management of STIs(MedFASH). Results of the audit dated January 2014rated them as compliant with all standards.

Competent staff

• Processes were in place to ensure staff were competentto care for children and young people.

• There were 22 registered nurses on NNU of whom 18were qualified in their specialty and two others were inthe process of completing this additional training.

• NNU had competencies that staff needed to completebefore undertaking procedures, for examplecompetencies for taking neonatal blood pressures.

• A practice educator was supporting burns unit andSarum Ward with developing competencies for adultnurses in caring for children. This was being supportedby a local university for nursing education to ensure itwas valid.

• Student nurses were supplied with information onSarum Ward as an induction programme and staff werebeing developed as mentors to support the studentnurse programme. Staff told us they had no problemsaccessing further training to extend their skills. SarumWard held team meetings three times a year whichsupported staff development and included updates onclinical procedures.

• Outreach nurses had extra qualification in their specialtysuch as cystic fibrosis and oncology. Specialist nursesworked with regional networks to support and updatetheir own practice and shared updates and training withpaediatric ward staff.

• All staff we spoke with were aware of the procedures forappraisals and said they were notified when these weredue by an e mail from the electronic tracking system.Supervision was led by managers of the units with oneto one meetings being held.

• Revalidation for consultants was linked to the appraisalprocess. The responsible officer ensured revalidation ofmedical staff was up to date. Medical staff told us theyhad job plans and the ones we saw were appropriate forthe grade. Appraisal rates were measured as adirectorate and not isolated to the clinical areas. Thecompleted appraisal rate for April to September 2015was 66% for non-medical staff and 82% for medical staff.The ward manager kept a record of staff appraisal ratesand told us 75% of Sarum Ward staff were up to datewith their appraisals.

• Medical handovers and ward rounds included ateaching element so that more junior staff weresupported in ongoing learning. Training times were alsooffered for medical staff on a monthly basis.

• All staff caring for children in recovery areas hadcompleted paediatric immediate life support modules.Consultants had completed Advanced paediatric lifesupport training. Ward managers informed us that allnursing staff working with children had undertakenpaediatric life support training. The data was notavailable to view.

• Consultant anaesthetists were trained in children’sanaesthesiology and would be available when childrenwere undergoing surgery.




• The pharmacy department delivered training for newmedical staff on prescribing for children.


• Ward and department staff worked with a range of otherprofessionals to ensure a multi-disciplinary approach tocare and treatment. We saw examples ofmultidisciplinary team working in the areas we visited.We were told of close working relationships with otherhealth professionals, physiotherapists, school staff,occupational therapists as well as contacts with healthvisitors and social workers.

• Pharmacists who had completed paediatriccompetencies supported areas where children werecared for. They visited Sarum Ward, NNU and burns unitdaily to support the supply of appropriate medicines forchildren and were able to offer specialist advice to staffwho were writing prescriptions.

• Child and adolescent mental health services (CAMHS)which were provided by another NHS organisationcontacted Sarum Ward daily and would visit the sameday if a child needed an assessment.

• A play specialist was available from Monday to Friday tosupport children and young people who were anxiousor distressed. Toys were used to help a child tounderstand a procedure. This support was offered toany child in the hospital if it was needed.

• Transition services were being developed for childrenwith long term conditions that would require ongoingsupport from adult services. A programme of supportwas being offered by paediatric and adult diabeticspecialists for diabetic children between the ages of 12and 19 years old. Specialist staff were working with alocal supermarket and offering cookery courses fordiabetic children and their families.

• Discharges were discussed at ward rounds and parentswere kept updated by nursing and medical staff. GPswere informed of discharge either electronically or byletter. Other professionals would be contacted by phoneor by letter depending upon the need for follow up care.The day assessment unit could be used for more urgentfollow up of discharged patients. We saw a child whohad been contacted to return the day followingdischarge for further tests.

• The CQC children and young people’s survey 2014showed that parents thought Salisbury hospital staffwere better than other hospitals in England for workingwell together.

Seven-day services

• Radiology and diagnostic imaging services wereavailable for children and young people seven days aweek.

• Consultants reviewed their patients daily seven days aweek. A paediatric consultant was resident at thehospital on an on call basis at weekends and eveningsfor advice, support and treatment.

• Out of hours paediatric pharmacy support was availablefor children’s services from pharmacists who had gainedextra knowledge specific to children.


• Staff across the children’s service were able to accessinformation in a timely way. Information for GPs wasmade available through discharge processes.

• GPs were given a summary of a child’s admission andinformed of their discharge from hospital. Theinformation was sent either electronically or in papercopy if the GP did not share the secure informationsharing system. We saw a discharge letter which hadbeen recorded as having been sent electronically withintwo hours of the patient’s discharge.

• GPs could refer patients to the children and youngpeople’s day assessment unit for further specialistopinion.

• Children’s oncology service used parent held recordswhich were updated by staff each time the child wasseen.

• The children’s outpatient department had a system toensure records were available for the child or youngperson’s attendance. Staff we spoke with told us theyhad not experienced any difficulties in accessingrecords.

Consent

• Staff demonstrated the use of Gillick competencyprinciples (used to help assess whether a child or youngperson has the maturity to make their own decisionsand to understand the implications) when assessingpeople’s ability to consent to procedures. We witnessednurses involving children and young people in makingdecisions about their care and treatment and usingterminology the child could understand.

• Consent was obtained by staff from children and youngpeople and if they were too young or unable to legallyconsent for themselves, parents or carers would be




asked for their signed consent. Parents told us childrenwere spoken to in a way they could understandespecially if their understanding was below the averagefor their chronological age such as children withlearning disabilities.

• We were told by staff of how children’s decisions wererespected and every effort was made to support thechild’s wishes.

• We saw records of how staff in sexual health supportedpatients with learning disabilities to enable them toaccess treatment they needed appropriately.

Are services for children and youngpeople caring?

Good –––

We rated the children’s and young people’s services asgood for caring.

Feedback from children and young people who used theservice and their families was positive with quotes of“kindness”, “staff were always cheerful even at the end of along shift”, “unconditional support” and “patience”.

Time was always given for patients and families to askquestions. We saw how staff talked with patients and theirfamilies in a way they could understand and wereempowered to make their own decisions. We saw how stafftalked together to ensure parents had a consistentmessage from professionals.

Facilities were used flexibly to provide privacy andconfidentiality for patients and their families wherever itwas needed. Double bedrooms were provided so that bothparents could stay near to their baby on the neonatal unit(NNU). Children and young people’s views were listened toand acted on wherever possible. This was demonstratedwhen accommodation was used creatively on Sarum Wardfor a family to be near their child who was near to end of lifeto fulfil the child’s wishes. When a child or young persondies caring for the baby, child, young person and theirfamilies continued with memory boxes to meet familywishes. Psychological services were available and activelyencouraged for patients and families.

Compassionate care

• We saw compassionate and caring interactions betweenstaff, patients and their parents or carers. We were toldby a young person how the nurses explainedprocedures calmly to reduce the patients’ anxiety.

• Privacy and dignity of patients were protected by theuse of children specific bays and curtains used to screenchildren from other patients when needed. As anexample, day surgery unit had two bays used forchildren in an area where adults were also cared for.Curtains were drawn across to protect children fromwitnessing adult care and to protect the child’s privacy.

• We saw neonatal unit (NNU) staff encouraging andsupporting a parent to have skin to skin contact withtheir child in a kindly way and protected their privacywith screens.

• Thank you letters we saw from patients and theirparents/carers included comments about the kindnessof staff, their “unconditional support and care”,“cheerful, even at the end of a long shift” and “patienceand honesty”.

• Friends and family test feedback stated the team werevery caring and showed no negative comments. Aprocess of real time feedback was also used to gainviews from the child’s perspective. Hospital governorsand volunteers engaged with patients and their families.Results between April and August 2015 showed positivecomments.

• One parent we spoke with felt lucky that her localhospital had been full and they had been directed toSalisbury for the care of their child.

• The CQC children and young people’s survey resultsfrom 2014 showed that staff at Salisbury hospital werebetter than other hospitals in England in staff beingfriendly, looking after the child well and were availablewhen parent or child needed attention.

• Between 1 April and 30 June 2015 there were 103compliments received by the directorate which was splitinto 14 areas. 50 Of these were from patients or theirfamilies from Sarum Ward.


• Parents told us they felt involved and informed aboutthe care and options for treatment of their child. Parentswere offered the opportunity to be with the childwhenever it was appropriate and possible.

• We saw all grades of staff talking to parents of veryyoung children in a way the parents could understand.




Parents were given time to ask questions which wereanswered by staff in a relaxed manner. We saw howparents on day surgery unit were gently encouraged tointeract with their child who was recovering from asurgical procedure.

• Children and young people were spoken to with respectbut in a way they could understand. Staff were aware ofthe facility for using interpreters if there were languagedifficulties. A parent of a child with learning difficultiesdescribed how a doctor had communicated with thechild in short, clear sentences to help understanding.

• Staff in NNU explained procedures to parents anddirected them to recognised charitable organisationsthat would support them further with any ongoingneeds.

• The CQC children and young people’s survey resultsfrom 2014 showed that staff at Salisbury hospital werebetter than other hospitals in England in keepingparents informed, encouraging parents to ask questionsand giving advice to parents on how to care for theirchild when they went home.

Emotional support

• Parents told us they felt able to leave the ward or area inwhich their child was being cared for and their childwould be safe.

• Clinical nurse specialists supported children who wereliving with long term conditions offering outpatientappointments and activities outside of the hospital thatwould support management of their condition.

• Sarum Ward had a recent occasion when ward facilitieswere used to accommodate parents and siblings of achild, who lived a considerable distance from thehospital. This was to support the wishes of a child andtheir end of life care.

• Psychological services actively supported children andtheir parents. Psychologists attended meetings of thesexual health department, were developing anassessment tool for new fathers with children in NNUand were part of the continuing support offered todiabetic patients.

• There was a teenager’s area which was separate to theyounger children’s play area and could be used for olderchildren to see a therapist or professional in private.

• Children attending for day surgery were provided withreward certificates. Anaesthesia was administered in thesurgical theatre as there was no anaesthetic room.Screens were provided to shield the child’s view of

equipment but we were told these were not alwaysused by theatre staff. If this was noticed by an registerednurse (child branch) they would ensure the screens wereput in place.

• There was bereavement suite which provided facilitiesin the event of a child death at the hospital. Parentswere able to stay with their child and were supported togrieve in a way that suited them. The pathologytechnician supplied a memory box for parents of adeceased child. The technician would include a lock ofhair and take casts of foot prints and hand prints andinclude anything else the family chose if it was possible.The multi faith chaplaincy supported families in a waysuitable for the faith of the family and to meet theirwishes.

Are services for children and youngpeople responsive?

Good –––

We rated services for children and young people to be goodfor being responsive. Children and young people and theirfamilies’ views were sought, listened to and acted upon.Staff worked creatively to provide care and fulfil the wishesof their patients.

Communications between hospital and communityservices promoted continuous care for the patient. We sawhow staff were working with other areas of the hospital toprovide support and advice in developing an improvedexperience for a child or young person who might bevisiting an adult area.

Individual needs were taken into account in all areas wevisited. Children were prioritised above adults on surgicallists, areas were dedicated to children where possible andactions were taken to improve the environment forchildren.

All staff we spoke with in every area of the hospital told usthey were either working with the children’s department toimprove services they provided for children and youngpeople or they would seek advice from them if there wereany concerns.

Staff worked creatively to capture views of children youngpeople and their families in a way that would be suitablefor all ages and abilities including collecting drawings of




younger children. These feedback methods were shared inall areas of the hospital where children and young peoplevisited. Comments from patients and their families wereanalysed and acted upon to improve services. A snookertable for teenagers had been provided based on feedback.

Children who needed respiratory assistance could benursed on Sarum Ward as an alternative to being cared ofin an intensive care unit. This was due to advancements inrespiratory equipment available. However, the patientswould need higher dependency nursing care which had notbeen commissioned. There were not always enoughnursing staff to care for these high dependency patients aswell as other patients on the ward.


• The children’s ward and outpatients department hadbeen redesigned and was completed in 2010. The trusthad involved children, young people and their familiesin the design of the building and its facilities. Anexample of this was colour changing lights in thebathrooms which were controlled by the child.

• Feedback was actively sought from all ages of childrenwho visited the hospital. Age appropriate methods ofgathering views from children and young people wereused. As an example, boards designed to look likemonkeys asked children to say what they would like tosee in the hospital for children. We saw commentswhere children and young people had added what theythought. Day surgery unit had started using the samemethod for gathering patient views.

• Sarum Ward was able to care for children with highdependency nursing (HDU) needs if they had the staff.They could accommodate 16 patients on the ward andcould increase capacity to18 if needed. Between Mayand August 2015, there were three occasions when morethan 16 patients were being cared for on Sarum Ward.The HDU care and extra two patients were not fundedby commissioners. We saw how a decision was made tocare for a baby who needed more specialist care but nobed was available within the local areas meaning a longjourney of over 100 miles to the nearest suitable care. Aneonatal nurse cared for the baby at the trust overnightand transfer had been arranged to specialist unit closerto Salisbury. This meant the baby and family couldreceive appropriate care closer to home.

• Sarum Ward, outpatients and day assessment unit hadplay areas for young children equipped with appropriatetoys and activities. There were separate areas for olderchildren and teenagers equipped with activities suitablefor their age group. Day surgery unit had a play room forchildren equipped with a DVD player and suitableviewing material for all ages. Some children were seenin areas used for adults. As an example, the generaloutpatient department saw children and young people.Within the adult waiting area was a small play area forchildren to wait for their appointment. Staff couldrequest support from the children’s department staffincluding the play specialist if they needed it. We weretold of plans the general outpatients department hadfor developing a room into a child friendly space byworking with nurses from Sarum Ward.

• Sarum Ward had 16 drop down beds positioned next towhere children would be nursed. If there were 18patients on the ward two reclining seats were available.There were private facilities for parents, carers andsiblings of patients on both Sarum and NNU. If parentsof children on NNU needed to build their confidencebefore taking their baby home, there were private roomsavailable for them to use. Sarum Ward had a separatespace which they used flexibly just before children wenthome, if families had travelled a long way or on otheroccasions to meet the needs of the child or youngperson. Both areas had kitchens and sitting areas forparents and families away from the ward and facilities toexpress breast milk and store it for future use.

• There were links with community services such aspublic health nurses, social services, GPs andcommunity adolescent mental health services (CAMHS).Staff from CAMHS called Sarum Ward seven days a weekto assess if they needed to visit. The specialist nurses forchildren and young people with long term conditionsprovided links between community care and hospitalcare for the patients and their families. We spoke to stafffrom burns unit and Sarum Ward who were workingwith practice nurses in the hospital to improve care forchildren in all areas of the hospital. We saw thedocument for adult nurses to gain competencies withnursing children and young people. This was indevelopment at the time of our visit but was supportedby practice educators working with a local university fornurse education to ensure it was valid.

Access and flow




• Children and young people were supported to accesscare and treatment across the range of servicesprovided at the hospital this included those at transitionbetween child and adult services.

• Children and young people under the age of 16 yearswere cared for on Sarum Ward. The policy for admissionof 16 and 17 year olds gave guidance and choice toyoung people regarding whether they would prefer to benursed on an adult ward. Issues such as clinical need,learning difficulties and safeguarding issues were takeninto account. Young people with learning difficultieswho were already under the care of a paediatricianwould be cared for on the paediatric ward until theywere 19 years old.

• Admission to Sarum Ward could be from the emergencydepartment, as planned admission procedures, andfrom the assessment unit. The paediatric assessmentunit took referrals from GP services when advice wasneeded but there was no need to attend the emergencydepartment. We saw a child admitted from the dayassessment unit who required further observation.During the time the patient was waiting for a decisionon the need for admission they were able to remain inan area that kept them occupied and was suitable fortheir age. Patients would be offered an appointment atthe day assessment unit at a time suitable for thepatient. One parent told us they had their called the unitand had their appointment brought forward as she wasconcerned about her child’s condition worsening.

• Sexual health department operated clinics within thehospital and in ten other locations across Wiltshire.These could be accessed on a self-referral basis forpeople of 13 years and over.

• Babies in NNU were cared for depending upon theirclinical need. There were separate areas for babies whoneeded close observation and those who could receivemore contact with their mothers. There were twointensive care cots and two high dependency cots. Forthe period between April 2014 and March 2015 thesecots were used to 19.7% and 55.9% of their availabilityrespectively. For the same period of time the 10 specialcare level cots were used to 47% of their availability.Babies who needed longer term ventilation weretransferred to a more specialist unit.

• Children and young people on the day surgery unit wereable to have both of their parents with them before andafter their surgical procedure. There was no anaestheticroom which meant the child was taken straight into the

operating theatre before having their anaesthetic. Assoon as the child was recovered enough they would betaken to their parent or carer with further nurseobservation on the ward area. We saw how nursesencouraged parents to be involved in the care of theirchild when they were on the ward.

• All surgical lists were arranged with children undergoingtheir surgery early in the day and before adults where itwas possible.

• The outpatients department was used by therapists,specialist nurses and consultants. Therapists used a setof criteria to prioritise their patients. This ranged fromtwo weeks for urgent referrals to 11 weeks for routinereferrals.

• The paediatric transfer policy was followed by staffwhen children needed to be transferred to another areaof the hospital or to another hospital. This could be dueto the deteriorating condition of a patient or when therewas a greater demand for paediatric beds. At the time ofour visit we saw how a patient was collected by anotherspecialist unit and how staff communicated with eachother to ensure the needs of the child were met.


• Children and young people would be cared for byspecialist surgeons regarding their condition forexample and orthopaedic surgeon. In addition apaediatrician would offer advice if it were needed.Processes were in place to provide continuity of careand meet the needs of individual children and youngpeople. Older children with learning difficulties up to theage of 19 who were already under the care of apaediatrician would be cared for on Sarum Ward. Youngpeople who may pose a risk to children on Sarum Warddue to extreme emotional state would be cared for onan adult ward. CAMHS services were delivered by analternative provider who liaised with the ward daily.

• Children we saw before their planned surgery hadattended a clinic prior to this and had the surgeryexplained and the consent discussed. We were told bystaff from theatres, day surgery unit and ward staffabout a DVD that was being developed to informchildren of what to expect when attending for surgery.This was designed to reduce anxieties in children andyoung people. The play specialist used toys to explainprocedures to children and reduce their anxieties. Daysurgery unit encouraged children to have a favourite toyavailable for when they recovered.




• Specialist nurses liaised with the ward staff to providecare for children and young people living with long termconditions or needing end of life care. They also linkedwith non-NHS organisations to provide information,practical skills and social events to help patients incoping with their long term condition. An example wascooking lessons being held at a local supermarket.

• Staff communicated with social care when there was aconcern or a need for further social support. On oneoccasion social care were informed of a patient’sdischarge and arrangements were made for support atthe time of discharge.

• Physiotherapists used technology and equipment tomotivate children and young people in completingexercises or movement. This was so that therapistscould assess progress and advise further treatmentappropriately. An example of this was using interactiveprojected images of bubbles encouraging the child oryoung person to move around and ‘burst’ them.

• The radiology department had facilities to distractchildren while they underwent planned procedures.One room had a DVD player with viewing material thechild could choose. There were mobiles hanging fromceilings and stickers on walls that children could see.

• The ward area also had rooms used for distraction, play,dining, school work and facilities for parents andfamilies to sleep wash and prepare food. A sensoryroom on Sarum Ward provided a great environment forchildren and received positive feedback from patientsand their carers. It was equipped with a variety of lights,sounds and cushions and available for use by patients.Nursing staff told us it was useful to help children andyoung people with learning difficulties, challengingbehaviours to reduce anxieties and stay calm.

• Sarum Ward, day assessment unit and the children’soutpatient department had appropriate waiting areas,equipment and toys for children of all ages. There wasaccess to secure outside space with age appropriatefacilities.

• Written information was provided for children in aformat that made it interesting to children and usedsimple language. Day surgery unit had leaflets tellingchildren what they could expect from their procedure.The burns unit had information for parents so theycould support their child.

• The day surgery unit had a recovery area used for adultsand children. Each trolley area was separated by acurtain. At the time of our visit we saw a child being

nursed on a trolley next to an adult with no curtainhaving been drawn between them. The child would beat risk of being upset by witnessing adult behaviours asthe adult recovered from their anaesthetic. Recoveryarea in the main theatre suite had no separate are forchildren. They used spaces at the end of a room andcurtains to obscure the child’s view of adults. Wallstickers were used in these areas as a distraction forchildren.


• Information was displayed and leaflets were availablefor patients and their families to feed back theircomments to the trust. The friends and family test hadbeen designed for children and young people tocontribute their own comments with a child friendlydesign of an owl and simple language.

• Staff we spoke with were aware of the complaintsprocess and told us they would try to resolve any issuesimmediately. If this was not possible they would directthe family to the complaints process.

• There was a system of gathering views from patientsand their parents on a monthly basis with volunteer staffundertaking a survey. These results were analysed andchanges made to improve the experience of the childrenand parents. Some of the changes in response to thisfeedback were the purchase of a snooker table for theadolescent room, name boards were introduced assome parents/children could not remember the nameof who they were being cared for and ward clerksstarted working 8am until 6.30pm during the week, towelcome people to the ward and to assist with security.

Are services for children and youngpeople well-led?


We rated services for children and young people asrequiring improvement for being well led.

Senior staff we spoke with had no clear vision for the futureof children and young people’s services.

Risks were identified at ward level and fed up to directoratemanagers but sustainable action was not taken to mitigatethe risks. This left some staff feeling unsupported in theirspecialty.




All the areas we visited told us they were well supported bytheir managers at ward level. All staff in the areas workedtogether and supported one another displaying caringattitudes to their colleagues.

Staff demonstrated a patient-centred approach to theirwork by raising concerns when they thought things couldbe improved or when there was a perceived risk.Improvement initiatives for children and young people’scare were in progress in many areas of the hospital. Theatrestaff were developing information for children attending forsurgery and burns unit were developing plans forimproving care of children on their unit. These were bothwith the input of the Sarum Ward manager and staff.

The neonatal unit (NNU) had released an APP for mobilephones. This was in conjunction with the area neonatalnetwork with which they worked.


• The trust values of ‘being patient centred and safe,professional responsive and friendly’ were displayedaround the hospital areas we visited. All staff we spokewith knew about the values and demonstrated them intheir actions and approach to their work.

• Senior staff did not appear to have a clinical servicestrategy or clear vision for the future of the service forchildren and young people. Some senior staff statedthey felt there were too many uncertainties in theservice to plan effectively for the future.The recentsuccessful tender for children and young people'scommunity services by another provider was having aneffect on forward planning in the acute service.

• Staff we spoke with were clear that they wanted toprovide the best possible service they could for theirpatients.


• The directorate clinical governance structure supportedthe children and young people’s services to monitor andreport a range of information through the trustgovernance system.

• Staff we spoke with escalated risks they had identifiedto their managers and we saw these recorded on therisk register. Actions were not always taken to mitigaterisk to patient safety. As an example, the risk registershowed that patient safety based on staff ratios hadbeen entered by Sarum Ward manager in December

2014. An action plan was produced which relied on theward manager researching and using an acuity tool andproviding a workforce review for the executive team. Theinterim plan was to use nursing staff from other areas inthe hospital or from the nursing bank. The workforcereview had been presented to the trust board in August2015. The acuity tool for staffing levels based on patientneed was being trialled by the ward and reported tomanagers but was not embedded as a tool to identifylevels of nursing staff needed. No action had been takenfollowing the workforce review.

• Children’s services were part of the clinical support andfamily services directorate. There was representationwhen required at trust board from the directorate’ssenior nurse and a clinical director. The senior nursewould raise issues on behalf of the ward managers forneonatal unit (NNU) or Sarum Ward. The clinical directorwould raise issues on behalf of the clinical medicalleads. The trust chairman acted as the non-executivedirector as a champion for children and young people’sservices on the trust board.

• The trust board discussed a six monthly skill mix reviewfor all services which included shortfalls in nursing hoursof children and young people’s services and wardclosures. The August 2015 board meeting notedconcerns raised by the paediatric matron regarding thechildren’s unit not meeting the 2013 RCN guidelines forsafer staffing. No action plan for addressing theconcerns raised was noted at this time.

• We saw minutes of monthly team meetings held insexual health, NNU and Sarum Ward where discussionsincluded clinical updates, updates on risk, complaintsand shared learning.

• Staff in all areas we visited were clear about their rolesand understood what they were accountable for.Safeguarding overview was reported to the trust boardon a quarterly basis with the most recent report havingbeen written for the period July to September 2015. Thisincluded progress of the identified actions forsafeguarding concerns incorporating staff compliancewith training and any reported child protection issues. Atraining needs analysis had been produced by thenamed nurse for children’s safeguarding and a strategyidentified to meet the guidelines for staff working withchildren. This had been agreed with the trust board.




• Results from national and internal audits werediscussed at team meetings and reported to the trustboard with action plans identifying how improvementcould be made.


• Managers of Sarum Ward and NNU were confident intheir skills with children and young people they caredfor as well as providing expert advice to other staff. Allthe staff we spoke with who cared for children in otherareas of the hospital told us they received support andadvice from the Sarum Ward manager. The staff wespoke with were aware of who their immediatemanagers were and described the managers of bothSarum Ward and NNU as being supportive andapproachable.

• The demands of clinical work often prevented the wardmanger fulfilling their supervisory and managementrole.

• Senior management were not familiar with the acuitytool being trialled by Sarum Ward and did not show aninsight to the specific challenges of caring for children inthe clinical environment.

• All consultants had job plans which were appropriate fortheir specialty. These were linked to the appraisalprocess.


• Throughout the areas we visited there was anatmosphere of caring and supportive interactionsbetween all grades of staff. Sarum Ward staff were alsoinvolved in improvements for children and youngpeople in other areas of the hospital working in acollaborative way to ensure children were placed at theheart of all those areas in the hospital which providedcare and treatment for them.

• We saw supportive, friendly and appropriatecommunications between staff and patients. Parentswere given time to ask questions even when the staffwere visibly busy and told us they felt fully informedabout their child’s care.

• Staff worked together flexibly to cover the changingneeds of the children often working extra shifts whenbank nurses were unavailable. NNU, burns unit, SarumWard and day assessment unit would move staffbetween them when they were able, In order to supportthe areas that were busy.

• Staff felt cared for by their colleagues and we sawnursing staff encouraged to leave the ward at the end oftheir shift. However, the extra shifts being worked bynursing staff was making them feel some level ofexhaustion.

• We saw how staff were working with different areas ofthe hospital to provide safe and appropriate care forchildren and young people such as when there werechildren on the burns unit and no registered children’snurse available. Different options were being exploredby the burns unit and the children’s ward managers. Theplay specialist and oncology nursing staff workedtogether to provide sterilised toys for oncology patients.

Public engagement

• In each area of the children’s unit we saw opportunitiesfor children, young people and their families tofeedback their thoughts on the service they received.The methods used were designed to enable children ofall ages to feedback often with a picture of what theywould like to see. It included the friends and family testwhich gave much positive feedback.

• The specialist diabetic nurse linked with privateorganisations to provide support for families of diabeticchildren. These have taken the form of ‘fun days’ andcooking sessions outside of the hospital premises andused as an opportunity to encourage feedback frompatients about the diabetic service. The oncologyservice responded to results of an annual questionnairefor children and young people by arranging a greatervariety of foods to be made available while childrenwere in hospital.

• The children’s unit had engaged with charities toprovide improvements for the children and youngpeople. Funds raised by the hospital’s charity had beenused to finance much of the purpose built children’sunit and children and young people had been consultedin the design of the new build.

• Child friendly surveys developed and used by children’sunit staff were also used in other areas of the hospitalwhere children were nursed.

Staff engagement

• Most staff we spoke with would escalate a concernthrough their line manager.

• We were told by Sarum Ward staff that if they felt animprovement was needed or there was a need for more




equipment they could approach the ward manager whowould usually manage to provide from the ward budget.One instance is when replacement soft spoons areneeded for children who have had cleft palate surgery.

• Team meeting minutes from all areas recorded theviews of the staff with actions allocated to staffmembers and updates on previous actions.


• We saw areas of practice that were being reviewed andchanged in order to improve the services. Sarum Wardstaff worked with other areas of the hospital to improvethe care of children and young people. A group ofprofessionals including anaesthetists and nursing stafffrom day surgery unit, main theatres and Sarum Wardwere developing a DVD for children and young people toview before their surgery, informing them of what toexpect.

• The NNU had very recently released an App for mobilephones. This was for parents to access for support andadvice and was developed in conjunction with theThames Valley and Wessex Neonatal Network. It was tooearly for any feedback to have been received.

• Sarum and burns unit were investigating how they couldprovide safe care with appropriately qualified nurses ina cost effective way. They were in discussion with thedirectorate manager and using expertise from theregional burns network. This had prompted thedevelopment of competencies in nursing children andyoung people that adult nurses could complete.Practice educators were supporting the initiative.

• Sexual health department had been commissioned in2015 to extend their service to a larger area of thecounty.

• The trust had a process where staff could be recognisedfor work and achievements. Sarum Ward had beenawarded a Pride in Practice Award in March 2015 forworking flexibly to fulfil the wishes of a palliative patientand their family.

• Partnership working was encouraged throughout thechildren’s and young people’s services. NNU were partof the Thames Valley, Oxford and Wessex NeonatalNetwork which supported staff to provide high qualitycare in their specialty.




Safe Good –––






Information about the servicePalliative and end of life care encompassed all care given topatients who were approaching the end of their life andfollowing death. Care of the end of life patient could bedelivered on any ward or within any service of the trust andincluded aspects of basic nursing care, specialist palliativecare, bereavement support and mortuary services. Thedefinition of end of life includes patients who areapproaching the end of life when they are likely to diewithin the next twelve months, as well as patients whosedeath is imminent.

During the year 2014 the trust reported there had been 762deaths in the hospital. Between April 2104 and March 2015there were a total of 454 referrals made to the specialistpalliative care team. Over the past five years that had beenan increase in referrals to the team of 45%. The team hadresponded to 80% of referrals within 24 hours.

The trust has its own ten bedded hospice located on thesite that is physically connected to the hospital. Based inthis building is the Salisbury Specialist Palliative Careservice. This is an integrated service that provides aninpatient service to the hospice, a community service, aday care service, a bereavement service and a palliativecare hospital team. The hospice, which has its own nursingstaff team, falls within the governance of the trust. Locatedwithin the Hospice is a family support team made up ofsocial workers. All hospice staff were employed by the trust.

Patients can be admitted to the hospice from thecommunity and from the hospital. Reasons for admissionwere complex symptom control, rehabilitation,

multi-disciplinary assessment, respite and terminal care.Members of the team provided a service to the acute trustfor patients who had an advanced and progressivepalliative illness and were usually within the last six totwelve months of their life. The care of a patient within thehospital remained under the core clinical team with thepalliative care team offering specialist advice.

The HPCT comprised a team of three band 6 (1.9 wte) andone part-time band 7 team leader who supports thecommunity and hospital clinical nurse specialists and ateam of three consultants, 2.2 whole time equivalents, whodivided their time between the hospital, the hospice andthe community team that worked out of the hospice. Thetrust had employed two nurse end of life care facilitators,1.3 whole time equivalents, who were working on thewards providing training to staff around the introduction ofnew documentation and process for end of life care.

During the inspection we visited eight wards and theemergency department. We spoke with five patients andten relatives. We talked to five consultants, eight nurses,four health care assistants and two ward receptionist/administrators. We visited the bereavement suite, whichincorporated the mortuary, and also the chaplaincyservice. We spoke with staff working in these areas and alsoportering staff. We also met with the medical director whois the board lead for end of life care in the trust.

Endoflifecare

End of life care


Summary of findingsWe have judged the overall end of life service as good.The Trust had taken part in the National Care of theDying Audit 2014 and had poor results and put in placean action plan which was being reviewed every 6months. In the most recent review in September 2015we saw there had been improvements made both in theorganisational and clinical key performance indicators,with many of the red and amber ratings havingimproved and changed to a green rating. Theleadership needed to develop a trust wide policy for endof life care.

The Trust could organise rapid discharges effectively butthere were delays usually due to the lack of carer/carepackage availability in the community. The trust hadcompleted local annual end of life care audits whichincluded data on patients’ preferred place of death in2012, 2013 and 2014. The 2015 audit was delayed untilMarch 2016 whilst the Personalised Care Framework wasrolled out across the Trust.

There was an improvement plan in place for end of lifecare that was being overseen by a strategy steeringgroup. There had been a number of changes put intoplace in the previous twelve months. These wereinitiated following the results of the National Care of theDying Audit that was completed in 2014 and also torespond and implement national directives such as theNICE Quality Standard on End of Life Care. Theseincluded a new personalised care framework, to replacethe discontinued Liverpool Care Pathway, improvedrapid discharge processes and the appointment of twoend of life care facilitators to roll out the newdocumentation and provide training. Whilst some of thechanges were not fully imbedded the staff werecommitted and motivated to provide an improvingservice and embraced the initiatives that were beingdeveloped by the end of life steering group.

There was evidence of leadership in both the palliativecare team and at board level however despite the workundertaken to deliver the improvement plan there wasno trust wide policy on end of life care. This wascombined with limited representation at the strategysteering group from board members.

Staff understood their responsibilities to raise andreport concerns, incidents and near misses. They wereclear about how to report incidents and we sawevidence that learning was shared across the teams.

Equipment was readily available and properlymaintained for the use of patients. Anticipatorymedicines were always available and patients beingdischarged home had their medicines providedpromptly.

There were processes in place to assess and respond topatient risk. Staff were able to contact members of thepalliative care team for advice about deterioratingpatients and this team was responsive and supportiveto urgent requests for input. The palliative care teamwere staffed sufficiently to provide the advice andsupport that was requested.

The Trust was providing a seven day service frommembers of the palliative care team but this was onlycurrently being funded until end of March 2016. Theteam told us that funding of this service was subject toon-going review and has been funded for a further12month period to March 2017.

There was a range of training that was provided formembers of the palliative care team and also trainingthat was available to other staff if they could be releasedfrom their duties but there was currently no mandatoryend of life training for staff trust wide.

Patients received compassionate care and were treatedwith respect and dignity by staff. Patients werecommunicated with sensitively and kept informedabout their diagnosis and prognosis.

Staff worked in a positive and open culture and feltsupported by their colleagues and line managers. Stafffelt valued by the trust and were engaged with the trustobjectives.

Endoflifecare

End of life care


Are end of life care services safe?

Good –––

We judged the safety of end of life care as good.

Staff understood their responsibilities to raise and reportconcerns, incidents and near misses. They were clear abouthow to report incidents and we saw evidence that learningwas shared across the teams.

Equipment was readily available and properly maintainedfor the use of patients.

Records were completed and stored appropriately toprotect patient confidentiality.

Anticipatory medicines were always available and patientsbeing discharged home had their medicines providedpromptly.

Staff working in the hospital palliative care team were up todate with their mandatory training.

There were processes in place to assess and respond topatient risk. Staff were able to contact members of thepalliative care team for advice about deteriorating patients.Nursing and medical staff said the team were veryresponsive and supportive to urgent requests for input. Thepalliative care team were staffed sufficiently to provide theadvice and support that was requested.

Incidents

• Staff understood their responsibilities to raise concerns,to record safety incidents and near misses reportedthem appropriately. Feedback was provided to staff andlearning disseminated. On one ward staff told us theyreceived feedback from incident reports at wardmeetings. After the morning handover meeting thetrained staff shared any issues pertinent to their patientsand any incidents that needed reported were discussed.We saw minutes from one ward team meeting whichincluded the details of the incidents that had beenreported.

• There had been fourteen incidents reported in respectof end of life care and the mortuary services during thefourteen month period between September 2014 andOctober 2015. Three of these were recorded as minorincidents and the others as no harm. We saw that the

action or investigation was recorded. This includedarranging meetings to discuss concerns, makingsafeguarding referrals, taking action to increase themortuary capacity and escalating issues to otherdepartments. One example was the mortuary receivingitems unlabelled and not in the correct property bags.The bereavement team arranged for the wards torecieve an updated copy of their policy for ward staff toread and sign to say they were aware of the guidance.

• Lessons were learnt and action taken as a result ofinvestigations. On one ward we saw feedback fromrecorded incidents displayed on the staff notice board.We saw notes that showed discussions around incidentswere also held at the quarterly ward meetings. All staffwe spoke with were aware of how to report incidentsand the process to be followed. On another wardfollowing a number of incidents around falls the wardmanager attended the hospital falls forum meeting. Theassessment tool was subsequently updated andintentional rounding, (checking patients every hour) wasstarted. From there it had been recorded that the fallsrate for the ward had decreased.

• New fundamental standards and regulations for theprovider came into force in November 2014 regardingDuty of Candour. Nursing staff we spoke with wereaware of the duty to be open and honest with patientsand relatives about any care or treatment that may havegone wrong. On one ward we were given an example ofhow a patient had required restraining and how this hadsubsequently been investigated and the informationgiven to the family. We were told of another examplewhere after a patient had fallen and broken their hip thefamily were called with regular updates. When the riskanalysis was completed a copy of the report was sent tothe family. Staff we spoke with said they believed theyworked in an open culture and would be confidentabout reporting concerns or possible mistakes that hadbeen made.


• The hospice building appeared clean and hygienic. Thecleaning staff had a cleaning schedule to follow and thebuilding was regularly checked by the manager. Wewere told the cleaning team responded quickly torequests for rooms to be deep cleaned. Relatives wespoke with said the rooms were well maintained andthey had no concerns over cleanliness.

Endoflifecare

End of life care


• There were hand hygiene dispensers in place andwritten reminders for visitors to clean their hands. Weobserved staff and visitors following the correctprocedures and wearing the appropriate protectiveclothing.


• The National Patient Safety Agency recommended in2011 that all Graseby syringe drivers (a device fordelivering medicines continuously under the skin)should be withdrawn by the end of 2015. An alternativehad been provided across the trust and guidance aboutthe use of the new equipment was provided on everyward.

• Staff told us there was a sufficient supply of syringedrivers and pressure relieving equipment and thisequipment was provided promptly when requested.There was a central store of syringe drivers which weremaintained by the clinical engineering department.Checklists were in place on the wards to remind staff ofthe correct procedures to use.

• The mortuary was well organised and appeared cleanand well maintained. Equipment servicing was up todate and recorded.

Medicines

• Patients receiving end of life care were prescribedanticipatory medicines, these were prescribed inadvance to promptly manage any change in thepatient’s pain or symptoms. If however, further advicewas required this could be sought from the end of lifecare team or the Hospital Palliative Care Team (ClinicalNurse Specialist or Consultant) Monday to Friday 9-5, orthe 7 day working Clinical Nurse Specialist at weekends,or out of hours advice from the Hospice staff nurses oron call doctor available 24 hours a day, 7 days a week.

• Patients being discharged home could have theirmedicines ready within one hour. The discharge teamsaid the preparation of medicines for rapid dischargepatients was done effectively and did not cause delays.

• In the new information pack on end of life care, whichwas available on every ward, there was advice andguidance for staff in relation to medicines. We spokewith three end of life link nurses, all were well informedabout end of life medicines and knew where to accessfurther information. On two wards we checked thestorage of medicines and saw that all the normal end of

life medicines were there. We saw that the controlleddrug book was located and completed correctly. In thepatient’s records we looked at medicines correctly andclearly recorded.

• We observed one of the end of life care facilitatorsinitiate a medicine review by directing ward staff tocontact the clinical nurse specialist for Parkinson’sdisease. This followed questions raised by the ward staffin discussion with the end of life care facilitator about apatient.

• The clinical protocols for the prescription for medicinesfor the five keys symptoms at the end of life had beenreviewed in September 2014. A recommendation thatthe review should include a prescription for dyspnoeahad been completed and recorded.

Records

• We looked at a sample of 12 patient records and sawthat the Do Not Attempt Cardio PulmonaryResuscitation (DNA CPR) forms were in place andcompleted in most cases. The forms that were notcompleted fully had been completed whilst the patientshad been in the community and had not beencompleted by trust staff. We saw an example where theward staff had completed a further DNA CPR form as thecommunity form did not contain sufficient detail aboutthe involvement of the family in the decision making.

• A new personalised care planning format had beenintroduced and was being rolled out across the trust bythe recently appointed end of life care facilitators. Thisdocument was in two parts, one was a personalisednursing care plan and the second part was apersonalised medical and nursing care plan for the lastfew days of life. The details and information on theforms complied with the recommendations of the latestguidance. We saw a sample of these forms that hadbeen completed. They recorded what discussions hadtaken place with the patient and relatives, includingrecognition that the person was dying and also withregards to spiritual or cultural needs. Nursing andmedical information about symptom management andfluid and food intake was also clearly recorded. Theforms provided guidance for staff, including informationabout anticipatory prescribing.

• Records were stored securely and patient’sconfidentiality was protected.

• We were shown the recording system for the movementof the deceased through the mortuary. There was a

Endoflifecare

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clear recording process in place from the point of arrivaluntil the deceased was collected by a funeral service.We looked at a sample of the recording and saw that itwas completed in detail with appropriate signatures anddates in place.

• The bereavement team had a checklist they completedfor every patient they received into the mortuary. Thesections included all the personal information about thedeceased as well as the next of kin, potential tissuedonation guidance and also a checklist of StandardAfterlife Guidelines for the mortuary technicians.

Safeguarding

• Systems, processes and practices were in place to keeppeople safe identified, through policies, procedures andtraining for staff. All of the palliative care team and endof life facilitators had undertaken the trust’s mandatorysafeguarding training. Safeguarding information wasavailable on all the wards we visited and staff hadcompleted the mandatory safeguarding training. Staffwere aware of how to report concerns and the processto follow

Mandatory training

• Staff working in the hospital palliative care team wereup to date with their mandatory training. Staff explainedhow they received reminders via email and from theirmanagers when updates were due and had to bebooked. The staff team working in the hospice were 91%compliant with mandatory training.


• On every ward there was a daily ward meeting whereconcerns about patients were discussed. Nursing staffsaid they had a good rapport with the medical staff andthat they listened to any issues that arose. Patients whowere receiving end of life care and whose treatment wasdocumented on the new personalised care frameworkhad their regular observations recorded and a threetimes daily review of their nursing goals undertaken anddocumented in their records.. Staff explained howeveryone was listened to at the morning meetings andthat discussions about identifying a dying patient couldhappen there. The discharge team also attended thesemeetings. If required they could then start a rapiddischarge process.

• Staff were able to contact members of the palliative careteam for advice about deteriorating patients. Nursing

and medical staff said the team were very responsiveand supportive to urgent request for input. Therecording in the personalised care framework providedguidance for staff around nutrition and hydration for theindividual patient. Staff explained how it was importantto maintain mouth care for patients after they hadstopped receiving fluids orally.

Nursing staffing

• The hospice was staffed by its own team of nursing andcare assistants, who only worked in this location. Thehospice also accommodated family support services,who also worked with the community service.

• The trust employed three clinical nurse specialists toprovide palliative care advice and support to staff acrossthe hospital. Staffing of this team constituted three band6 nurses (1.9 wte) and one band 7 (0.8 wte) team leader.These nursing specialists advised on symptom controland complex discharge planning. They also had a role inproviding support and education to staff and helpingwith transfers to the hospice inpatient unit. Togetherwith the medical staff they provided an out of hourson-call advice service for staff.

• Since May 2015, the trust had also employed twonurses, at an equivalent of 47 hours per week, as end oflife care facilitators. These staff, a band 7 and a band 6nurse, were providing support, advice and trainingacross the hospital wards to staff. They were deliveringtraining across all the wards on the new documentation,the personalised care framework and the accompanyingguidance. They were covering two wards at a time fortwo weeks and planning that all wards would becompleted by the end of January 2016. The processensured that every staff member on the ward engagedwith the nurse specialists at some point over the twoweeks.

• Each ward had a named link nurse for end of life care.These staff have completed a two day palliative caretraining programme run by the palliative care team.They were also required to have spent time shadowingthe palliative care team.

Medical staffing

• Medical support for palliative care was provided by ateam of three consultants, who worked across all wards,the hospice and also undertook work in the community.The consultants provided advice and support to theclinical nurse specialists and to hospital medical staff.

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End of life care


They also provided education sessions on palliative carefor the junior doctors. The consultants told us thecurrent cover arrangements were adequate butconsidered that the nursing cover was stretched attimes.

• We spoke with two consultants (not palliative care)working on two separate wards. They told us thepalliative care consultants were very responsive torequests for input and felt there was positivecommunication and sharing of knowledge.


• The trust had a major incident policy in place that staffwe spoke with were aware of how to access.

• There was an escalation plan in place for the mortuary.Following an identified risk with the storage capacity,temporary storage equipment had been provided andwas available if required.

Are end of life care services effective?

Good –––

We judged the effectiveness of end of life care as good.

The Trust had taken part in the National Care of the DyingAudit 2014 and had poor results. The Trust had an actionplan in place and reviewed progress against this. Newdocumentation to support the end of life care pathway,called the Personalised Care Framework (PCF) had beenintroduced. The end of life care facilitators who wereundertaking this work were motivating their colleagueswith their enthusiasm for the new initiatives with supportfrom the palliative care team and overseen by the End ofLife Care Steering Group. We heard from staff that the newPersonalised Care Framework and education programmehad been positively accepted by clinical staff on the wards.

The trust had systems to ensure there was an appropriateidentification of people requiring end of life care, either onadmission or whilst deteriorating as an inpatient. Thepalliative care team responded to 80% of referrals within 24hours.

End of life care training was not mandatory for all staff butvarious training was available if staff were able to bereleased.

There was evidence of excellent multi-disciplinary workingacross hospital teams and with the staff in the hospice.Staff communicated effectively and information wasshared. The palliative care team responded quickly torequests for advice and support.

Pain relief was effectively managed and recorded andanticipatory medicines were appropriately prescribed.


• The trust had taken part in the National Care of theDying Audit in 2014 and had not achieved six out of theseven key organisational targets and had scored belowthe national average for nine of the ten clinical keyperformance indicators. Action had been taken toimprove the performance in all these areas. The trustwere in the process of completing the latest NationalCare of the Dying Audit at the time of the inspection.

• Following the withdrawal of the Liverpool Care Pathwaythe trust had implemented a number of improvementsplans to replace this methodology. Action was alsobeing taken to address the five core recommendationsfor care of patients in the last few days of life in theDepartment of Health End of Life Care Strategy 2008.The recommendations from “One chance to get it right”published by the Leadership Alliance for the Care of theDying were also being worked towards. Care was beingdelivered in line with National Institute for Health andCare Excellence (NICE) guidance S13.

• Patients had their needs assessed and their careplanned and delivered in line with evidence-based,guidance, standards and best practice. The newpersonalised care planning document was in two parts,one was a personalised nursing care plan and thesecond part was a personalised medical and nursingcare plan for the last few days of life. The details andinformation on the forms complied with therecommendations of the latest guidance.

• Nursing staff we spoke with were positive about the newpersonalised care framework documents and wereaware of the new end of life care pathway. They thoughtit was easy to follow and the training had helped ensurethe forms were completed consistently. Several staffcommented positively on the rate of change over theprevious six months and the increased awareness of allclinical staff around the changes being implemented inthe end of life care pathway in the hospital. Staff werevery positive about the work being done by the end of

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life care facilitators, both in terms of the training and theon-going support they were providing to staff. Onesenior ward nurse said their knowledge and enthusiasmwas really motivating to all the team on the ward. Aconsultant commented that the new care planningdocument had improved the confidence of all the staffon the ward around the end of life pathways. The trusthas been running an improvement Commissioning forQuality and Innovation CQUIN) initiative project calledthe Conversation Project. The CQIN payment frameworkenables commissioners to reward excellence by linkinga proportion of healthcare funding to the achievementof local quality improvement goals. The project wasaimed at helping patients talk about their wishes forend of life care, before a medical crisis occurred. Thiswould help the planning and recording of the care andtreatment that was agreed with the patient and theirfamily and help ensure that a ceiling of treatment plan isin place. The standards identified as being improved bythis project included the early identification of a patientapproaching end of life, recording of conversations withthe patient and relatives and ensuring there was goodrecording of the medical plan that was regularlyreviewed. Agreement had been reached to run theCQUIN scheme for a further year to build on the progressthat had been made so far.

• The chaplaincy service based its practice on theupdated NHS 2015 Chaplaincy guidelines, PromotingExcellence in Pastoral, Spiritual and Religious Care.These had been updated from the original 2003guidelines. The service had reviewed itself against thenew guidelines and updated various leaflets andpractice guidance for the staff and volunteers. The teamhad provided an information sheet for the new end oflife personalised care framework and had also providedan information folder to every ward about spiritual care.

Pain relief

• Patients who were identified as requiring end of life carewere prescribed anticipatory medicines. These “whenrequired” medicines were prescribed in advance of needto be available to manage changes in patients pain orsymptoms. Information was provided to staff in relationto pain management and for the medicines used forpain relief.

• Pain was monitored using an assessment tool. Painscoring was completed for patients everytime theirobservations were recorded. For patients on the end oflife care framework this was a minimum of three times aday.

• Staff had quick access to supplies of syringe drivers andthe medicines to be used with them when required.


• Nutrition and hydration needs were included inpatient’s individual care pathways. In patient records wesaw that nutritional assessments had been completedand were regularly updated. In the new personalisedcare framework document guidance was includedaround feeding and fluids. Staff were required tocomplete whether artificial hydration and nutrition wasappropriate.

Patient outcomes

• The regular ward meetings and communicationbetween medical staff ensured there was anappropriate identification of people requiring end of lifecare, either on admission or whilst deteriorating as aninpatient. The palliative care team responded to 80% ofreferrals within 24 hours. The level of input dependedupon the needs of the individual patient. The Trust wasplanning a further local end of life audit in March 2016after the complete roll out of the Personalised CareFramework in line with its previous annual local auditsundertaken in 2012, 2013 and 2014. The SalisburySpecialist Palliative Care service collected data bothnationally for the Minimum Data Set and quarterlystatistics for local ClinicalCommissioning Groups. Theseincluded the numbers of deaths in the hospital knownto the Hospital Palliative Care Team.

• The trust had participated in the National Care of theDying Audit in 2014 and met only two of the 17organisational and clinical KPIs. An action plan hadbeen developed in 2014 which was overseen by the Endof Life Care Steering Group. The action plan had beenreviewed on a 6 monthly basis. In the most recent reviewin September 2015 there had been improvements madeboth in the organisational and clinical key performanceindicators.

• The Trust had undertaken local annual end of life careaudits in 2012, 2013 and 2014 which included data onpatient’s achieving their preferred place of dying. The2015 local annual audit was delayed until March 2016

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whilst the Personalised Care Framework was rolled outacross the Trust. In the meantime, the end of life careteam had kept a real time database which includedpreferred place of dying and if this was achieved.

• A survey of bereaved relatives had been undertaken in2014 and had produced mainly positive feedback abouttheir experience and that of their deceased familymember. The Trust were also taking part in a VOICESsurvey which is a survey designed and validated by theUniversity of Southampton to look at the experiences ofbereaved relatives about the care of patients who haddied both in the Hospice and the acute Trust in theprevious 6 to 12 months..

• The hospital was not participating in any nationalaccreditation scheme in relation to end of life care.

• Palliative care was provided to patients with a differentlife limiting illnesses. Between April 2014 and March2015, 69% of patients supported by the palliative careteam had cancer and 31% had non cancer relatedconditions

Competent staff

• The end of life care facilitators were providing training toall ward staff around the new documentation that wasbeing introduced. The training included input on theassociated guidance, the completion of the new formsand when these were to be utilised. A programme was inplace to have all wards completed by the end ofJanuary 2016. On the wards we visited were the traininghad been delivered we found all staff had completed it.This included reception staff and clinical staff. Staff wereaware of the location of the supporting guidance on theward and the staff to contact if further clarification wasrequired.

• From January 2016 all newly appointed health caresupport workers will receive two hours of end of lifetraining as part of their trust induction. Also from thisdate overseas nurses and newly qualified nursesattending preceptorship courses will receive a half daytraining session on end of life care.

• Each ward had a named link nurse for end of life care.These staff had completed a two day palliative caretraining programme run by the palliative care team.They were also required to have spent time shadowingthe palliative care team. We spoke with three link nurseswho described their role and described the priorities ofcare for the dying patient. They felt empowered to

support and advise staff and said how well supportedthey were by the palliative care team. Staff on the wardswere aware of who their link nurse was and the role theyfulfilled.

• There was no mandatory training for end of life care intrust but the hospice ran an education programme. Staffacross the trust could apply to undertake courses thatwere run. The courses included training for qualifiednurses, health care assistants and administration staffon areas such as communication and managing difficultsituations. The trust annual end of life reports statedthere was a need to establish a formal end of lifeeducation programme for staff with some mandatorycomponents but this was yet to be put into place. Thereport stated that the trust needed to ensure that staffwere able to be released to attend training, however thepalliative care team said this was not always possible.The specialist palliative care service had produced aneducation strategy document which covered their aimsand challenges for the next five years. This hadidentified four strategic aims. These were workingtowards having a sustainable education programme,promoting supporting and providing palliative careeducation to the area they serve, working with otheragencies to look at ways of sharing knowledge andresources and to produce an annual action plan andreport to review and evaluate education provision.

• The palliative care consultants provided training to thejunior doctors with 5 to 6 formal teaching sessions everyyear.

• Bereavement officers completed in-house training thatwas provided alongside the trusts mandatory training.We saw records that showed this was being updateannually. This training contained competencies aroundareas such as what issues were reportable to thecoroner’s office and the process for contacting the out ofhour’s emergency registrar. Staff said they were wellsupported by their manager and that advice andguidance was always available when required.

• Palliative care staff said they had an appraisalcompleted within the previous twelve months. Staff toldus they were well supported by managers and that therewas a supportive culture on the wards from all thesenior staff.

• Within the hospital palliative care team and the hospiceteam staff were achieving 90% compliance with

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mandatory training. A band seven nurse on one wardexplained how they got an email every month with allthe staff training that was due to expire. Staff were giventime away from the ward to complete their e-learning.


• All staff we spoke with were positive aboutmultidisciplinary working. We observed ward meetingsbetween palliative care staff, ward based nurses andmedical staff which were professional and effective andensured high quality care. We spoke with a patient whohad been admitted through the emergency departmentthen moved, following an operation, onto theorthopaedic ward and then to the hospice. Theconsultant surgeon had liaised with the palliative careteam and there had also been input and support fromthe occupational therapy and physiotherapy teams.There had also been communication with the GP in thecommunity. Two consultants we spoke with said thepalliative care team were good at networkingthroughout the hospital and always responded quicklyto requests for advice and input about patient care andtreatment.

• The end of life care facilitators told us there was goodengagement from the medical staff over the newdocumentation that was being introduced.

• There were multidisciplinary team meetings on everyward at the start of the day. Notes were not kept of thesemeetings but the ward board was updated and relevantinformation was entered into a patients notes. Nursingstaff could discuss any concerns around end of life carebefore the medical staff visited a patient.

• Within the hospice there was good engagement withlocal GPs. The team were informed electronically aboutpatients admitted from the community who werealready known to the specialist palliative care team. Thehospice had good links with the rest of the hospital, forexample oncology consultants attended a weeklycommunity meeting with other staff in the hospice. Arelative of a patient treated by the community teambeing admitted to the emergency department rang thehospice. The palliative care consultant contacted theemergency department to liaise over treatment.

• The chaplaincy service were represented on the trustend of life strategy group and also attended the hospicemulti-disciplinary meeting.

• Staff on the wards felt having the expertise of thehospice staff on site helped with the sharing of goodpractice.

Seven-day services

• The palliative care team provided a full service to thehospital Monday to Friday between 09.00 and 17.00. Thisincluded advice, support and clinical assessments fromnurses and consultants. At the time of the inspection theservice was piloting a seven day working of clinicalnurse specialists until March 2016. This providedassessments and telephone advice for patients, carersand healthcare professionals at weekends between09.00 and 17.00. There was also a 24 hour telephoneadvice line that was manned by the Hospice nurses andsupported by the on-call medical team.

• Consultants and nurses were keen for the seven dayservice to be extended but said they felt this requiredadditional staffing to be run effectively. A business casefor this service had been submitted as part of the end oflife strategy plan.

• The hospice inpatient service accepted admissionsseven days a week.


• Staff had access to the information they required toprovide good patient care.

• Every ward had been provided with an informationfolder about the new end of life care pathway whichaccompanied the new care plans that were to becompleted. Another folder had also been supplied toevery ward about patient’s spiritual needs. Staff alsohad access to hospital policies and guidance via thetrust intranet.

• There was also a 24 hour telephone advice line that wasmanned by the Hospice nurses and supported by theon-call medical team that the hospital staff could usewhen required..


• Nurses we spoke with were aware of the Deprivation ofLiberty Safeguards and we were shown the process thatwas followed and the forms that were to be completed.

• Not all nursing staff had done training on the MentalCapacity Act but more senior staff understood theprocess and procedures to be followed if a patient’sability to provide informed consent was in doubt.

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Medical staff would be involved if a capacity assessmentwas required. Information about a person’s capacity wasrecorded in the patient notes, and their involvement inthe decision making was recorded in most cases.However in three sets of notes we looked at it wasrecorded that a person lacked capacity but there wasnot a record of how or why this decision had beenmade. Three patients told us about their involvement inthe decision making around their treatment andmedicines. They also described how their families hadbeen involved and informed of all the ongoing decisionsand that their consent had been sought.

• Staff told us how best interest meetings were organisedand the decisions recorded. We saw the record of onemeeting which was recorded in the patients notes.

Are end of life care services caring?

Good –––

We judged caring in end of life care to be good

Compassionate care was consistently provided to patientswho were treated with respect and dignity by staff.

Communication was sensitive and patients and relativeswere kept informed about their diagnosis and prognosis.

Patients and their relatives were involved and informedabout their care and any decisions that were required to bemade about treatment.

Patients and those close to them received support to copeemotionally. There was a family support team based in thehospice that provided bereavement support andproactively contacted bereaved relatives. The hospitalchaplaincy service also provided support to patients, theirrelatives and staff. Staff also supported each otherrecognising how different people can react to end of lifesituations.

Compassionate care

• Staff provided compassionate care and support topatients and treated patients and relatives with dignityand respect. We spoke with five patients and tenrelatives and all said they were well informed abouttheir diagnosis and treatment and were communicatedwith sensitively by staff.

• We saw a selection of 13 letters that had been sent tothe customer care department that praised the end oflife care that patients of relatives had received. Thesementioned the palliative care team and the ward basedstaff. On the wards there were also numerous cards fromrelatives thanking the staff for their care and work.

• Three staff members who had experience of relativesreceiving end of life care in the hospital during theprevious two years told us the care was excellent andthat they could not fault the approach of any of the staff.

• We spoke with a family whose relative had died afterbeing admitted to the emergency department. Theyexplained how the consultant had telephoned twoweeks later to ask if there was anything else theyneeded to know or wished to discuss. The end of lifecare was described as “exemplary” and the family saidthey felt well supported by all the staff in thedepartment.

• We observed patient care in the hospice, where sixpatients were receiving symptom control and four wereon end of life care. We saw staff being caring andpatient, spending appropriate time with patients. Staffensured they had the required information aboutindividual patients before talking to them and thenproviding care in a friendly and supportive manner.

• Patients we spoke with in the hospice described thestaff as “brilliant”, “excellent” and told us they had nocomplaints about the care and support from any of thestaff.

• We observed a discussion between a patient and aconsultant about their treatment and diagnosis. Theconversation was realistic and compassionate with clearanswers given to the questions asked. They discussed apreferred place to die and the possibility of respite carein the hospice.


• The patients and relatives we spoke with said they feltthe hospital staff explained any matters to do with theirillness or treatment in an informative andunderstanding manner.

• One set of relatives told us how they had beentelephoned several times at home with updates andhow they had been involved in the discussion with the

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consultant about their relatives preferred place of dying.They said all the potential issues were explained andalso how they would be able to access additionalsupport from the community service.

• Two sets of relatives explained how the chaplaincyservice had spent time with them and made sure theywere clear about the support they could provide.

Emotional support

• The emergency department ran a follow upbereavement service for relatives of patients who haddied after being admitted through the department.

• The family support team based in the hospice provideda service to any relatives of patients known to anybranch of the specialist palliative care service. Theservice had a team of trained bereavement counsellorswho were available to relatives. Staff contactedbereaved relatives immediately following a death andthen would follow up this phone call four to six weekslater. Staff followed a policy or bereavement pathway.

• Three times a year the family support team ran abereavement support group for six weeks. These groupscould possibly lead to further social contact forparticipants and help with avoiding social isolation aftera bereavement. The team sent a card to families on thefirst anniversary of a bereavement.

• The chaplaincy service was available seven days a weekand provided a service to patients, their relatives andstaff. The service promoted that it provided spiritual,pastoral and religious support. The service couldprovide memorial services for staff, both religious andnon-religious and also ran regular “days of reflection”when anyone, including staff, could visit the chapel area,light candles and listen to prayers or poetry that wererecited throughout the day.

• Following a day, recent to the inspection visit, when fourpatients had died on the same ward in one day the endof life care facilitators had organised a supportivedebriefing session for staff. The chaplaincy service alsoattended this meeting.

• The hospice staff ran a well-being group for all staff whoworked there; this was attended by the chaplaincyservice.

• Several nursing staff said their teams were good atproviding emotional support to patients and relatives.We were told how staff will get involved and try providesupport, answer questions and listen to people. Staffexplained how they are offered debriefing sessions if

they find something upsetting. One nurse said hercolleagues were “excellent at supporting one anotherand recognised how different people can react todealing with end of life care”.

Are end of life care services responsive?

Good –––

We judged the responsiveness of the service as good.

The Trust could organise rapid discharges effectively butthere were delays usually caused by the lack of careravailability in the community.

The trust had completed local annual end of life careaudits which included data on patients’ preferred place ofdeath in 2012, 2013 and 2014. The 2015 audit was beingdelayed until March 2016 whilst the Personalised CareFramework was rolled out across the Trust.

Patients at the end of life could be provided with a sideroom if one was available but this was not always possible.There was some accommodation available on the hospitalsite for relatives and there was also some provision forovernight stays on the wards with the use of collapsiblebeds.

The palliative care team responded well to the needs ofpatients and also the needs of the local community. Theservice had responded to the requirements of changingnational guidance and expectations by implementingchanges and improvements to the end of life care pathwayin the hospital.

The specialist palliative care team responded quickly toreferrals that were made and ward staff were positive aboutthe support, advice and input provided.

Various information leaflets were available from thepalliative care team, the bereavement service and thechaplaincy service. These had recently been reviewed andupdated.


• During the year 2014 the trust reported there had been762 deaths in the hospital. Between April 2104 andMarch 2015 there were a total of 454 referrals made to

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the specialist palliative care team. Over the past fiveyears that had been an increase in referrals to the teamof 45%. The team had responded to 80% of referralswithin 24 hours.

• Both the Hospital Standard Mortality Ratio and theStandard Hospital Mortality Indicator were reported as107 as at July 2015.

• The Trust had undertaken local annual end of life careaudits in 2012, 2013 and 2014 which included data onpatient’s achieving their preferred place of dying. The2015 local annual audit was delayed until March 2016whilst the Personalised Care Framework was rolled outacross the Trust. Staff said that provided there were noproblems with funding they could usually get peoplehome if this was their preferred wish’. Data produced bythe trust showed that they were 2.6% below or betterthan the national average for patients dying under theircare compared to those who were discharged home. Inthe trust annual end of life report they reported that thetrial of seven day working for the specialist palliativecare team had produced some encouraging outcomesaround the avoidance of hospital admissions andpeople being supported in their place of choice. Nodefinitive data had yet been collected around this. TheTrust had plans to undertake a further local end of lifeaudit in March 2016 after the complete roll out of thepersonalised care framework in line with its previouslocal audits in 2012, 2013, 2014.


• Patients individual wishes were recorded in thepersonalised care framework documents. This couldrecord their preferred place of dying and any wishesthey had for their spiritual needs. We saw examples ofpatient’s wishes being recorded and in some records itwas recorded that it “had been discussed with patient”or “patient in agreement”.

• Staff tried to accommodate individual needs with theprovision of side rooms for patients receiving palliativecare though this was not always possible if a room wasnot available. We were told of one patient who wasadmitted to hospital whilst their partner was receivingpalliative care in the hospice. The staff worked togetherand provided them with a joint room until the patientpassed away.

• There were various leaflets and information available forpatients and relatives. The hospice had produced aleaflet entitled “What do I do now” which provided

information and guidance for relatives for what theyneeded to do following bereavement. Relatives wespoke with said they were provided with all theappropriate information they needed in respect ofcollecting belongings and making any necessaryarrangements over death certificates. Staff had providedthe information that was required in a compassionatebut timely manner.

• The bereavement office was located next to themortuary, the whole area being called the bereavementsuite. The staff worked closely to ensure that relativeswere treated with compassion and received an efficientand professional service. After receiving a deceasedpatient’s notes the bereavement office would wait forthe family to contact them but if this had not happenedwithin 48 hours they would make contact themselves.The staff arranged viewings if this was requested andthese were done in one hour appointments. If possiblestaff tried to arrange the viewings to coincide with thecollection of the death certificate to minimise the traveland distress for families. If requested the staff wouldarrange for a member of the medical team to meet withrelatives to clarify any issues over what was written onthe death certificate. The viewing area was comfortableand well maintained.

• The bereavement suite provided a five day service andviewings could not be routinely arranged over theweekend. We were told that this had rarely beenrequested. However if a request for weekend viewingwas made ward staff had been instructed to escalatethe request to the hospital site duty manager. Theviewing would then be organised using on call staff. Thesame process would be used if there was request for aquick release of a body for religious or cultural reasons.However there were some inconsistencies in staffunderstanding of weekend viewings. Some staff saidthey understood they could not be arranged while someunderstood that the request should be escalated anddealt with by the site manager, who could arrange aviewing if this was deemed necessary. The issue ofdifficulties with weekend viewing was on the trustregister as a moderate concern.

• The chaplaincy service provided a seven day 24 hourservice with two full time staff, three part time staff and38 volunteers. The chapel was presented as a multi-faitharea with various changes having been made to thelay-out in recent months and some more alterationsplanned. The chaplaincy staff had consulted with staff

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from different faiths and cultural backgrounds about themost appropriate use of the chapel space. Outside ofthe chapel was a board where anyone could leaveprayer requests or messages. There was also a “prayertree” located within the main chapel area. The servicevisited every ward at least once a week. Staff said theyalways spoke to ward staff first if possible. The chaplainswould also undertake follow up visits to patients whohad been visited by volunteers if this had beenrequested. When a patient was identified as being onthe end of life pathway, and had a personalised careframework document completed, a member of thechaplaincy staff would visit that ward every day. Theywould ask the staff if they were required to visit and talkto the patient or their relatives.

• The chaplaincy service had produced a leaflet that waswidely distributed through the hospital which promotedthe work they undertook and the services they provided.This explained the multi-cultural and multi-faithapproach of their service and the links they haddeveloped with other faith networks.

• On the majority of the wards there were quiet roomsavailable for relatives and some also had a kitchen areathat could be used. Some wards had collapsible bedsthat could be put into side rooms for relatives. Locatedin the grounds of the hospital was a bungalow thatcould be used by relatives. The ongoing refurbishmentof wards within the hospital contained plans to ensurethat every ward would have a designated quiet room forrelatives.

• Non traumatic dying patients who were admittedthrough the accident and emergency department weremoved if possible to a side room on a short stay ward.However this was not always possible and somepatients had to be accommodated on the ward. Whenthere was a traumatic death a patient was moved into aside room in the department and there was also a familyroom that was available for relatives. The team accessedthe palliative care team for advice and there was also anend of life link nurse in the department. The accidentand emergency department had its own dedicatedbereavement service. Relatives were phoned after a fewdays and staff would call again after a further period.Staff could also arrange, if required, for relatives to talkto medical staff.

• When a patient died who had been referred to thepalliative care team a nurse from the team wouldcontact the family within one week of the death, after

which they handed over the liaison responsibility to thefamily support team. If requested they would contactthe relatives to answer any questions or meet with themif required.

• Located within the hospice building was a day centrewhich opened four days every week. This serviceprovided support for patients and respite for somecarers. There were also certain days every month whenpatients and carers attended together. We spoke withpatients attending the centre and they were verypositive about the resource and how it afforded respitefor carers as well as a chance to meet other patients.

• The trust had an open visiting policy for relatives ofpatients on end of life care. Relatives we spoke with saidthey were usually offered refreshments by staff or wereable to use the kitchen facilities. Concessionary parkingwas also available to relatives.

• Patients and relatives were positive about the quality ofthe food provided by the hospital. There was a goodrange of choice and we were told that is was usually ofgood quality.

Access and flow

• The trust had introduced some changes to the processto facilitate rapid discharge home for patients. Aplanning group had been meeting every month tooversee the action plan that was being implemented.The group had reviewed and updated the checklist forrapid discharge and the paperwork that was providedon every ward. We saw there was an effective workingpartnership between staff and the discharge team. Theworking group was also identifying and escalatingissues around delayed discharge.

• The trust had a discharge team who were able toorganise rapid discharge for patients when requested.They had contact with every ward every day Monday toFriday they were able to organise weekend discharges inadvance when requested. The team completed thenecessary paperwork and arranged transport,medicines and funding if required. The transport wasprovided by an external contractor and staff said therewere problems every week with delays over transport.There were also occasional delays due to the funding forsome community care packages and also due to waitingfor equipment to be delivered. We spoke with onepatient who had wished to go home but funding hadnot been agreed for the care package. The records

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showed that discussion had taken place with thedischarge planning team. The issue of delayeddischarge due to funding shortfalls was identified as amoderate risk on the trust risk register.


• When formal complaints had been investigated andcompleted the staff were shown a copy of the reply.There were very few complaints received in respect ofend of life care or the palliative care team. There hadbeen three formal complaint made in relation to end oflife care in the previous twelve months, two related tothe care provided and one to the dischargearrangements around a care package. Staff explainedhow they were provided feedback from complaints atward meetings.

Are end of life care services well-led?


We judged the leadership of the service as requiringimprovement.

There was evidence of leadership in both in the palliativecare team and at board level however there was not a trustwide strategy or policy on end of life care. This wascombined with limited representation at the strategysteering group from board members.

An improvement plan was in place for end of life care thatwas being overseen by a trust wide strategy steering group.The palliative care service had produced its own strategypolicy and an extensive educational strategy.

Staff worked in a positive and open culture and feltsupported by their colleagues and line managers. Staff feltvalued by the trust and were engaged with the trustobjectives. Staff were committed and motivated to providean improving service and embraced the initiatives thatwere being developed by the end of life steering group.


• There was an improvement action plan in place for endof life care. This was initiated following the results of theNational Care of the Dying Audit that was completed in2014 and also to respond to and implement national

directives such as the National Institute for Health andCare Excellence (NICE) Quality Standard on End of LifeCare. The action plan was being audited andbenchmarked against trust objectives.

• The Salisbury Palliative Care Service had produced afive year strategy and business plan that ran from 2012to 2017 and also an education strategy that ran from2015 to 2020. Both these documents stated a clearvision for the future of the service in terms of aims andobjectives. Since October 2010 there had been an end oflife steering group in place that met bi-monthly. Thisgroup was overseeing the improvement action plan forend of life care and the various developments, initiativesand changes that were being implemented followingthe ending of the use of the Liverpool Care Pathway.They also ensured the service moved in line withnational developments and guidance. Onerecommendation has been that there should be boardlevel leadership on end of life care. The medical directorfor the trust had the responsibility for this, and was theboard representative on the steering group. Howeverthey had been unable to attend the majority ofmeetings due to other commitments. They liaised withthe other senior managers who attended this group,including the manager for clinical effectiveness. Whilstthe steering group was overseeing a range of positivechanges and improvements, there was not yet any trustwide policy or strategy on end of life care thatover-arched all this work. The leadership and directionfor end of life care in the trust came primarily from thespecialist palliative care service. This was a role theservice had fulfilled for number of years due to the sizeof the Salisbury Hospice Service and its prominent rolein the hospital. The medical director acknowledged thata trust wide strategy was needed and that this wouldfurther promote the message that end of life care was“everyone’s business” and also allow more hospitalownership of end of life care.

• The palliative care service strategy and business planswere detailed, comprehensive documents that covereda range of areas, including the new end of life pathwayand also proposals for the community service. Themanagers of the palliative care service were supportedby the trust board and the strategy group but were keenfor a trust wide strategy and policy to be in place. This

Endoflifecare

End of life care


additional strategy would help the service share someof leadership of end of life care and improve the futureservice by increasing the impetus of the changes beingimplemented.


• There was a structure for governance reporting and riskswere identified and understood by the palliative careteam.

• The strategy group met bi-monthly and reported back tothe board on the progress of the improvement plan. Areview of the progress of the improvement action planhad been undertaken in January and September 2015and had been fed back to the Board through the ClinicalGovernance Committee’. This included risk ratingsagainst the key performance indicators. A full report onend of life care was being completed annually andsubmitted to the board and the clinical teams. We sawminutes from the Trust Clinical Governance Committeefrom February 2015 when members of the palliative careteam presented an update on end of life care in thetrust.

• The palliative care service was part of the medicaldirectorate of the trust and accountable to the widertrust management structure for operational planning.The hospice service was also linked to a charity, TheSalisbury Hospice Charity that provided over 50 % oftheir running costs. The hospice had an executive boardwith representatives from the trust senior management,Salisbury Hospice Charity, palliative care clinical leads,NHS Wiltshire and the local commissioning groups. Theexecutive board agreed developments and held theservice to account for the delivery of their strategic plan.

• The strategy group included a wide range of staff andalso two representatives from the governors of the trust.

• The palliative care team escalated concerns to the trustrisk register. At the time of the inspection there wereseven entries on the register. These included identifiedrisks around an unreliable electronic data base, thedifficulty of arranging mortuary viewings at weekendand the possibility of losing funding for the seven dayworking pilot. The register identified the groupresponsible for reviewing risks and where possible thestaff responsible for taking action and the requiredtimescale.


• The trust had an end of life steering group that metevery two months. This group was overseeing thevarious improvement plans that were in place tosupport the work towards meeting the five priorities ofcare for end of life, and also to the meeting of the NICEend of life guidance. The medical director had taken onthe board responsibility for end of life care and therewere also two governors on the steering group. Othersenior medical, nursing and managerial staff were alsopart of this steering group.

• Staff within the palliative care team were very positiveabout their leadership and the support andencouragement the senior managers and consultantsprovided. Staff said they felt able to approach managersfor advice and there was an open culture where issuesand concerns could be discussed.


• Staff all spoke of the supportive and open culture theyworked in. Nursing staff said they often saw the directorof nursing and chief executive of the trust who wouldcome onto the wards and speak to staff and patients.Staff said they felt valued as members of theirimmediate team and the wider trust. Staff spokepositively about the trust as a workplace that wasfriendly, and also supportive of staff that may havepersonal concerns outside of work. Staff said they wereproud to work at the hospital and proud of the goodreputation they felt it had in the local community.

• Two band 7 nurses who had started work at the trustwithin the last six months said the support when theystarted from all the staff on the wards had beenexcellent. They were also well supported by the directorof nursing through this period.

Public engagement

• The chaplaincy service had organised a meeting with arange of people from the community from differentfaiths to discuss the different views around organdonation. They were in the process of planning anothermeeting where end of life issues could be discussedmore broadly. The hospital had also hosted two eventsarranged by local community initiatives called ‘gravematters’ and the ‘death café’.These were designed toencourage patients, relatives and staff to attend and talkabout death and dying.

• The bereavement service had undertaken a survey ofbereaved relatives in June 2014 and we saw the results

Endoflifecare

End of life care


and report from this work. The feedback was positivewith comments about the ease of the process and alsosome suggestions around signage which the team hadacted upon. One relative expressed their gratitude fortheir relatives “last days and their aftermath were sogreatly eased”.

Staff engagement

• The hospice conducted its own staff survey annuallyand provided the feedback to all the different teamsworking there.

• The chaplaincy service had met with the staffrepresentative from the trust’s Black and Minority Ethnicsupport group to discuss suggestions to improve theirmulti-faith and multi-cultural services. One outcomewas the service will be in future broadcastinginformation about all the different religious and culturalfestivals throughout the calendar year.

• Information was provided to the staff through a regulartrust newsletter and also from email updates from thechief executive.


• Along with other stakeholders a business case has beenput forward to commissioners for the development of a

“hospice at home” service. If successfully implementedthis would have an impact on the ability to dischargepatients more easily into the community and also helpwith admission avoidance.

• The hospice had started having Schwartz rounds everytwo months. These are an internationally recognisedmethod for staff from all disciplines to discuss difficultemotional and social issues arising from patient care,and championed by the Kings Fund in the UK.

• Staff in the hospice had started running a “Carers SkillsCourse”. This was for relatives and friends and wasaimed to empower informal carers of patients whowished to be cared for at home.

• The accident and emergency department had set uptheir own bereavement service that had beensuccessful. This model was now also to be piloted in themedical admissions unit.

• The trust was taking part in a research project with theCollaboration for Leadership in Applied Health Researchand Care (CLAHRC) and University HospitalSouthampton which was looking at the development ofa treatment escalation plan (TEP) which would includea DNA CPR form that was used nationally.

Endoflifecare

End of life care


Safe Good –––

Effective Not sufficient evidence to rate –––





Information about the serviceSalisbury NHS Foundation Trust provided diagnosticservices at Salisbury Hospital. These included a range ofgeneral and specialist imaging procedures including plainX-rays, CT, MRI, Nuclear medicine and ultrasound. Thedepartment is supported by a GP and Spinal x-ray unit. Thedepartment is also responsible for providing x-ray servicesat three community locations in Shaftesbury,Fordingbridge and Westbury. In the year 2014 to 2015 thedepartment performed 170,539 procedures.

The trust served a local population of 240,000 (acrossWiltshire, Dorset and Hampshire) and saw over 188,000outpatients in the year 2014 to 2015. The trust also hadextensive links with the Ministry of Defence to provideoutpatient and diagnostic services to military personneland their families. On average the outpatient departmentsreceived over 7000 referrals each month from within thehospital, other local hospitals and GPs. For newappointments this accounted for 33% of all appointmentscompared to a national average of 25%. The majority ofappointments at Salisbury were follow up’s (61%)compared to a national average of 55%.

During our inspection we visited the main outpatientsdepartment for medicine and surgery. We also visited thevascular, rheumatology, ear nose and throat (ENT),orthopaedic, eye, breast, fracture and plastics clinics. Wevisited the diagnostic department including generalradiology and nuclear medicine. We spoke with 49 patients

and 28 relatives/carers. We also spoke to 42 members ofstaff including managers, clinical (doctors, nurses, alliedhealth care professionals and health care assistants) andnon-clinical staff.


Outpatients and diagnostic imaging


Summary of findingsSalisbury NHS Foundation Trust outpatient anddiagnostic services were overall rated as good.

There were good systems in place for incident reportingand learning from when things did not go as planned.Systems were in place for the safe administration ofmedicines and for the prevention of infection. Theoutpatient and medical records department achieved ahigh standard in making sure medical notes wereavailable for 99.91% of appointments. Staff wereknowledgeable about safeguarding and theirresponsibilities to vulnerable adults and children.During our inspection we observed an emergencysituation in the outpatients department. The way inwhich this was handled showed staff were aware of thehealth of their patients and responded quickly andappropriately to any deterioration in a patient’s health.

Staff were very competent in the roles they were beingasked to perform. There were some outstanding areasof practice including the nurse led pathways within therheumatology outpatients clinics and one stop clinicswithin urology outpatients. There was goodmultidisciplinary working both within the trust and withother external organisation such as other health careproviders and the Ministry of Defence.

Staff communicated in a professional but friendlymanner with patients and their families. Commentsfrom patients and relatives were very positive about thestaff and how they provided their care and treatment.Patients were involved in their care and treatment andalways put them first.

The departments provided a good service to make surepeople were not waiting long periods of time for eitheroutpatients or diagnostic services. The trust wasworking with other local hospitals and looking atcapacity demand in order to make sure waiting lists didnot increase. We saw that the trust was achieving92.94% for its cancer two week waiting time against astandard of 93%. The follow up appointment is agreedbetween the patient and clinician, within an agreedtimescale. The patient is then put onto a waiting list andthis is noted in the consultation letter to the GP. Thepatient is monitored and booked immediately if they

ask for a follow-up, or discharged if they choose not tohave a follow-up appointment. We saw evidence thatcomplaints were discussed at departmental meetingsand changes were made where necessary to helpprevent further complaints.

Staff were supported at all levels from their immediatemanager through to the trust executive team includingthe chief executive. Good governance systems were inplace across outpatients and diagnostics. Whilst somestaff described the culture as a ‘them and us’ we did notsee this view shared by the majority of staff. Themajority of staff we spoke with felt the culture was openand that staff strived to make sure the experience forpatients was outstanding in line with the trust vision.




Are outpatient and diagnostic imagingservices safe?

Good –––

We rated the safety in the outpatient and diagnosticimaging service as good.

There were systems in place that supported staff inprotecting patients from patients experiencing avoidableharm. This included reporting incidents when things didnot go as planned. Incidents were discussed at governancemeetings and changes put in place where necessary toprevent similar incidents from taking place. Other systemsin place included measures to prevent the spread ofinfection, the safe administration of medicines andmaintenance of equipment.

Staff were knowledgeable about safeguarding issuesrelating to both adults and children. Staff were encouragedto complete their mandatory training and we saw evidencethat the majority of staff in outpatients had completed theirmandatory training. Within radiology plans were in place tomake sure staff completed their training as quickly aspossible.

Staff responded well to any deterioration in a patient’scondition. We observed staff dealing with an emergencysituation which showed staff knew their roles andresponsibilities not just to the patient concern but theother patients in the department and each other after theemergency.

Incidents

• We looked at the incident reporting system used by theradiology department. This showed us that betweenApril to June 2015 staff reported 25 incidents. Theseranged from water leaks affecting the department (four,equipment failures (two) and errors made becausereferrals were not read properly (five). In outpatients,115 incidents had been recorded between April and theend of July 2015. All of these incidents had actionsagainst them where appropriate.

• Staff understood their responsibilities to raise concerns,to record safety incidents, concerns and near misses.Staff across both outpatients and diagnostics were fullyaware of the incident reporting procedures and told usthey would have no hesitation in reporting an incident.

We saw evidence that staff did report incidents. Stafftold us that they were always encouraged to reportincidents although they did not always receivedfeedback on the outcome of the investigation.

• Lessons were learnt, action taken and this shared toimprove safety for patients. Incidents were discussed atdepartmental meetings and where necessary via peerreview meetings. We saw evidence that incidents werediscussed and that learning took place as a result. As anexample, the ultrasound scheduling was changed sothat the monographers had access to radiologistsduring their lists for advice and support.

• There had been two IRMER (Ionising Radiation (MedicalExposure) Regulations 2000) incidents where the patienthad been exposed to more ionising radiation than wasrecommended. These incidents were reported to theradiation protection link and to the radiation protectioncommittee.

• Duty of Candour had been introduced to staff. All thestaff we spoke with in the outpatients and diagnosticdepartments were aware of the Duty of Candour andtheir responsibilities to be open with patients whenthings did not go as planned. From November 2014,NHS providers were required to comply with the Duty ofCandour Regulation 20 of the Health and Social Care Act2008 (Regulated Activities) Regulations 2014. Thisrelated to incidents or harm categorised as ‘notifiablesafety incidents’. We saw evidence that the Duty ofCandour had been followed in an incident that tookplace prior to our inspection. The patient had beenprovided with apologies and explanations.


• There were reliable systems in place to prevent andprotect people from a healthcare-associated infection.During our inspection we found all the areas we visitedto be clean and tidy. Cleaning audits (patient ledassessments of the care environment (PLACE)) had beencompleted regularly across all outpatient and imagingareas. Within these audits, areas were checked againstquality standards and given a rating of pass, qualifiedpass or fail. We looked at the results for 20 separateareas all of which had passed.

• We observed hand washing practices beingimplemented before and after patient interactions. Allthe staff we observed adhered to the Trust’s infectionprevention and control policy by observing ‘bare belowthe elbow’ rule.




• Information was displayed on the hand hygiene auditsthat took place across the different outpatientdepartments. A number of departments consistentlyscored highly achieving 100%. These departmentsincluded Vascular / diabetes, medical / surgical, ENT,eye, oral surgery, rheumatology and dermatologyclinics. The plastics clinics did not score as highly. InJune 2015 the plastics clinics achieved 86.36%. InAugust, the radiology department achieved 94.74% forits hand hygiene audit.

• Toilet facilities were located throughout the outpatientand diagnostic imaging areas and clearly signposted.We found these to be clean. Housekeeping staff wereavailable throughout the day to provide additionalcleaning facilities as necessary.

• Personal protective equipment such as aprons andgloves were available in all the radiology and outpatientdepartments. We observed staff using this appropriatelyand where necessary.

• During our inspection we observed an emergencysituation. We saw that all the staff involved wore glovesappropriately. Following the situation, the staff workedin conjunction with the cleaning staff to clean the areaappropriately so that it could be brought back intoaction for other patients as quickly as possible.

• Cleaning schedules were in place across the outpatientsand radiology departments. Linen skips were availablein radiology which reduced the risk of cross infectionbecause staff did not have to carry dirty linen along thecorridors. Special sealed boxes were in place for thedisposal of sharps, we saw that these were sealed andsigned appropriately. Systems were in place for the saferemoval of these boxes from the hospital.


• Systems were in place to ensure the use andmaintenance of equipment prevented avoidable harmto patients. Equipment was maintained according tomanufacturer’s instructions. Equipment was also testedfor electrical safety. Stickers on each piece of equipmentshowed when they were tested and when they are dueto be tested again.

• Emergency trolleys and bags were available in bothradiology and outpatient areas. These trolleys weretamper proof by means of security tags. The trolleys andbags were checked on a regularly basis and we sawevidence to confirm that these checks took place. Eachemergency trolley had an emergency medicines box

that had already been checked and sealed by thepharmacy department. If the seal was broken, staffwould return the box to pharmacy and receive areplacement. During our inspection we observed anemergency situation in one department. Following thisemergency, the emergency trolley was cleaned andrestocked by the staff before being resealed ready foruse again.

• None of the outpatient or radiology waiting areas wevisited had separate waiting areas for children. Therewas a dedicated children’s outpatients departmentwhich did see children from a number of specialties. Inthe main outpatient areas, there was a selection of toysfor different age groups available and systems were inplace to keep them clean and in a safe condition. We didsee evidence that some outpatient areas such as eyeheld dedicated children’s clinics so there would not beadult patients in the waiting area at the same time.

• Staff in radiology had access to specialised personalprotective equipment for use within areas that wereexposed to radiation. We observed staff using thisequipment appropriately. Staff wore personal radiationdose monitors which were monitored according to thenational legislation.

Medicines

• The outpatients and imagine departments hadarrangements in place for managing medicines whichkept people safe.

• Where necessary outpatient departments had systemsin place to review the prescription of high costmedicines. As an example, within one specialty it wasroutine to prescribe expensive medicines to patientswith chronic conditions. Patient receiving this medicineswere closely followed up to monitor the effectiveness ofthe medicines. Following this review, doses could beincreased, decreased or stopped altogether. This madesure patients were on the correct medicine for theirindividual needs. It also meant the department and thetrust was using the medicines in a cost effective way.

• We looked at how medicines were stored in radiologyand a selection of outpatient departments. We foundthat medicines were stored appropriately in lockedcupboards that only staff had access to. Wherenecessary fridges were available. The temperatures ofthese fridges were checked on a daily basis to make surethe medicines were being stored at the correcttemperature. We reviewed how controlled medicines




were stored, and found that these were locked awayseparately and checked by two members of staff andrecorded in a dedicated controlled drug book. We didnot see any medicines that were stored inappropriatelyor that were out of date.

• The outpatients departments kept stocks of twodifferent prescriptions for the medical staff. The majorityof medicines were prescribed on the ‘in-house’prescription sheet that patients could take to thehospital pharmacy. External prescription forms werealso kept that could be taken to any outside pharmacy.All the prescriptions pads were kept secured in lockedcupboards that only the nurse in charge had access to.The audit systems in place for the external prescriptionforms were not robust enough to make sure they werenot being used inappropriately because they onlyrecorded the patients’ name. We raised this with themanager who told us they would improve the systemacross the outpatients departments. The following day,the manager showed us the system they had alreadyimplemented. We found this to be appropriate toadequately record and audit the prescription forms.

Records

• People’s individual care records were written andmanaged in a way that kept people safe.

• The outpatients departments monitored how oftenpatients were seen in clinics without their medicalrecords. From January to July 2015 123,548 sets ofpatients notes were needed for the various clinicappointments across the trust. Out of these, 115 sets ofnotes could not be located for the appointment. Thedepartment identified that this was because the noteshad been miss-filed, staff had not used the case notetracking properly or the notes were off site for anotherappointment. Overall, patients’ medical notes werefound for 99.91% of appointments, which was a smallincrease from the previous two years. This showed thatthere was an effective system in place for making surepatients’ medical notes were available for theiroutpatient’s appointments. Where they were notavailable, a reason was identified to try and reduce thelikelihood of the issue happening again.

• Staff told us that the medical records departmentprovided a good service. Staff found requesting noteseasy for both routine appointments and last minuteappointments. We observed staff following trustprocedures for requesting and tracing notes.

• We looked at four sets of medical notes within thesurgical outpatients and two sets of notes in the eyeclinic. All the notes had a confidential cover to preventother patients and members of the public seeingpatients name and address. The notes were filedcorrectly and the entries from outpatients were datedand signed appropriately. Entries were legible andcontained information gained at the appointmenttogether with the future plan.

• During clinics, notes were stored at the nurse’s stationhowever, they were not locked away. A front‘confidential’ cover was placed on each set of notes sothat other people could not see any patient details.Outside of the normal clinic times, the notes weresecured in the clinic area which was then locked to thegeneral public.

• Patients were able to check in to their appointmentwhen they arrived at the department either via thereception desk or by using a self-service check in kiosk.These kiosks were touch screen computers wherepatients could input their details to check in for theirappointment. The screens for these kiosks were visiblefor every angle and therefore did not always protectpeople’s confidential information if several patientswere queuing to check in. The patients we spoken withduring our inspection told us they had no concernsusing the kiosks and they had the option of using thereception if they choose to.

Safeguarding

• The staff we spoke with in both outpatients anddiagnostics understood safeguarding for both adultsand children. Staff were aware of their responsibilities toreport and document safeguarding concerns and wouldhave no hesitation in doing so. Staff knew who thesafeguarding leads were, and where they could turn forfurther help, support and/or advice.

• Where children failed to attend for their appointments,the child’s GP and where necessary other professionalswould be contacted to make sure there were noconcerns.

• There were systems, processes and practices in place tokeep people safe and these were communicated tostaff. Training records for radiology showed that 87.39%of staff had completed the safeguarding training foradults. For children’s level one safeguarding 87.50% ofstaff had completed it and 75% of staff had completedlevel two. This was against an overall trust target of 85%.




Within outpatients, all staff had received training in thesafeguarding of adults and children. All clinical staffwithin outpatients had received training to level two inchildren’s safeguarding.

• Any safeguarding concerns were documented in thepatients’ medical notes. We were told that the staff werealways on the look-out for specific issues that individualpatients might have.

Mandatory training

• We looked at training records for the radiologydepartment. These showed that not all staff hadcompleted their mandatory training. The majority of thetraining was provided via e-learning. The departmentscored had not met the trust target of 85% in thefollowing areas: equality and diversity 76% fire training74%, infection control 81% for information governance77% and moving and handling training 72%.

• We looked at the training records for the outpatientsdepartment. These showed that the majority of staffhad completed their mandatory training. The recordsshowed that 100% of nursing staff had completed theirequality and diversity, fire safety and safeguardingtraining. The majority of other training such as infectioncontrol, information governance and resuscitation hadbeen attended by a large proportion of staff and planswere in place to make sure all staff achieved 100%compliance.

• Staff in both departments told us that they felt themandatory training was of a good level to ensure thesafety of patients.


• We saw examples that staff were aware of the patients intheir areas and what to do in an emergency or if apatient was feeling unwell. Staff knew how to contactthe resuscitation teams and knew where the emergencyequipment was kept within their own areas. As anexample, during our inspection a patient felt unwellduring their scan. They were monitored by the radiologystaff before being moved to a more appropriate area forfurther review. The staff monitored the patient closely,whilst also looking after the relatives.

• During our visit to outpatients, we observed staffdealing with an emergency situation with a patient. Thestaff recognised the emergency straight away andresponded immediately. Some staff immediately

attended to the patient whilst others cleared the waitingarea of the other patients. Help was summoned fromthe trust’s emergency response team. Staff were calmand professional in dealing with the emergency.

• Radiology used an adapted WHO surgical safetychecklist for all radiological interventional procedures.We checked six of these checklists and found them tohave been completed appropriately. Audits werecompleted with very positive results. As an example, outof 40 patients that were reviewed in one audit, all ofthem had the appropriate checks carried out.

• Any imaging requests for women included pregnancychecks to make sure staff were informed of any possiblepregnancy before exposure to radiation.

Nursing staffing

• An outpatient nursing consultation (led by the Directorof Nursing) ran from July to the end of August 2015 andrecommended a new leadership structure for thedepartment. At the time of our inspection, the trust hadimplemented the first recommendations of this review.A nurse manager had been appointed to lead the wholeoutpatients department. The second recommendationwas to review the staffing requirements using thebaseline taken in 2012 as a starting point. Prior to ourinspection a consultation took place in July and August2015. This consultation confirmed the overall nursemanager lead followed by a detailed review of the bandsix roles in the outpatient areas.

• The current staffing for outpatients is made up of 63.71WTE. As part of the outpatient nursing consultation thiswas planned to reduce to 54.64 WTE. The reductionwould come from the qualified nursing staff, butincreasing the band two health care assistants tosupport the various clinics. At the time of our inspectionthe departments were fully staffed.

• At the time of our inspection, a number of outpatientdepartments were operated separately. We were toldplans of how this would change to bring all outpatientsdepartments under one nursing manager.

• Plastics, oral and maxillofacial and orthodonticsoutpatients did not use any acuity tools to decidestaffing levels. Staff told us that they would regularlyreview the nursing staffing levels based on their clinicworkload. Staff we spoke with during the inspection toldus that whilst they would always like more staff, thecurrent staff numbers were sufficient to meet demand.




• The clinic staff rotas were staggered during the day tomake sure there were staff throughout when clinics areoperating. This extended into the evening for someclinics such as ear nose and throat.

Medical staffing

• Information provided by the trust prior to our inspectionshowed the staffing establishment for radiology was:

• Radiologists 13.30 WTE• Band 8a nursing / managers 4 WTE• Band 7 Radiographers/sonographers 11.73 WTE• Band 6 Radiographers 12.67 WTE• Band 5 Radiographers 22.64 WTE• Band 4 assistant practitioners 2 WTE• Band 2 radiology department assistants 10.80 WTE• Administration team 20.35 WTE

• The medical staff within the diagnostic imagingdepartment had rotas in place to show which radiologistcovered radiology, ultrasound, MRI etc. Rotas were inplace for on-call work which included weekends andnights.

• The trust had experienced difficulties in recruitingradiographers in the six to 12 months prior to ourinspection. This had been covered by existing staffworking additional hours and the use of agency staff. Atthe time of our inspection the department had fourwhole time equivalent vacancies for radiographers. Arecruitment plan was in place and the vacancies hadbeen identified as a risk on the risk register.

• The medical rota for radiology was produced six weeksin advance with the aim to have a minimum of fourradiologists on site each day Monday to Friday between9am and 8pm. The rota’s we looked at confirmed thiswas achieved.


• Staff we spoke with were aware of the major incidentpolicy and the action cards that related to theirdepartment. The action cards were kept in the accidentand emergency department and copies were also keptin the radiology department for easy referral by staff.

Are outpatient and diagnostic imagingservices effective?

Not sufficient evidence to rate –––

The effectiveness of outpatients and diagnostic was notrated due to insufficient date being available to rate thesedepartments effectiveness nationally.

The use of best practice was evident throughout theoutpatients and diagnostic imaging services. Staff felt theirtraining was good and provided them with the necessaryskills and knowledge to perform their role. Systems were inplace to assess competencies both in a department and forspecific pieces of equipment.

Multidisciplinary working was in place to ensure efficientpatient care. Staff worked in partnership with other hospitaldepartments, external health care providers and otherorganisations such as the Ministry of Defence. Diagnosticimaging was available seven days a weeks to inpatientswithin the hospital. The outpatient department providedevening and weekend clinics in some specialities and waslooking to increase this to improve availability for patients.


• We saw evidence that policies and procedures wereevidence based where appropriate. As an example thepathway for breast cancer was followed by the breastcare team. This pathway was based on the NationalInstitute for Health and are Excellence (NICE) guidelinesfor the diagnosis and treatment breast cancer.

• The radiology department had comprehensiveexamination protocols which were available to all theradiographers. These were audited on a regular basiswhich showed staff were compliant with the protocols.

• Clinical audits were undertaken, these included auditsas required by IR(ME)R. The results of these audits wereshared at staff meetings.

Patient outcomes

• A liaison service had started within rheumatologyoutpatients in November 2015. This service looked atpatients with low trauma fractures specifically for signsof osteoporosis. Once patients were identified they wereoffered a specialist DEXA scan (Dual Energy X-rayAbsorptiometry - a special type of x-ray that measuredbone mineral density). The staff liaised with the patientand their GP and started treatment where necessary.Where osteoporosis was not identified, the staff would




look at prevention with each patient. Helping to preventthe condition through lifestyle choices and preventingfurther fractures. Audit arrangements were in place tomonitor the effectiveness of the service. At the time ofour inspection the service was too new to show anybenefits. Staff told us that over time the service wouldimprove mortality by identifying the condition early,starting appropriate treatment and reducing the chancefor further fractures.

• We saw nurse led pathways being used. In one examplea nurse led pathway was in place for early arthritis. Thispathway had been ratified by the Royal College ofNursing. National best evidence showed that patientswould go into remission earlier if they were diagnosedquickly and started on the appropriate treatment. Thepathway was based on this good practice. This servicecame top in a national audit for patients with earlyarthritis. The staff had presented their service atnational and international conferences including theBristol Society of Rheumatology conference in 2015.When the service was audited it was found to be fullycompliant in the majority of areas. One action wasrequired following the audit. The action from the auditwas to make sure the nursing team were aware of thetime frame of making referrals. This action had beencompleted prior to our inspection and a re-audit wasplanned in 2016.

• Within the rheumatology clinics, patients on biologicaltherapies (biologics, newer and expensive medicinetherapies) were seen in one stop clinics. They could getan ultrasound if necessary which helped the doctorsand nurses explain how the therapies were working.Patients were able to see on the screen the effect or notof the medicines. This meant that the staff were able tofinely tune the medicine therapies which reducedunnecessary waste and cost. Since this service had beenintroduced, staff had been able to reduce the medicinedose for 15 patients and stop it all together for eightpatients. Four patients were also able to be switched tomore appropriate medicines for their particularcondition. At the time of our inspection, staff werecollecting additional data to show the benefits topatients and a cost improvement in medicinesprescribing.

Competent staff

• Information provided to us by the trust before ourinspection showed that 73% of radiology staff had

received their appraisal at the end of June 2015. Weasked why the figure had not met or exceeded the trusttarget of 85% and were told there had been a delay insenior staff receiving their appraisals. We were toldsenior staff needed to agree their objectives beforeappraising junior staff. The appraisals for nursing staffwithin outpatients and radiology department was 99%.The appraisals were linked to the trust values. Withinoutpatients, the manager carried out the appraisals ofthe band five’s and six’s who in turn did the appraisalsfor the band two’s and three’s.

• Radiology especially used a lot of different and veryspecialist equipment. Training records were in place foreach member of staff. These records showed whichequipment that member of staff had been trained tooperate safely.

• Staff in both the outpatients and imaging departmentshad received a trust induction and local departmentalinduction. For imaging staff, this also included theaccident and emergency department. When new staffstarted, they received a welcome pack, where able toshadow more experienced staff and completecompetency checklists before working alone. Staff wereable to rotate between different areas within their areasof work.

• We looked at the training records for six radiology staffand found them to be complete and comprehensive.The records showed that the staff had received adepartmental induction, together with an induction tothe accident and emergency department. Staff thenreceived a six month preceptorship programme duringwhich time competencies were assessed and signed off.Staff were assessed on their competencies for generalradiology skills and specific pieces of equipment.

• Competency documents were used in other areas suchas rheumatology outpatients. The documents werecomprehensive and covered the individuals’ skills andknowledge in a particular area. Where necessary thecompetencies were based on national evidence andprofessional regulations.

• The staff we spoke with felt the induction both trustwide and departmental was effective and preparedthem for their role. Staff were encouraged to completeadditional training depending on their role. As anexample, one member of staff told us they were trainingto be a scrub nurse within radiology.





• There was good evidence of multidisciplinary workingwithin radiology and outpatients. They worked withevery department across the trust. As an exampleradiology supported 24 multidisciplinary meetings.Radiologists and directorate managers also linked veryclosely with neighboring trusts and other colleagueswithin the South West and South Central regions.

• The bookings team regularly involved the relevantconsultants in the state of their waiting lists. Thebooking staff felt this was important in gaining theirco-operation in bringing the waiting lists down. Thebooking team also liaised closely with the theatrebooking team. As an example if a particular surgeonneeded to do more operations, it would be discussedwith the outpatients booking team to make sure itwould not impact on the consultants clinics.

• We saw examples of where staff worked acrossorganisational boundaries such as with the prisonsystem and the Ministry of Defense (MoD). As anexample, the hospital provided services to a largenumber of military personnel and their families. Theoutpatient and radiology staff would liaise directly withthe MoD’s family medical centres to make sure theyreceived the care they needed.

• Other examples of good multidisciplinary workingwhere seen within the one stop clinics where alliedhealth care professionals, nurses and consultants fromdifferent specialties came together in one clinic to seethe patient.

Seven-day services

• The radiology department provided a 24 hour a dayx-ray service for the emergency department, wards andtheatres. The majority of the other services werepredominately open from 9am to 5pm Monday toFriday. Outside of these hours, duty radiologists andon-call radiographers were available outside of thosehours so that patients had access to urgent imaging.Radiologists were on site on Saturday and Sundaymornings for urgent scans and reporting results.

• Outpatient clinics were provided Monday to Friday from8.30am to 5pm. Some of the specialties operatedevening and Saturday clinics and this was beingextended to include more specialties. The oraloutpatients operated an on-call service during theevening and weekends so that emergencies could beseen following referral from the accident andemergency department.


• All clinics and wards had access to the electronicimaging system. This meant that X-rays and scans couldbe viewed on computer systems throughout thehospital.

• Overall, patients’ medical notes were available for99.91% of appointments. Therefore appropriateinformation was available for the consultation with thepatient

.


• Staff within the outpatients and radiology departmentstold us they had received training in the Mental CapacityAct. This was confirmed in the staff training records. Staffwere aware of their responsibility surrounding patientsconsent.

• We observed staff seeking patients consent for generalcare and treatment. Where specific procedures tookplace, we saw that consent had been taken by a doctorand the consent form filed in the patient’s medicalnotes. The patients we spoke with confirmed that thedoctors had explained the procedure, and risks andbenefits before asking them to sign a consent form.

Are outpatient and diagnostic imagingservices caring?

Good –––

We judged the services provided to patients by theoutpatients and diagnostic imagines departments to begood.

Staff communicating well with patients of all ages, treatingthem with dignity and respect. Staff were kind andcompassionate and patients had no complaints with thecare they received.

Patients were involved in their own care and treatment,carers and where necessary relatives were also involved.Staff provided good support to patients and tried their bestto resolve any issues a patient might have. Someoutpatient departments had access to specialistpsychologist and counselling services for patients.




Compassionate care

• We observed that staff in both outpatients anddiagnostic departments spoke appropriately,professionally and kindly to patients. Staff listened towhat patients had to say and tried to make sure thetrust values were adhered to.

• Comments from patients in the outpatient areasincluded: “The rheumatoid arthritis clinic is very wellorganised, the attention given to patients is excellent. Ifeel that I am not just a number, but an individual thatneeds their help” (rheumatology clinic).

• We received very positive feedback from patients andrelatives visiting the diagnostic imagine departments.Comments included “I have always been treated well”.“All the staff are so friendly, I’ve been to most of thehospitals around here, but this is the best”. “Booking thescan was very easy, a very good experience”. “The staffare kind and explained things very well, they wereinvested in me as an individual”.

• Comments from patients visiting the outpatientsdepartment included “excellent service”. “Staff arefantastic and friendly”. “The department is brilliant”. “Ican only praise the staff, I can’t fault it, I’ve had perfectcare”. “The staff were very understanding andsupportive”. “My appointment time was changed withno reason given, but I have been treated well”. “This ismy sixth appointment now and I've never had onecancelled, the staff are excellent and I am happy withmy treatment”. “The staff are kind and very nice to me”.“My wife and I have only had positive experiences here,never had to wait long”.

• The culture within the outpatients departments wasvery open and it was obvious that staff treated patientsas they would like to be treated. A member of staff toldus “it's our job to put people at ease” and we sawevidence of this during our inspection.


• Staff understood and involved patients in their owncare. As an example, the clinical nurse specialist clinicswithin rheumatology looked at the whole patient. To dothis they helped educate each patient into theircondition, medicines and self-care. Counselling was alsoprovided to patients where necessary. Staff told us that

they had increased the number of patients who werecompliant with their treatment plans. This in turn hadreduced the number of problems that patients hadexperienced.

• Patients told us that staff discussed and involved themin their own care and treatment. Relatives were alsoincluded where appropriate and where the patientsconsent had been given.

Emotional support

• We saw evidence that staff provided initial emotionalsupport where necessary. Some of the more specialistteams such as breast care had psychologists included inthe team or had access to counselling services. We sawsome excellent support given to patients when theywere in a vulnerable position. As an example, we spokewith a patient who had turned up for an appointmentand x-ray following an injury a few days prior. Duringtheir admission for the injury, the communication hadbeen poor from the ward which left the patientextremely upset over the treatment for their injury andpossible prognosis. The patient had been instructed toturn up for their appointment, but when they arrived, noone was expecting them because the ward had notnotified the outpatient department. This experience leftthe patient with decreasing levels of confidence in thehospital and worried about the outcome of their injury.When the fracture clinic health care assistant heard this,they immediately organised an x-ray and for the patientto be seen by the specialist registrar. Notes wereobtained and support provided to the patient and theirrelative. The next appointment was made prior to thepatient leaving the department to prevent any furtherconfusion. The actions and support of the staff helpedthe patient to regain some of the confidence in thehospital and they left happier and more positive thanwhen they arrived.

• We observed staff being very supportive to patientsduring an emergency situation in the outpatientsdepartment. Staff moved waiting patients away fromthe emergency into another department and made surethey were ok. Staff remained on hand to look after thosepatients, answer any questions they might have andprovide reassurance where necessary.

Are outpatient and diagnostic imagingservices responsive?




Good –––

We rated the responsiveness of the outpatients anddiagnostic imaging services as good.

Overall, we found that the outpatients and diagnosticimaging services were meeting or very close to meetingtheir targets on waiting times. In July 2015 only 67 patientsout of 3,934 waited longer than the six weeks for diagnosticprocedures. For outpatients, the trust was meeting itsreferral to treatment time targets. Once patients arrived attheir appointment, 86% of them waited less than 30minutes to be seen.

One stop clinics were held in a number of departmentswhich meant patients could have their consultation andany diagnostic tests in the same appointment. Otherservices were available depending on the patient needs.For example a telephone advice line was available forrheumatology patients and a GP walk in service wasavailable for patients needed x-rays from the GP.

Complaints were discussed at departmental meetingsthere was evidence that the departments learnt fromcomplaints and put measures in place to prevent similarissues happening to other patients. Staff always tried toresolve concerns that patients had at the time rather thanwait for a complaint to come in.


• Some patients were concerned at the cost of car parkingespecially the additional charges if their appointmentover ran. We saw signs in place across radiology andoutpatients telling patients not to worry if the clinicswere running late, they would not be charged any more.

• Outreach clinics were provided in some specialties.These provided services nearer to people’s homes andmade sure they did not have to come to Salisburyhospital.

Access and flow

• At the time of our inspection, the trust was achieving92.94% for its two week cancer wait against a standardof 93%.

• One target within radiology stated that patients shouldnot wait more than six weeks for their diagnostic

procedure. We looked at the figures for July 2015 whichshowed us that during the month 3,934 patients haddiagnostic procedures carried out. The majority of thesepatients, 82.8% were seen within four weeks, 15.4% ofpatients waited between four and six weeks.

• Another target was for patients attending their GP withsuspected cancer to the time they are treated was 62days. The standard for all nine areas (breast, colorectal,gynaecology, haematology, head and neck, lung, skin,upper gastro intestine (GI) and urology) was 85%. Thetrust consistently achieved higher than this standard inthe majority of areas. In October 2015 the trustexceeded the 85% standard in seven of the areas, butfailed to achieve the standard in lung and upper GI.Overall the trust achieved 86.67% and 88.24%respectively for the 62 day screening target against astandard of 90%.

• The mammography scanner had been out of actionsince a flood in the department. This had an impact onthe women using the service because they had toattend a hospital in Southampton to have a wireinserted prior to breast surgery.

• Salisbury NHS Trust had a lower number of patientswho did not attend their outpatient appointments at 6%compared to an England average of 7%.

• We saw figures from April to August 2015 which showed82,489 patients were seen in the outpatient department.70,847 (86%) of those patients waited 30 minutes or lessonce they arrived at their clinic. Those patients thatwaited between 30 minutes to one hour amounted to9,416 (11%) and those waiting over an hour were 2,226(2.6%). This did not take into account those patientswho arrived early for their appointment. We saw thatstaff within outpatients were documented the arrivaltime of patients, what time their actual appointmentwas and when they were called for their appointment.This meant the staff were aware of the importance foraccurate waiting time figures to improve the waitingtimes for patients.

• Audits had been completed to find out more aboutdelays to appointments. As an example, in August 2015the ultrasound department carried out an audit on howlong patients waited above their allotted appointmenttime. The audit looked at 125 patients and found that 45of those were not seen within 10 minutes of theirappointment time. The standard the department setthemselves was 90% of patients be seen within 10minutes of their appointment time. The audit




highlighted that of those patients that waited longerthan 10 minutes; the main reasons for patients waitingmore than 10 minutes were portering issues, patientsarriving late and over running of maintenance. Thedepartment made changes to the patient lettersemphasising the importance of being on time, moreporters were allocated and additional staff wereallocated to the department. A re-audit was planned for2016 to see if the changes had been effective in reducingwaiting times for patients.

• One stop clinics were held by the breast care servicethree times a week. The service saw 4500 patients eachyear and consisted of radiologists, consultants,psychologist and specialist nurses. The patient wouldsee the consultant and be examined and then have thenecessary tests/biopsy with the results discussed at themulti-disciplinary team meeting within a week of thepatient being seen. If the result was positive the patientwould be seen in pre-assessment where all thenecessary information and support would be given. Awide range of information was available for the women,as well as a specialist illustrated book called ‘mummy’slump’ which was aimed at children and explained whattheir mother was going through. The team had beenvery proactive in providing the service to women andworked in conjunction with the STAR charity in raisingthree quarters of a million pounds towards a newdedicated unit expected to be completed in 2016.

• The trust had met all its referral to treatment targets buthad seen challenges in four specialties. The trust wasaware of the challenges within these specialties. Forexample within dermatology there had been problemsin appointing consultants. This was recognised as anational problem;, as a result the trust had beenreviewing the care pathways with the commissioners.The waiting time targets were constantly reviewed anddiscussed at the monthly waiting list group meetings.We were told that the Trust had consistently exceededtheir targets but was finding it increasing harder to meetthem. As a result work was being undertaken ondemand forecasting to increase the capacity of theoutpatients and radiology departments.

• For the outpatients departments, the target was forpatients not to be waiting longer than 18 weeks from thetime their GP referred them to the hospital to when theystarted treatment (known as the referral to treatmenttime or RTT). Overall we saw that the outpatientsdepartment was meetings its targets.

• The radiology department aimed to report on x-rays forthe emergency department and inpatients within 12hours and for other patients by the end of the nextworking day. It achieved this for 85% of the time forinpatients and 90% for outpatients. These keyperformance indicators are reviewed in conjunctionwith the patient flow project management board.

• The urology team had established one stop clinics forpatients with kidney stones. The clinics ran twice amonth. Patients presenting with renal colic with their GPor at the emergency department could be referred tothe clinic. At the initial outpatient appointment, anydiagnostic tests were completed. This had led to areduction in the waiting times for appointments andtreatment.

• All referrals to outpatients come into the centralbooking office. These referrals could be madeelectronically or paper. The electronic referral systemwas instigated following requests from GPs and wasinitially only used for rapid referrals. Because of thesuccess electronic referrals were used for all referrals,however, paper referrals were still accepted.. Once thereferral was received it was sent to the relevantconsultant for grading (routine or urgent). Theconsultants had to grade the referrals within twoworking days and return them to the booking office.Appointments were then allocated and confirmationletters sent to the patient who in turn phoned to confirmthe appointment. If the bookings team had not heardfrom the patient within a week, a further letter was sentasking the patient to make contact to accept theappointment. If the patient did not respond to theseletters they are discharged.

• When follow-up appointments were needed, staff inoutpatients generated an ‘outcome’ form. Urgentfollow-up appointments were dealt with straight away.For routine follow-up appointments some patients weregiven a patient initiated follow up appointment, withthe timescale agreed between the patient and theclinician. The patient was monitored and bookedimmediately if they initiated the follow-up appointmentor discharged if they choose not to have theappointment within the agreed timescales.

• The outpatient booking system and the process ofdischarging someone back to their GP was flexible. Asan example, one patient ignored the appointmentletters because of issues they were dealing with at thetime. As a result the patient was discharged back to their




GP. When the patient made contact to explain thesituation, they were reinstated and given theirappointment. This showed that whilst a policy was inplace to make effective use of outpatient appointments,it was flexible enough for staff to take individualpatient’s situations into account.

• Patients could email or use the automated telephoneservice to accept their appointment. They would alsotelephone to speak to a booking clerk to confirm anappointment or to obtain further information. Patientswere able to cancel or request a change of appointmentusing the online tool on the hospital's web pages.

• Within the outpatients and radiology departments,patients could choose to book in at the normalreception areas or use the self-check in machines. Staffwere on hand to explain how the check in machinesworked for those patients who had not used thembefore. Reception was automatically notified whenpatients had used this check in facility. This gavepatients the option to use different check in methodsdepending on their preferences.


• The outpatients and diagnostics were located in anumber of different departments across the hospital.We found all the departments we visited were fit forpurpose with enough seating for patients. The onlyexception to this was the Haematology waiting whichwe observed was extremely busy with patients standingin the waiting area and out into the corridor. We askedstaff if this was normal for this clinic and were told itwas, we were told it was a very busy clinic.

• We saw that some of the outpatient areas had beenredesigned to make the experience better for patients.As an example, rheumatology outpatients had colourcoded all their clinic rooms to make it easier for patientsto find the right room for their appointment. Patients wespoke with in the waiting area told us they preferred thecolour system and found it worked well for them.

• Seating was available in all the waiting areas. Watermachines were available for patients and staff use in thedepartments we looked at. For some of the clinics suchas haematology offered patients the chance to go andget a drink or food in the hospital restaurant and becalled via their phone when their appointment was due.

• The rheumatology outpatient department provided aphone line where patients could call and leave amessage with any queries. When the service was

audited, it showed that patients did not find this servicevery useful. When patients had queries on their care andtreatment, they wanted to speak to a nurse rather thanleave a message. As a result, a pilot manned nursehelpline was established for two hours each day. Thenew service was again audited and this showed 100% ofthe 100 patients asked preferred the new service.Patients (97%) said their query was dealt with and theservice was helpful. Patients we spoke with inrheumatology outpatients all complimented the servicebut wished it was open longer.

• Some rheumatology patients needed their medicinesvia infusions that could sometimes take all day toadminister. Usually this would take place in a genericday unit setting. At Salisbury hospitals dedicatedrheumatology rooms were available for patients whoneeded infusions. Patients who used this service told usthey preferred it because the staff were much moreaware of their individual needs.

• To make x-ray services more accessible to patients, a GPwalk in service was established which proved popularwith both GPs and patients. Patients were very positivewith the accessibility and promptness of diagnosis. Thisservice was initially introduced in the satellite unit atWestminster Memorial hospital, Shaftesbury, followedby the main hospital and another satellite service inWestbury.

• When patients arrived whose first language was notEnglish, interpreters were provided. The booking teamhad access to face to face interpreters and were able tobook an appropriate interpreter for the patientsappointment. If information leaflets were need in otherlanguages, this was arranged as necessary. The eyeoutpatients department automatically sent out theirclinic letters in large print to make them easier to readfor their patients.

• Appointment reminders were sent out via text where thepatients consent had been obtained.

• Within the outpatients department, there was adementia champion and link worker who acted as atrainer for other staff as well as a point of contact forfurther advice and support.

• Staff told us that when patients attended thedepartment living with dementia, they would fast tractthem through the department to make sure they did not




become distressed. Staff would also fast track otherpatients such as children, those with learning difficultiesor anyone with increased anxiety because of being atthe hospital.

• The signage overall in the hospital was good althoughwe did speak to a few patients who were confused whenfinding their way to the radiology department.

• A range of patient information leaflets were available forthe various clinics and procedures undertaken inradiology. These leaflets were sent out withappointment letters but were also available in thedepartments themselves. The leaflets were available inother formats as necessary such as other languages,audio and large print.

• Information boards were in place across eachoutpatient department. These gave any waiting timesfor the clinics and reasons for delays. Staff updated theboards throughout the day to keep patients informed ofwhat was happening. Staff reinforced these with verbalexplanations when necessary. The patients we spokewith confirmed that kept them informed of any clinicdelays.

• A range of information was sent out with appointmentletters including consent forms, maps of the hospital,contact details and any specific do’s and don’ts that thepatient should be aware of.

• We saw that a member of staff had been specificallyfunded by the Royal National Institute for the Blind andtrained to run her own clinic. They were able to assesspeople’s eyesight and if any visual impairments werefound they initiated and coordinated any services thatpatient might require. This meant patients were able tobe diagnosed quickly and receive and treatment orservices they might need.

• At the time of our inspection the machine used formammograms had been out of action for someconsiderable time following a flood in the department.Other provisions had been made for patients to attendthe hospital in Southampton for their scans. Howeverstaff were concerned at the length of time it was takingto replace the equipment. The issue was documentedon the department’s risk register.


• The patients we spoke with told us that they felt able totalk to staff if they had any concerns. Patient said theyhad confidence that staff would resolve their concerns ifthey could. When themes or trends were noted in

complaints or concerns, the customer care team wouldwork with the departmental managers to look at thethemes and identify any work that could be undertakento improve the patient experience.

• We saw examples of where the departments hadlearned from complaints and put measures in place toprevent similar complaints. For example, one complainthad highlighted a particular patient call bell in a toiletdid not work. Following the complaint a system was putin place to check all patient call bells in theradiology department on a regular basis to make surethey were all working appropriately. In another example,maps were changed that directed patients to the mobilescanner following complaints from patients who foundthe previous maps confusing.

• In another complaint, patients complained aboutwaiting in fracture clinic without having their X-rays first.This resulted in increased waiting times for patients. Asa result staff now speak to each patient as they arrive toacknowledge their arrival and to check they had beenfor their X-ray. Information was also included in theappointment letters and the self check in kiosks.

• Complaints and concerns were discussed at themulti-disciplinary team meetings held monthly. Thethemes were discussed together with any actions thatneeded to be taken as a result. We saw evidence ofthese discussions in the MDT meeting minutes forOctober and November 2015.

Are outpatient and diagnostic imagingservices well-led?

Good –––

We rated the leadership in the outpatient and diagnosticimaging department as good.

Both departments were led by senior clinical staff wihsupport from the directorate management team. Staff toldus they felt very well supported by their immediate linemanagers, the divisional management team and the trustexecutive team. Staff knew the vision for the trust andconstantly strived to make sure every patient’s experiencewas outstanding.

Governance systems were in place. Staff understood therisks within the departments and where improvementsneeded to be made. Action plans were in place where




necessary with appropriate timescales. The diagnosticimaging department was working towards achievingaccreditation with the Imaging Service AccreditationScheme.

We saw that in the friends and family test, 96% of patientssaid they would be very likely or likely to recommend thedepartments to others. However, this rose to 100% in someof the outpatient clinic areas such as urology,rheumatology, plastics and oral surgery.


• The overall vision for the trust was to provide anoutstanding experience for every patient, throughpatient centred and safe care, professional and friendlystaff/service and a service that is responsive to people’sneeds. Staff we spoke with were all aware of the overalltrust vision and strategy. Staff were aware of the rolethey played in helping the trust to achieve its vision andfelt proud that they worked the trust values into theirdaily work.

• The wide strategy for the outpatients department wasfor all outpatient areas to be under a singlemanagement and single booking service The start ofthis strategy was to implement the outpatientmanagement and nursing structure. Once this had beenachieved, action plans would be developed with staff toachieve the strategy. The purpose was to make sure alloutpatient areas were providing a consistent qualityservice to all patients. The single booking service wouldmean that all appointments for patients would comefrom one department. This would reduce the chances ofa patient getting numerous letters for differentappointments on different days.


• We saw that within the outpatients and radiologydepartments, everyone was encouraged to be involvedin governance. Staff told us that it was all of theirresponsibility and not just managers. Issues would beraised and discussed at a local level at team ormulti-disciplinary team meetings. The minutes of thesemeetings would feed up to directorate meetings and thedivisional managers and then to the ‘three on three’meetings which contained senior managers andexecutives. Information was also cascaded downthrough this governance structure.

• At the time of our inspection the radiology departmentwas working towards achieving Imaging ServiceAccreditation Scheme (ISAS) accreditation. ISAS is apatient-focused assessment and accreditationprogramme. It is designed to help diagnostic imagingservices make sure that their patients consistentlyreceive high quality service, delivered by competentstaff working in safe environments. As the only nationalaccreditation scheme for diagnostic imaging, it showedthat the department wanted to make sure the services itprovided to patients were the best that they could be.

• Peer review meetings were held within radiologybecause staff recognised the need for shared learningfrom complaints and incidents. Cases were presentedand discussed at the meetings which was open to allradiologists and radiographers. The objective was toidentify the cases that had an effect on the patient’soutcomes and where possible put measures in place toimprove the patient experience.

• Radiologists participated in an online resource from theRoyal College of Radiologists. The ‘educational rescue toimprove safety’ allows consultants to submit totallyanonymised cases which all members of the collegehave access to. This allowed shared learning through alarge number of consultant colleagues across thecountry.

• Risk registers were in place. When the risks wereidentified, they were colour coded depending on therisk score. These ranged from blue, minimal risk to red,high risk. The risk score were reviewed following anyinitial action that had been taken. All the risks hadtimescales and actions against them. The majority ofthe risks on the risk register were current, however wedid see two long standing risks. Both risks had beenacknowledged they were long standing but werereviewed regularly. As an example one of the risksrelated to the lack of availability of medical notes atappointments. As a trust the incidents of notes notbeing available were very low however, this risk hadbeen present on the register since February 2003.

• Where risks were identified, we saw evidence that theappropriate actions were taken. As an example, gapshad been identified in the IR(ME)R procedures especiallyaround theatres. Once this had been identified the riskassessment was updated and actions identified. Weobserved the department was resolving these risks atthe time of our inspection.




• Radiology had a clinical governance lead that organiseda half day study day every two months for clinical staff.We were told a key focus was to make sure informationwas fed back to staff as much as possible in relation toincidents and complaints.

• We were told that a significant problem for bothoutpatients and radiology was the delays incurred bythe patient transport system. Whilst this was outside ofthe department control, staff were encouraged tocomplete incident forms as necessary. These incidentswere fed through and discussed at the transport projectmanagement group held monthly. Concerns werediscussed directly with the provider responsible forpatient transport so that improvements could be made.The outpatients manager told us that they had startedto see improvements in the service. This did not appearon the risk register that we were provided with by theTrust prior to our inspection but was added to the riskregister in October when initial attempts to resolve thetransport issues with the provider had failed.


• The majority of the staff we talked with in thedepartments spoke highly of their colleagues,immediate managers, directorate and trust managers.In outpatients, staff particularly felt their new managerwas very supportive and valued them as individuals.

• Staff told us that the chief executive was approachableand knew what was going on in their departments.


• The culture within the departments was focused on theneeds of their patients. The culture was open andhonest. One member of staff summed up the culturewhen they told us “we do what the patients want andneed, not what we as staff want.”

• Staff told us they felt valued and respected by theircolleagues and managers.

• Some staff were negative about the culture withinradiology, with it being described as a ‘them and us’culture. We were told that imaging directoratemanagement did not understand the specialty. Wespoke with a number of staff within radiology and themajority of staff did not share this same feeling on theculture.

Public engagement

• The friends and family test data for outpatients werevery positive. The departments overall got a lowresponse rate (8.3%) in patients completing thequestionnaires. But for those that did, in September2015, for outpatients overall, 96% of patients were eitherlikely or very likely to recommend the department toothers. A lot of the individual outpatient clinic areasscored 100% such as Urology, Oral surgery,Rheumatology and plastic surgery. The general medicaland surgical outpatient area was the only departmentthat scored less that 90% (88%).

• Comment boxes were in place across all the outpatientand radiology departments. Comments were reviewedand the themes displayed in the waiting areas togetherwith a ‘you said, we did’ board. This showed that thepatients views were listened to and acted upon whereappropriate. Explanations and reasons were givenwhere changes could not be made.

Staff engagement

• We saw evidence that the feedback given by patientswas fed back to staff within each department as well astrust wide. As an example of this, we saw emails fromthe trust informatics team to the rheumatologyoutpatients department. This detailed the feedback thedepartment had received the previous week. Staff wereable to see if patients would recommend thedepartment to others and any comments that thepatients had made. The majority of these commentswere overwhelmingly positive.

• The bookings team regularly involved the relevantconsultants in the state of their waiting lists. Thebooking staff felt this was important in gaining theirco-operation in bringing the waiting lists down.

• Staff we spoke with felt actively engaged in changes thataffected their departments. They told us they hadopportunities to give their views and felt listened to bytheir managers.

• Regular staff meetings were held across both imagingand outpatients departments. The minutes of thesemeetings showed a range of issues were able to bediscussed. Feedback was given from previous meetingsand from patient feedback.


• The urology team had established one stop clinics forpatients with kidney stones. The clinics ran twice amonth. Patients presenting with renal colic with their GP




or at the emergency department could be referred tothe clinic. At the initial outpatient appointment, anydiagnostic tests were completed. This had led to areduction in the waiting times for appointments andtreatment.

• To make x-ray services more accessible to patients, a GPwalk in service was established which proved popular

with both GPs and patients. Patients were very positivewith the accessibility and promptness of diagnosis. Thisservice was initially introduced in the satellite unit atWestminster Memorial hospital, Shaftesbury, followedby the main hospital and another satellite service inWestbury.





Effective Requires improvement –––


Responsive Inadequate –––



Information about the serviceThe Duke of Cornwall Spinal Treatment Centre specialisesin the total management of patients paralysed followingspinal cord injury or non-progressive spinal cord disease.This includes ongoing advice and support to meet thechanging needs of the patient.

The centre provides this service for the whole of theSouth and South West of England and serves apopulation of 11 million people. The Centre is situated atthe Salisbury District Hospital site. There are two wards inthe Spinal Treatment Centre, Avon and Tamar wards,each with 21 beds (although four were closed on Avonward at the time of inspection.

The service also provides an acute outreach service forpatients living with a spinal cord injury or disease.Diagnostic imaging is carried out by the ClinicalRadiology Department. However, staff from the SpinalTreatment Centre provide staffing.

During our inspection a team of inspectors, a pharmacyinspector, specialist advisors, and an expert byexperience observed practice and spoke with 32 staff,four volunteers, 20 patients and two carers and looked in15 medical records and ten care plans. We received onecomment card relating to the spinal treatment centre.

Summary of findingsOverall we rated the Duke of Cornwall Spinal TreatmentCentre to require improvement.

There was inadequate management of a videouro-dynamics and outpatient appointment backlogwith poor understanding from the trust as to thenumber of patients waiting on the lists or identificationof the risks posed to this group of patients.

There was a dichotomy between the experiences ofinpatients in the Spinal Treatment Centre. Somepatients were having positive experiences and were partof a community which included the staff. However,some patients who were not part of this group feltisolated, ignored and lonely. Some said they felt thedays were very long and they had nothing to do. Accessto therapies was limited due to staffing shortfalls forboth physiotherapy and occupational therapy and thiswas having an impact on patients rehabilitation.

Some patients told up of positive experiences of careand said that they were treated like friends to the staffalthough this was not universal. We saw good examplesof where group work was conducted to prepareinpatients for living with their injury after discharge. Theinclusion of charity workers in the group gave patientsinformation and knowledge based on experience. Therewas a robust MDT process in place to ensure that all


Spinal injuries centre


patients and their carers were included in their care.Goal planning meetings were used to track progress andthere was good relationships with organisations outsideof the hospital.

A requirements notice was issued around the accuraterecording of resuscitation equipment records to ensurethat equipment used was safe to do so. Records weremissing multiple times in the months prior to theinspection showing that this equipment was notchecked for safe use.

Are spinal injuries centre services safe?


We found spinal services to require improvement forsafety.

Staffing levels on a daily basis were inconsistent and reliefheavily on bank, agency and additional nursing assistantstaff to fill gaps, although they were inducted. Ventilatedpatients who required one to one care were not receivingthis increasing the risk of issues or complications goingunnoticed. However, when raised by CQC inspectors thiswas quickly rectified. Doctors were stretched andsometimes struggled to maintain their day to dayresponsibilities. Resuscitation trolleys and resuscitationcrash bags were regularly not checked in line with trustpolicy. Some areas in the spinal treatment centre wereunclean and dusty. Some staff were not following thetrusts infection control policy. The use of medicines werewell documented in patient charts. Incident reportingsystems and processes were robust and staff wereencouraged to report on a computerised incidentmanagement system. Duty of Candour was understoodby all staff we spoke with.

Incidents

• Openness and transparency was encouraged aroundsafety, and incidents had appropriate throughinvestigations with learning shared widely.

• Staff understood their responsibilities to raise concerns,to record safety incidents, concerns and near misses.The spinal treatment centre reported a total of 23incidents between the months of October 2014 andNovember 2015. All incidents were reported on andinvestigated using a computerised incidentmanagement system. Three of these were classified asserious incidents requiring investigation (incidentswhere patients, staff, visitors, or members of the publicexperience serious or permanent harm) which were allinvestigated appropriately. All three had detailedinvestigation reports dictated by terms of reference anda list of recommendations and actions.

• Staff we spoke with were aware of all three seriousincidents and could describe the learning from them.For example, one serious incident was concerning agrade four pressure ulcer acquired within the service.




This individual received care at the spinal treatmentcentre. However was considered non-compliant withthe use of pressure relieving equipment resulting in thepressure ulcer. Learning was taken from thisinvestigation and shared with the whole centre. Whenquestioned staff could identify the causes of theincident and describe how practice has changed as aresult.

• Nurses described the procedure for reporting incidentswhich involved letting the nurse in charge know, as wellas the doctor, in addition to reporting through thecomputer management system. Incidents wereinvestigated by the ward sister, who provided individualfeedback and areas for improvement. In addition to thislearning improvements resulting from incidents wereshared at weekly team meetings, and via email.However, some nurses we spoke with said that therewas disparity between the level of detail of feedbackreceived on both Avon and Tamar wards.

• The Duty of Candour is a regulation in the Health andSocial Care Act 2008 Regulations 2014 which describeswhat providers must do to make sure they are open andhonest with patients and their families when somethinggoes wrong with their care and treatment. All staff wespoke with were clear in both their understanding andpractical application of the Duty of Candour. The safetythermometer is a national prevalence audit whichallows the establishment of a baseline against whichimprovement can be monitored. There are four keymeasures as part of the safety thermometer whichincluded falls, pressure ulcers, venousthromboembolism and urinary tract infections inpatients with catheters. Managers stated that they didnot have oversight of the safety thermometer results asthis was managed by the central governance team in thetrust and could not tell me how the centre wasperforming and did not regularly receive copies of this.

• It is best practice for the safety thermometer to bedisplayed in ward areas to indicate to patients andmembers of the public on their performance. This wasnot displayed however the spinal treatment centre’s keyperformance indicators were. This information was insmall print and elevated to a high position on a noticeboard meaning it would be difficult for patients in awheelchair or with visual impairment to read.

Safety thermometer

• The safety thermometer is a national prevalence auditwhich allows the establishment of a baseline againstwhich improvement can be monitored. There are fourkey measures as part of the safety thermometer whichincluded falls, pressure ulcers, venousthromboembolism and urinary tract infections inpatients with catheters. Managers stated that they didnot have oversight of the safety thermometer results asthis was managed by the central governance team in thetrust and could not tell me how the centre wasperforming.

• It is best practice for the safety thermometer to bedisplayed in ward areas to indicate to patients andmembers of the public on their performance. This wasnot displayed however the spinal treatment centre’s keyperformance indicators were. This information was insmall print and elevated to a high position on a noticeboard meaning it would be difficult for patients in awheelchair or with visual impairment to read.


• We observed on Tamar ward that some equipment didnot look physically clean. We also observed that toiletson the ward were not clean and had rust on the fixings.In the pool area we saw suction equipment which wasvisibly dirty and dusty. This was raised with a seniormember of staff who said it was never used or would beused as no one is trained in its use.

• We saw on several occasions that staff were walkingaround the ward in gloves and aprons without changingthem between patients.

• Infection control audits for the four months prior to theinspection were generally good but could be improvedin some months. Data provided to us showed that inApril 2015 no doctors which were observed passed thehand hygiene audit and that in June 2015 no data wasprovided for either Avon or Tamar wards. The spinaltreatment centre outpatient department performedpoorly on the hand hygiene audit for the last fourmonths with some data missing and the averagecompliance for June 2015 being 26%. However, 100%compliance was obtained in July 2015. The impact ofthis was not seen in performance results of hospitalacquired infections as there were none in the six monthsprior to the inspection.





• Between both Avon and Tamar wards there was oneresuscitation trolley. Hospital policy states that thisshould be checked daily to ensure reliability and toallow for the replacement of essential equipment. Thisdaily check was missed nine times in October 2015 and11 times in November 2015. This was raised withmanagers during the inspection and an email was sentto all staff reiterating the importance of these checks.

• There were incomplete records for the weekly checkingof cardio-crash bags. The forms used did not allow fordates to be included therefore staff could not reassureinspectors as to when the last weekly check wascompleted.

• There were call bells in bed bays which were digital. Thismeant that patients could take their call bells anywherein the unit without loosing signal. Patients had access toa large dining room where there were tables, chairs andtelevisions. Staff had limited visibility of patients in thisarea.

Medicines

• Nursing staff we spoke with reported a good medicinessupply from the pharmacy department with dailydeliveries, even at weekends. We were informed thatpharmacy staff undertook weekly stock checking, topup, and date checking. Nursing staff undertook checksfor additional items such as fluids and patient specificitems. A clinical pharmacy service was available for onehour each weekday to manage concerns.

• In relation to medicines, we were given examples ofwhere incidents had occurred, for example, omitteddoses and changes in controlled drug storage. Thesewere reported appropriately and staff had a goodunderstanding of trends in these incidents.

• The treatment room was locked with access restrictedby swipe card; we were told that all Band 3 staff andabove have access to this room. However, medicineswithin this room were stored within locked cupboards,and we were told that only Band 5 nurses and abovehad keys to open these cupboards. We saw theseparation of storage of topical, oral and injectablemedicines, as well as segregation of patients ownmedicines.

• Within the treatment room were two locked medicinestrolleys. However, these were unorganised andcontained medicines for six patients which should havebeen in the patient’s own cabinets at their bedside. Thisincluded medicines for one patient who was no longer

on the ward. We additionally saw three bottles of liquidmedicines that were in use but had no date of openingon them, and three further medicines that were storedon an open shelf, under the trolley, instead of beinglocked away. Stock medicines, such as antibiotics, wereheld in the treatment room and we spot checked threeitems and found them to be appropriate and withindate.

• Nurses described that patients’ own medicines werestored in locked cabinets by their bedsides; these hadbeen in place for four months. We were told this systemworked well and reduced stock holding. During the timeof the inspection two patients on the ward werecurrently self-medicating.

• Medicines requiring refrigeration were kept in a lockedfridge. There was regular recording of fridgetemperatures which were within range. However, onlysingle, current readings were recorded withoutmaximum or minimum temperatures which areconsidered best practice. We spot checked three itemsstored in the fridge, and found them to be appropriateand within date. However, we also saw medicines for apatient no longer on the ward kept in the fridge.

• We observed storage of controlled drugs (CD) within themetal CD cupboard, which was locked with restrictedaccess. Nurses told us the CD cupboard was stockchecked once weekly by two nurses. We spot checkedthree items in the cupboard and found them to beappropriate and within date, with suitable recordingand quantities. We also saw the storage of emergencymedicines; we spot checked three items and foundthem to be appropriate and within date. We were toldthat these items were checked by pharmacy staff, butstaff were unable to show us a list of contents thatshould be included. There was an accessiblehypoglycaemia treatment box with suitable contents.

• In the corridor, there was a resuscitation trolley with acrash bag which was sealed. This included anappropriate oxygen cylinder, with additional cylinderskept in a decommissioned shower room which has beenallocated as a storage room.

• Although medicines risk assessments were presentthere were various inconsistencies in the recording ofmedicine management in all five of the records wechecked. In three of the five records we found thatweight was inconsistently recorded. We also found thatindication of doses for treatments were infrequent in allcase notes we reviewed.




Records

• Patients either admitted as an inpatient or as anoutpatient to The Spinal Treatment Centre had theirown set of spinal notes separate from the main hospitalnotes. These were kept for life by the service. We foundthat all records were stored securely in locked cabernetswhich could only be accessed by relevant staff. Therewas an office where all records were stored which waslocked securely.

• Records audits were completed on a monthly basis.Both Tamar and Avon wards performed well in theseaudits highlighting good compliance with recordcompleteness.

• We looked in fifteen care plans and sets of notes. Amajority of these were completed, legible and inchronological order. However, we found that someforms within them were not always completed in atimely way. Three of the ten records we looked in hadcommunication records not completed by nurses ortherapy staff. We found that some records were noteasily legible and the wording used within them unclear.Phrases such as “by the looks of it” were used makingtheir purpose unclear.

Safeguarding

• Systems, processes and practices were in place toprotect people from avoidable harm and these werecommunicated to staff.

• Mandatory training in safeguarding adults and childrenwere both above the trust target of 85% (adultssafeguarding training at 97% and children’ssafeguarding training at 96%). When questioned aboutit staff had a good understanding of safeguarding andtheir responsibilities within it.

• Staff in the outpatients department had received extratraining in the management of patients dealing withemotional distress after discharge and were trained inpicking up the signs and signals from the patient whichmay raise safeguarding concerns. The team had directlinks with the trust safeguarding team and localauthorities.

Mandatory training

• Compliance with the trusts target of 85% was variablefor mandatory training levels. The lowest levels oftraining were around hand hygiene with 69%compliance. For some areas there was missing data. For

example, in terms of mental capacity act training andresuscitation training there was data missing for eitherTamar or Avon wards bringing the averages ofcompliance down. Resuscitation training levels were atand 76%. Information governance training was at 94%compliance, infection control training was at 92%compliance, moving and handling was at 87%compliance, fire training was at 88% compliance.

• Student nurses were given a welcome pack whenattending the spinal treatment centre with a list ofmandatory training competencies which needed to bediscussed with qualified staff and achieved.


• We found that risk assessments were completedappropriately and when asked staff were able todemonstrate understanding and knowledge aroundthem. Record audits demonstrated that compliance wasgood with the number of observations recorded, thetimeliness of these observations and appropriateactions completed as a result of these observations.This showed that staff responded well to the changingrisks of patients.

• Staff we spoke with were clear of the process involvedwhen managing a deteriorating patient although itrarely happened in the Spinal Treatment Unit. Staff wereaware of who to contact when this did occur andreceived training in basic life support.

• Call bells and nursing responsibilities were dividedbetween nurses and nursing assistants in relation togeographical areas in the ward, meaning that they lookafter clusters of patients. However, nurses were alsoresponsible for ‘long stay’ patients in different parts ofthe ward meaning that when a call bell was used theycould be away from their main patient group for sometime. Two weeks prior to the inspection Avon and Tamarwards worked on different call bell response systems.Tamar ward had adopted Avon wards system to gaincontinuity between wards, improve call bell responsetimes and improve staff visibility to patients. Nursescommented that the system was difficult to get used toand complicated. We were told that although full timestaff had training in the use of the new system bank andagency staff had not. The change had been discussed atWard Team Meetings and all bank & agency staff areinformed about it in their recorded ‘ward orientation’.

• All patients had call bells and there were emergency callbells in every bay. Patients who were unable to use their




arms had head operated call bells to get the attention ofstaff. We observed one of the ventilated patient’s callbells went off. However, the staff nurse did not respond.When questioned as to the reason we were told “its ok,the physiotherapist will be in there giving treatment”.She could not confirm that this was happening and thepatient may not have been seen as quickly by a nurse asthey could have been.

• Pressure care was managed well in the spinal treatmentcentre. Avon ward had two grade two pressure ulcers(some of the outer surface of the skin (the epidermis) orthe deeper layer of skin (the dermis) is damaged,leading to skin loss) attributable to the service in the sixmonths prior to the inspection.

• Tamar ward had three grade two pressure ulcers andone grade four pressure ulcer (The skin is severelydamaged and the surrounding tissue begins to die(tissue necrosis) with the underlying muscles or bonehaving the potential to be damaged) in the last sixmonths.

• The spinal treatment centre had access to equipment toreduce the occurrence of pressure ulcers. Pressuremapping equipment and software were used to identifywith accuracy the exact pressure points on a patient’sskin and provide intervention to relieve these areas. Forpatients who spent long times in bed an automaticturning board could be used to ensure appropriateturning. Patients who would benefit from these wereable to continue to use them after discharge in acommunity or social care setting.

Nurse staffing

• As defined in the NHS standard contract for specialisedrehabilitation it stated that the centre should have,based on 42 beds, 63 whole time equivalent nurses, athird of which should have specialist rehabilitationtraining. The trusts establishment was comparable tothis. However, it was highlighted in the trusts mostrecent skill mix review that the number of registerednurses in post was below 50% of what it should be andcommented that this was supported by a larger thanestablishment cohort of band three nursing assistantswith specialist rehabilitation competencies and the useof bank and agency staff. For example in August 2015 onTamar Ward out of a total of 93 shifts, 27 of them hadstaffing levels for registered nurses between 80% and

60% with three of them having staffing levels ofregistered nurses below 60%. When this occurred moreband three staff were placed on shift or staff from otherwards were seconded to the ward.

• At the time of the inspection there were four bedsclosed to maintain a suitable staffing level for the openbeds. This reduced the risk of staff being stretched todeliver care to too many patients at once.

• During the inspection there were three patients whowere ventilated. These patients were high risk due totheir lack of physical ability to raise the alarm ifsomething went wrong and was identified on the trustrisk register that they required one to one nursing careat all times. We found that this was not happening andthat patients were left unattended and that they werenot in clear sight of the nurses station. We raised thiswith the trust who added an extra member of staff and atemporary nurses station (a computer on wheels)outside of the ventilated patient’s room to ensurevisibility. During an unannounced inspection we foundthat this was continuing and that patients remained tobe safe.

• The spinal treatment centre offered an outreach servicefor potential inpatients to meet with a nurse prior toadmission at their acute hospital. However, this servicewas not continued when staff were on leave due to lackof additional staff.

Medical staffing

• As defined in the NHS standard contract for specialisedrehabilitation it stated that the centre should have,based on 42 beds, 4.2 whole time equivalent spinal cordinjury consultants and 5.25 whole time equivalenttraining grade doctors. During the time of the inspectionthe Trust employed one Associate Specialist and twoConsultants, reducing the capacity and medical coverfor the centre. The centre was out to advert for one morejunior grade doctor and job plans were being producedfor consultant roles.

• We were told by doctors that over the last few years thespinal treatment centre had seen a change in itsdemographic to older patients with more complicatedco-morbidities such as diabetes, heart disease, renalfailure and other chronic conditions which resulted in agreater workload for staff which they struggled tomanage at times.

• Junior grade doctors provided general day to daymedical cover for the whole unit. One of the doctors was




a locum who has been working in the unit for the lastfour years and the other had only been in position forseveral weeks prior to the inspection. The longevity ofthe second junior doctor role was uncertain as theircontract was due to end several weeks after theinspection. One junior doctor commented that the roleof managing the spinal patients can be daunting andhad a heavy workload.

• Consultants felt there was too much reliance on juniormedical staff to perform duties such as taking bloods,rolling patients and moving beds. Although this wasdeemed essential for patient care having more nursingstaff would allow the doctors to perform the roles theyshould be doing.

• Due to staffing shortages when junior staff took annualleave consultants would be required to ‘act down’ tocover routine care having an impact on their outpatientcapacity and administration capacity.

Allied Health Professional Staffing

• As defined in the NHS standard contract for specialisedrehabilitation it stated that the centre should have,based on 42 beds, 11.5 whole time equivalent’sphysiotherapists 11.5 whole time equivalentoccupational therapists. At the time of the inspectionthe centre had six whole time equivalentphysiotherapists and 5.4 whole time equivalentoccupational therapists. Although not unsafe, this washaving an impact on the levels of physiotherapy andoccupational therapy services available to patients, thetimeliness of these appointments, and access toadditional facilities.


• The major incident plan was available in the spinaltreatment centre. Senior staff were aware of its locationand understood the centre’s roles and responsibilitiesduring a major incident. The impact a major incidentwould have on the spinal treatment centre would beminimal. However the nearest car park to the centrewould be used as a media point.

Are spinal injuries centre serviceseffective?


We found spinal services to require improvement for itseffectiveness.

Evidence based fundamental standards were agreednationally between all spinal treatment centres. However,compliance with these standards was inconsistent. Datacollection around patient outcomes was limited and wasnot used to assess and improve the service. There weremultiple training programmes and competencyprogrammes for all grades of staff, including students,bank and agency nurses, but at the time of theinspection there was no oversight as to who wascompetent at which task. Staff were asked to perform aself-assessment of their competence rather than having itmonitored and effectively evaluated. Since the inspectiona skills and competency database has been introduced.

There were positive examples of multidisciplinaryworking both within the spinal treatment centre and withorganisations outside of the hospital. We were givenexamples where challenges were managed well using amultidisciplinary team approach. Patient goals were anactive part of the rehabilitation process in the spinaltreatment centre with meetings including the patientsand their relatives. Although limited, patients had accessto access to a gym and swimming pool.


• Patients did not consistently have their needs assessedand their care planned and delivered in line withevidence-based, guidance, standards and best practice.The spinal treatment centre had worked with otherspinal services nationwide and the spinal cord injuryclinical reference group to define the FundamentalStandards for Adults Requiring Spinal Cord Injury Care,the document which all centres use as baselinestandards. The spinal treatment centre was compliantwith many of the fundamental standards. However, itwas not meeting criteria including: timely review ofpatients post discharge and the evaluation of patientoutcomes.




• The centres local and trust policies were easilyaccessible on the intranet. Staff we spoke with wereconfident about finding information quickly.

Pain relief

• Pain was well managed in the unit and patients whorequested analgesia received it quickly.

• Either upon referral from a member of staff or at thepatients request a referral could be made to the painmanagement team within the hospital to manage morecomplex pain relief requirements. This included theassessment and management of pain for patients lessable to communicate.


• All patients had their nutrition needs and hydrationneeds met. They were well documented in all patientrecords and in care plans we looked in.

• Although dieticians were not stationed directly in thespinal treatment centre, referral to them was actionedquickly.

Facilities and equipment

• The centre had a dedicated wheelchair workshop toensure that every patient got a bespoke wheelchairmade for them which could be changed and altered atany point during their recovery. This included batterypowered wheelchairs as well as standard wheelchairs.

• The spinal treatment centre had access to software andhardware to allow patients to control a computer usingeye movements. This allowed them to have use oflaptops and to aid communication and access facilitieswhich may otherwise have been unavailable to them.

• The centre had access to a hydro therapy spinal pool.The pool was approximately 15m long and the watertemperature was warmer than that of a swimming poolwhich helps with rehabilitation. The centre also hadaccess to a gym which was also available to patients forlimited times.

Patient outcomes

• Managers said that although personal outcomes wererecorded (such as length of stay, ranges of movement,hand outcomes and muscle chartings) they did not havean oversight of how effective the centre is as a whole ofproviding care and patient outcomes.

• The spinal treatment centre contributed to nationalspinal databases for data collection and analysis

purposes but has not contributed to this for a longperiod of time nor could they tell inspectors informationconcerning the results of these databases and actionstaken as a result.

• Outreach teams were able to attend geographicallydistant patients within five days of referral which waswithin national targets.

• A clinical audit programme was used within the spinaltreatment centre to assess the effectiveness of thetreatment they are giving which generally producedgood results, for example….. Some improvement wasrequired with the discharge summary audit which led tolearning and processes and protocols being changed.This was due to be re-audited shortly after theinspection.

Competent staff

• There was limited oversight of staff competence with norobust system to ensure competence of all staff. Wewere told that in order to gain oversight the managerswould be required to read through everyone’s personalfile to record competence. Staff were asked to fill in aself-assessment for competence in all tasks in the centreincluding specialist tasks such as spinal manualhandling. After the inspection a matrix approach tocompetency had been developed to assist in gainingoversight.”

• All new staff (between HCA and senior nurse level) weregiven a development and competency pack to completewith the aim of introducing them to specialist skillsrequired for spinal treatment and to develop their ownpersonal continual professional development. However,there was no indication in these packs that staff neededto read policies and standard operating proceduresaround the competencies they were getting.

• Agency staff attended a spinal cord programme whenthey were inducted and a register was kept of thiscompetence. Locum medical staff were well supportedduring their induction period by both consultants andnursing staff. Appropriate training was offered whichallowed them to perform their role effectively and safely.

• Student nurses were given a welcome pack whenattending the spinal treatment centre with a list ofcompetencies which needed to be discussed withqualified staff and achieved through practice.




• Staff we spoke with said they were supported inrevalidation and had their annual appraisals on time.They complimented the good quality of the appraisalsystem and said it had been improved since it changedearlier in the year.

• We were given conflicting information concerning thecompetencies of staff looking after ventilated patients.The critical care team were contacted for advice in anemergency situation concerning ventilated patient andall concerns went through respiratory physiotherapists.We saw a clear competency framework specifically forteaching all staff in the management of respiratorypatients.

• Through charitable funding the trust employed tworecreational co-ordinators. This team managed days outand activities for patients being treated at the spinaltreatment centre. It was not clear what formal trainingthese staff members had received to manage patients inthese environments. We were told that sometimes aHCA attended these events and if anything happened999 would need to be dialled. The recreationalco-ordinators had both received appropriateassessment to drive a patients' minibus. We wereinformed of the types of manual handling performedbut could not be told about training offered or given toallow them to do this safely.

• Outpatient staff delivered multiple study days to alllevels of staff including local staff, community staff andagency staff in topics such as bowel care and deliveringongoing care in the community.


• All necessary staff, including those in different teamsand services, were involved in assessing, planning anddelivering people’s care and treatment. Each patient atthe spinal treatment centre had a monthly meeting withtheir doctor, named nurse, physiotherapist,occupational therapist, and other key staff to discussdischarge and progress with their rehabilitation. Theprevious months goals were discussed and reflectedupon and the next month’s goals were set.

• Three patients’ we spoke with were positive about thegoal setting process. One patient commented that thesemeetings were good and allowed them to understandwhere they were in the rehabilitation process. At the

Goal Planning Meeting a record sheet was completed bystaff in conjunction with the patient, to reflect thediscussion and outcomes of the meeting, and this wasplaced in the patient’s records.

• All staff were actively involved in team working for thebest interest of the patients. Communication was goodbetween both clinical teams and non-clinical teams(such as housekeepers). It was clear from care plans andrecords that all teams within the unit workedcollaboratively rather than as separate specialities.

• There was a programme of clinical multidisciplinaryteam (MDT) meetings ranging from spinal surgery, toradiology and urology. Patients were also discussed inrelation to specific audits which highlighted concerns orissues. Each patient discussed had comments madeeither in their notes or dictated for letters with someMDT meetings having specific record sheets.

• Specific issues were discussed in MDT meetingsincluding delayed discharge of patients, and managingthe care of bariatric spinal patients with detaileddiscussion and knowledge sharing as to the challengesthese bring.

• Staff said there were good working relationships withboth GP’s and social services although commented thatthe geographical and various ways of working fromthese services can be challenging. Links had been set upwith the discharge co-ordinators to have named links inall services they cover to ensure smooth transition andtransfer of information. Patients were also given thenames and telephone numbers of social workers toallow them to call at any time.

• We were told of one example with a particularlychallenging patient was requiring discharge so socialservices met with them for a whole day to attendtherapy sessions, talk to staff, the patient and theircarers and relatives.

Rehabilitation, pathway and transition

• Patients were assessed for admission using nationallyagreed criteria. The weekly referral meeting wasattended by the patient, their family, Acute OutreachNurse Specialists, the Outreach Admin Assistant,Spinal Respiratory Specialists and the Spinal Centre’sConsultants. Additional information (previouslyrequested) from GPs and staff from otherspecialties was discussed to enable the team toeffectively assess the patient’s suitability for inpatientadmission.




• The centre had access to dedicated dischargeaccommodation where patients who were nearingdischarge were able to attempt living independentlywith the security of staff nearby. This flat contained twobedrooms, a bathroom, a lounge and a kitchen. Onepatient who was being discharged was due to spend aweekend in the flat with her husband to see how theycoped.

• Prior to discharge the outpatient team met with thepatients to introduce themselves and to discussongoing care after discharge and the process forattending as an outpatient. This ensured continuity incare after discharge.

• Quality dashboards indicated that the centre wasgenerally below but near to national average for itslength of stay targets. For two indicators the centreperformed poorly (non-clinical delayed discharged forventilated and non-ventilated patients). However, therewere justified reasons for these breaches in targets.Doctors we spoke with commented that managingdischarge can be difficult depending on thecomorbidities of patients and the level of ongoingrehabilitation they need provided by the communityteams post discharge. The trust tried to communicatewell with community hospitals to support patientsthrough a staged discharge home.

Seven-day services

• Out of hours medical cover was provided by the on-callmedical team at weekends. A spinal centre consultantwas on call 24 hours a day who could be contacted viathe trusts main switchboard. We saw evidence in patientnotes of medical care being provided at weekends in atimely way after request. One example was with aphysiotherapist who requested a medical examinationof a patient which was completed within two hours on aweekend.

• Access to therapies during the weekend was limited.One patient commented that there was limited accessto therapy staff at the weekend and that they did notalways have their therapies appointments due tostaffing shortages.


• The information needed to deliver effective care andtreatment available to relevant staff in a timely and

accessible way. Test results and diagnostic imagingresults were available when required and there wereminimal delays in receiving these. There wereprocesses in place to receive urgent results if required.

• Patients had appropriate checklists and forms filled inprior to discharge. These were completed by thedischarge co-ordinator. These forms were different fordischarge home or discharge to a community hospitalor adult social care setting.


• Consent, mental capacity act and deprivation of libertysafeguards was considered for every patient and wherethere were concerns these were generally acted upon.However, we saw one example in patient notes wherecapacity was questioned with no capacity assessmentto follow this up. We saw that any do not attemptresuscitation forms in place were discussed andupdated at handover.

Are spinal injuries centre services caring?

Good –––

The care in the spinal treatment service was rated asgood.

Staff provided compassionate care and respectedpatient’s privacy and dignity. There was a dichotomybetween patient experiences in the spinal treatmentcentre. Some Patients spoke about staff as if they werefriends rather than nurses. A patient got married in thecentre and had the full assistance and support from staffthat went above and beyond the call of duty to ensuretheir day was special. Through structured sessionsinpatients and their carers and relatives were fullysupported and involved in their care both in the spinaltreatment centre and on discharge. Sessions called ‘liveit’ enabled patients to discuss concerns and gaininvaluable information for living with a spinal cord injury.

Compassionate care

• Patients were treated with kindness, dignity, respect andcompassion while they received care and treatment. Wesaw multiple examples of compassion being deliveredby staff to both patients and their carers and relatives.




Patient’s privacy and dignity were respected withcurtains and doors shut appropriately. When they wereclosed staff asked permission of the patient before theyentered.

• One patient we spoke with described the staff as if theywere friends rather than nurses and gave us exampleswhere they had sat with the patient and had longconversations with them about something other thantreatment. Another patient commented when talkingabout the staff that “nothing was too much trouble”when caring for them.

• A patient got married in the spinal centre in the weeksprior to the inspection. The staff went with the patient’spartner to get food from a local supermarket and usedthe discharge accommodation kitchen to prepare it.One staff member, who owned a classic car, collectedthe bride on the wedding day from their house and tookthem to the centre. After the wedding the patient andhis wife were allowed to use the dischargeaccommodation that evening.

• Two patients commented on the caring and supportivenature of the staff at the spinal treatment centre. Onepatient said they were kind, considerate, and gavepatients their full attention when listening.

• Friends and family tests were available for all patients totake and completion was encouraged by staff in thecentre. Results were very good with 100% of patientswho responded recommending the service in the last sixmonths. However, it was unknown how many peopleresponded to the survey as data provided wasincomplete.

Understanding and involvement of patients andthose close to them

• An educational programme for patients called ‘live it’had been set up for inpatients to manage thepsychological wellbeing of patients after discharge.These sessions included looking after skin, bladder andbowel conditions as core topics as well as a range ofadditional topics including discussing sex,understanding pain and eating well.

• We observed a ‘solve it’ educational session where tenpatients and one relative attended to discuss how todeal with everyday situations outside the hospital. Inthis session were two staff from the centre and avolunteer from a charity who was an ex-patient of thespinal centre. This session was focused on managingrelationships and confidence after discharge. Patients

were discussing their anxieties and concerns as a groupand were having these addressed. Further support wasalso offered to the patients after this if they wished tohave it. The centre also developed a range of ‘discuss it’sessions to enable patients to discuss things which weregoing well or not so well in their rehabilitationprogramme.

• Six inpatients we spoke with commented positivelyabout the verbal information received from staff, inparticular the acute outreach team who encouragedpatients to ask questions on their care in the centre andforward after discharge.

• All doctors in the spinal treatment centre have an opendoor system which patients are informed about. Thisallows patients and relatives to come and talk withthem at any time.

• Outpatient appointments were 40 minutes longallowing ample time for patient and their carers andrelatives to discuss any concerns or worries. In theseappointments were various staff members to allow fordifferent inputs from different professional groups.

Emotional support

• We observed on multiple occasions staff giving goodemotional support to patients who were evidently indistress. During these occasions the patients had thecomplete attention of the nurse who remained with thepatient as long as necessary. Although this positiveexperience was not universal. One patient and relativewe spoke with raised concerns that communicationbetween the patient and staff was limited and felt thatstaff were avoiding talking to them. They felt that staffcome to see them daily without an introduction orexplaining why they are there. Another patient felt thatthey felt isolated from other patients.

• Patients who had infrequent visitors had regular visitsfrom the hospital volunteers. This was arranged by thevolunteer co-ordinator. One example was with onevolunteer who built a strong relationship with thepatient and supported and encouraged them duringtheir time at the centre. Three patients we spoke withappreciated the work done by the volunteer’s to ensurethat the patients had someone to talk too and engagewith.




• Three patients we spoke with found the chaplaincyservice helpful. One patient said that they can be calledanytime when required and another said that althoughthey were not religious just talking to them sometimeshelped with their mental wellbeing.

Are spinal injuries centre servicesresponsive?

Inadequate –––

We found the spinal service to be inadequate for itsresponsiveness.

People were frequently and consistently unable to accessservices including video uro-dynamics (VUD) andoutpatients in a timely way for diagnosis, follow up andtreatment and experienced unacceptable waits for theseservices. There were 467 patients waiting for VUD and1024 patients in a waiting list for an outpatientappointment with no clear understanding from the trustas to how the risks to these patients were assessed.

Patients who contacted the centre get their scans andappointments first regardless of risk. There was no clearstrategy to reduce these backlogs. Services were notplanned or delivered to fully meet patient’s needs.

There was a disparity between the experiences of somepatients. While some patients were making use ofgardens and away days to, for example football matches;there was a cohort of patients who felt lonely. One patientdescribed that the days felt very long as there wasnothing to do.

Patients and carers had access to a wide range ofinformation and materials both through various charitiesand the treatment centre. When complaints werereceived they were managed well. However, we saw thatthere was local resolution of complaints and concernswith no oversight from managers as to the themes ofthese.

Service planning and delivery to meet the needs ofpeople

• In addition to re-admissions from the existingoutpatient cohort requiring medical or surgicaltreatment, patients were admitted to the Spinal InjuryTreatment Centre from acute providers, with the

majority of these coming from the three major traumacentres in their catchment area (North Bristol NHS Trust,University Hospital Southampton, and DerrifordHospital). Between August 2014 and September 2015there were a total of 127 referrals.

• We found that during outpatient appointments therewas reliance for GP’s to arrange follow up examinationsand investigations for ongoing care and support. Thelevels of support differed between differentgeographical areas. However, it meant that patientscould have these appointments close to where theylived.

• We observed one outpatient appointments where thepatient had had a long journey where there was aconsultation but no other interventions such asdiagnostic imaging or blood tests. The patient was notoffered the choice of being offered a telephone orwebcam consultation for future reviews.

• When we asked a manager about dementia awarenessand management of patients living with dementia wewere informed that they do not accept this patientgroup as they cannot be rehabilitated effectively.

Access and flow

• People were frequently and consistently not able toaccess services in a timely way for an initial assessment,diagnosis or treatment and people experienceunacceptable waits for video uro-dynamics andoutpatient appointments.

• There was a significant backlog in the number ofpatients awaiting a diagnostic procedure called videouro-dynamics (VUD) although the trust did not know thescale of this backlog or who was at risk by not having it.This procedure showed, through the use of X-rays, whathappens in a patient’s urinary tract when it is filling andemptying. If a patient with a spinal cord injury hadsignificantly reduced function to their bladder or bowelthere is an increased risk of permanent damage andeventually raised blood pressure which could lead to astroke. Data provided by the trust showed that duringNovember 2015 there was a total of 467 patients on a listwho required a scan.

• Best practice stated that a VUD should be done within12 weeks of injury with follow up scans every threeyears. The longest waiting patient dated back to March2012.




• Managers in the spinal service told us that there were noactions in place to identify which patients were atgreater risk of harm as a result of not having the scanand required it more urgently or how long patients hadbeen waiting for their scan. This meant that thosepatients who required the scan most were not beingseen first. One member of staff told an inspector that it’sthe patient’s “who shout the loudest get seen first,rather than the ones who need it”.

• As a result of the delay in patients receiving videouro-dynamics a patient who was due to be discussed inan multidisciplinary team meeting had to be delayed byone week as the scan had not been done delaying theirtreatment and management of their spinal injury.

• During the inspection capacity allowed for 20appointments a month (provided there were nocancellations) with an average of 18 referrals per month.Action was being proposed to increase the capacityfrom two clinics (seeing five patients per week) to fourclincis (seeing 10 patients per week).

• The centres capacity did not allow for swift clearance ofthe backlog with only 51 patients being cleared eachyear (which would take 6.5 years to clear the backlog).Costing and forecasting exercises have been completedto establish the commitment needed to clear thebacklog. The most productive of these clearing thebacklog in only 8.8 months which includes extendingservices in the evenings and weekends however this wasperformed in February 2015 with little progress since.

• One consultant commented that they were underpressure from managers to increase clinic capacitywhich would not be appropriate for the current medicalstaffing levels due to the reduction in inpatientworkload. This concern was raised with seniormanagement although no clear action plan wasproduced or shared with staff.

• Similarly there was a significant backlog in the numberof patients awaiting outpatient appointments althoughthe trust did not know the scale of this backlog or whowas at risk by not having it. Data provided by the trustshowed that during November 2015 there was a total of1024 patients on a waiting list who required anoutpatient appointment. However, we were told bymanagement that there were patients who wererequiring appointments on the list multiple times as

well as patients who may not need a follow upappointment and the actual scale was unknown. Thisincreased the risk to patients who may have symptomsbut were not being seen.

• It was a recognised national spinal standard that allpatients discharged or referred for review by a spinalcord injury centre should receive appropriate life timefollow up and within no more than three year intervals.The risk register stated that there had been patientswaiting since 2010 for a follow up appointment.However managers challenged that the data wasincorrect and told us that until a scoping exercise hasbeen completed the length of waits would be unknown.

• Work had been done to minimise the number ofpatients who cancelled their appointments by callingthem prior to their appointment. The number ofpatients who did not attend their appointment was at7% in November 2015.


• Staff vacancies were having a negative impact on theresponsiveness of the service to meet patients’individual needs. One patient we spoke withcommented that the nurses struggle to get patientsready for rehabilitation in the mornings. We observedone patient who returned from the pool and was stillwet. It took ten minutes before a member of staff wasavailable to assist them in drying and changing.

• Reduced staffing numbers for physiotherapist andoccupational therapists were also having an impact bysignificantly reducing the time available for each patientto have access to physiotherapy and occupationaltherapy increasing their rehabilitation time. Whenspeaking to managers we were told that although theydo not record or monitor the impact of this reduction,patients were being discharged prior to having optimumamount of rehabilitation and were coming back tooutpatient appointments sooner.

• The average length of stay for patients in 2014 was 116days meaning that patients became veryknowledgeable about staffing levels and theircompetencies. Six patients commented that there was adifference in the ability between agency nurses and fulltime nurses in the centre. One patient commented thatthey felt more comfortable and confident in the nursesthey knew well and that agency nurses did not knowwhat they could do on their own without assistance. Apatient commented that there were a few staff which




understood them however some of the newer staff didnot which affected the patients confidence. The patientsaid that “they can set you backwards” and that “youhave to explain everything to them”. Three patients saidthat they had to tell agency staff which medicine theyneeded to take to prevent them from making mistakes.There were no incident reports to reflect near misseswith medicine errors.

• We spoke with two patients who had negativeexperiences when being admitted to the spinal centre.One patient felt that they had taken a ‘step back’ whenbeing admitted to the spinal treatment centre as theyhad been making progress with their rehabilitationwhile in an acute hospital and had been walking andbuilding their mobility. However, upon arrival to thecentre was placed on four weeks of recumbentrehabilitation bed rest setting them back. They felt thatall they had gained in the acute hospital was lost andwas “back to square one”. Another patient who wasadmitted spent one week on recumbent rehabilitationbed rest was not given any explanation as to why asthey had been sitting up and mobilising in their previoushospital. Although this is considered best practice thelack of communication left patients not understandingthe reasons why this was required.

• Patients had access to psychological services althoughsometimes this was limited. Patients were able to haveeither male or female psychologists who were availableduring the day. This service was available for carers andrelatives also. However, one patient we spoke with wasconcerned about access to psychological services andthe processes behind this. They said they filled in a formto get this service and was asked to fill in another formthree weeks later by a nurse. The patient told us thatthey had not heard anything and had “given up on it”.The psychology team had recognised that sometimesreferrals got lost and have tried to reduce thishappening but couldn’t provide inspectors with detailas to how this was being achieved.

• We spoke with three patients who felt that access tofacilities and therapy time was limited. Two patients wespoke with said they would have liked to get into thepool or the gym more and felt they should be availableto patients. However, this was limited due to staffingrestrictions.

• We spoke with four patients who felt that there wereoften no activities on for them although took part in theones that were available. A patient commented that the

days were very long when there was nothing to do. Onepatient we spoke with who was in a side room felt lonelyas they do not see anyone or get to know the otherpatients. Although, doctors and nurses did come andspeak with them several times a day. Another said thatunless their activities were scheduled (such asphysiotherapy and pool sessions) there was nothingelse to do and felt that they could be doing more”. Athird stated that socially they only talk to nursing staffand doctors and have limited time with other patients.

• Patients who did not like the food provided were givenvarious options. One patient we spoke with was givenspace in a freezer in order to buy his own microwavemeals ensuring the patient continued to eatappropriately.

• Through charitable funding the spinal treatment centreemployed two recreational co-ordinators to manageactivities for patients including: visits to the local racecourse; motorcycle events; and football matches. Theyalso organised birthday parties and leaving parties.However, they did acknowledge that some patients didnot engage.

• Patients had access to a purpose-built garden within thespinal centre called Horatio’s Garden. This gardenallowed patients (including those in a bed) toaccess outside space in what was abeautiful environment. A room with glass walls, calledthe garden room, had also been built to allow patientsto look out at the garden when it was cold or wet. It wasrun by a charity and staffed by volunteers, which meantat times it was not staffed and was thereforelocked. However, patients were given access codes forthe locks allowing access even when it wasn't staffed.

• We spoke with volunteers who worked in the gardenwho told us that they have regular garden workshops toteach patients how to manage a garden. Patients wespoke with and staff commented that access to a gardenwould not suit all patients.

• Patients and carers had access to a wide range ofrelevant information about spinal injuries and the spinalcentre. Available to patients and carers was aninformation booklet containing information about thehospitals facilities, additional facilities provided in thespinal centre, maps, details on staff groups and theiruniforms, and a glossary of terms and abbreviations.




Also available was a room dedicated to informationprovided by charities. This included informationbooklets, DVD’s, posters, and access to computers foronline materials.

• Translation services were easily accessible to all patientswho required it.

• Information booklets were prepared for patientscontaining in depth information about pressure ulcersand their management. This booklet described theimportance of good pressure management makingpatients more aware of the risks involved. These weregiven to all patients admitted to the spinal treatmentcentre and at outpatient appointments.


• When asked about the management of complaints wewere told that they receive very few and those whichthey do receive are managed by either a senior memberof staff from another area or by an investigating officerfrom outside of the unit. There was a complaints lead inthe centre.

• Both Tamar and Avon wards collected feedback frompatients. A total of 79 were comments received betweenMay and July 2015. Tamar ward accounted for 46% of allcomments and Avon 54%. 62% of all comments werenegative of which many related to the lack of food anddrink choices, or being served cold or small portions.There were 16 comments about treatment and care ofwhich 10 were positive. We were not informed of actionsas a result of these comments.

• Patients we spoke with were unsure how to make aformal complaint. There was limited informationavailable in the outpatient areas about making acomplaint.

Are spinal injuries centre serviceswell-led?


We rated well-led to require improvement.

Although there was a strategy document called a modelof care it left patients confused and staff felt that it was

not meaningful or reflected practice in the centre. Thestrategy for the service, to expand with a new building,was not underpinned by detailed or realistic objectivesreflecting the current health economy.

Although risks were identified through governancemeetings and recorded on risk registers serious risks suchas backlogs in video uro-dynamics, backlogs inoutpatients, and ventilated patients requiring one to onecare were identified but the pace at which improvementswere made was slow.

The trust had recognised that there were somechallenges for leadership within the spinal services andwas providing increased support through both themedical and nursing directors. Local leadership waspositive and staff felt there was an open and honestculture with positive examples of staff and publicengagement including input into improvement projectand the collection and analysis of staff and patient viewsand opinions once a project had been implemented toassess its impact on patient care.. The centre contributedto national and international innovation and researchand was regularly represented at conferences.


• In October 2015 the spinal treatment centre developeda model of care presenting the care pathways they weredelivering. This was developed in a format for patientsto understand. Managers highlighted this to us as theirstrategy for the service alongside their missionstatement and this was being implemented into theservice at the time of the inspection. However, somestaff said that patients were left confused by this. Onestaff member commented that the model of care andstrategy were not meaningful or supported what wasactually going on in the centre.

• Managers told us that the centre would soon be movingto tariff based commissioning through the specialistcommissioners of NHS England. Although they do notknow when this will be implemented no trajectoryplanning for financial stability at different tariff levels orgap analysis had been conducted or were beingplanned.

• Managers told us that the vision for the centre was tohave a new building to improve their services and toexpand capacity with a feasibility study being




conducted alongside a business case. When inspectorsasked about financing such a project managers saidthey would have to do a lot of self-funding for theproject.

• As well as this project there were ongoing projects toimprove the services they currently have. For example acapital bid had been developed to replace the pool.


• The governance structure was clear and managementstaff were clear on the cascade of information both upto the board and down to ward level. On a monthlybasis managers reported on their performance to themusco-skeletal governance meeting and individualsfrom the unit (for example the therapies lead) presentedtheir own performance reports. Actions from thesemeetings were disseminated to staff on the wardthrough weekly staff meetings. Where items appearedon the corporate risk register reports were required forthe board to analyse and action.

• Significant issues that threatened the delivery of safeand effective care were being identified through the useof a risk register. However adequate action to managethem was not always taken.

• Increased staff turnover and a need for recruitmentsince January 2013 appeared on the departmental riskregister and was rated as a 12 (major risk which willprobably occur). It was identified that ventilatedpatients required one to one nursing to ensure patientsafety. However, during our inspection this was nothappening increasing the risk of patient harm. Whenasked consultants were under the impression that theratio should have been 1:2 which was not represented inany guidance or on their risk register.

• Patient appointment backlog for video-urodynamicsappeared on the departmental risk register and wasrated as a 12 (major risk which will probably occur).Mitigating actions included booking patients inchronological order based on complexity. However, thiswas not happening effectively. Managers told us thatthey do not currently do this. Capacity of the centre,both inpatient and outpatient, appeared on thedepartmental risk register and rated as nine (moderaterisk which is possible to occur). Mitigating actionincluded booking patients into available clinics. Therewas no indication of forward planning on the riskregister to increase the number of clinics available.

However, a scoping exercise had been conducted tolook into how many additional appointments wererequired. Managers also told us that they were going tolook at ideas on how to streamline the capacity theycurrently have and increase capacity overall.

• We were told that there were plans in place to changethe consultants job plans to increase capacity for bothVUD’s and outpatient appointments. However, this hadbeen ongoing for the last two years with no change.

• Low levels of therapy staff appeared on thedepartmental risk register and currently rate as six(moderate risk but unlikely to occur). Mitigating actionsincluded the co-ordination of time and staff to minimisethe impact to patients. However, there were no forwardplans on the risk register to increase the staffing levels oftherapy staff to manage the problem.

• The centre had a team of people involved ingovernance. When we asked one key senior staffmember involved in this these processes how they fit inthe governance framework we were told their role wasto set meeting agendas and arrange clinical governancemeetings. We were told that audit information wentstraight from the ward managers to the centralgovernance team as “the wards know audit better thanme”.

• Managers told us that there were different managementstyles on Tamar and Avon wards which affected theirunderstanding of governance. For example we were toldthat staff on Avon ward were less engaged withgovernance because the clinical manager did notdiscuss this with staff regularly.

• Another example was with sharing good practice withmedicines management. Tamar ward have recently gota second medicine trolley as it was found having twowas proactive on Avon ward. However, Avon ward hadthe second trolley for two years prior to Tamar.


• Junior doctors felt they were well supported byconsultants and that any ideas or concerns were takenseriously, acted upon and were informed of changesbeing made. We were told that the consultants wellsupported by the deputy medical director.

• Managers said that there was a positive relationshipwith the senior management team in the trust and feltthat they were being well supported. One example wasthat the leadership team was identified to be weak in amock CQC inspection performed by the trust. Support




was provided by the director of nursing to improve this.However, one staff member commented that as a resultof bed closures they were challenged by the senior teamand the executive team to open them again eventhough it was unsafe to do so.

• We were also told that the chief executive regularly visitsthe centre and talks with all grades of staff. Staff wespoke with said that the executive team wereapproachable and would listen to what was said.

• Although there was instability in the leadership of one ofthe wards the local ward leadership was positive. OnAvon ward the ward manager was on annual leave.However, the nurse in charge clearly knew the servicewell and was supportive of their staff and the duty ofcare required. They demonstrated positive knowledgeof staffing and skill mix and recognised the need toinclude patients in their care and clearly led by exampleand valued the views of patients and relatives. They hada good knowledge of local audit and current issues andmanaged the staffing rota well.

• Staff nurses were offered leadership training and aworkbook to develop these skills on the ward. Thesewere knowledge and competency based and helpedcurrent and prospective leaders to develop the skillsnecessary for a leadership role.

• Tamar ward was being supported to improve andsustain good care during the temporary absence of theward leader. This included weekly meetings with thedirector of nursing and senior staff. An action plan wascreated alongside these meetings with clearidentification of responsibilities for changes and anaudit trail of progress.


• It was clear that the staff clinically worked as a cohesiveunit with the best interest of the patient at heart.Management were approachable and were visible onthe wards and in outpatient areas. Staff we spoke withwere overwhelmingly positive about working in the unitand were proud to be part of the spinal treatment team.

• Staff felt they were listened too and that concerns weremanaged where possible and that there was no worryfrom staff when either questioning managementsdecisions or suggesting improvements or ideas.

• Staff had received equality and diversity traininginforming all staff of their responsibilities for equalopportunities in the workplace. It was clear fromdiscussions with management that there was nodiscrimination in the workplace.

Public engagement

• The centre had close engagement with spinal injurycharities who sent volunteers on a regular basis whohave suffered from spinal injuries to speak with patientsand deliver educational sessions. We observed a ‘live it’session where an ex-patient from the service wasdiscussing relationships with friend and co-workers afterdischarge and the challenges associated with this.

• The centre had developed friends and familyinformation days where relatives and carers of patientsliving with spinal cord injury could learn more about theinjury, symptoms and side effects of treatments, caringskills, and inform them of where to look for moreinformation. During these sessions people were able toleave feedback with the nurses to improve the service.

• The centre had developed friends and family leafletsencouraging people to come to the department and askquestions. Every day there was a member of staffallocated to this activity and was available five days aweek.

Staff engagement

• There were weekly staff meetings which were welldocumented. We looked at a selection of these minutesand found the meetings were informative and used as aforum for discussion and debate for ideas and change.

• Staff had access to psychological services to managetheir own health and wellbeing. Staff we spoke withfound this was helpful as it gave them support whenmanaging difficult or stressful situations.

• Staff were regularly asked about ways in which theservice could be improved and were actively involved inthe development of these service improvement. Thisinformation was then released as a newsletter to informstaff of the changes. These changes included thedevelopment of a trust integrated website,improvements to documentation management, a staffphoto board, and an agency staff induction. During thetime of the inspection there were 22 improvementprojects with updates discussed.

• Staff feedback was taken when new systems were put inplace. These systems were then modified to reflect




concerns raised by staff. One example was with a newhandover sheet which was not being used effectively bystaff. The reasons for this were collected and data wasanalysed and changes were made based on thelearning.


• The spinal treatment centre was involved in variousresearch programmes locally, nationally andinternationally and regularly presented and hostedvarious spinal conferences and study days.

• The spinal treatment centre was developing a methodof spinal assessment to perform more assessments in asmaller amount of time. This was being used in practiceat the spinal unit and was presented at internationalconferences.

• The spinal treatment centre regularly attended nationalmeetings with other spinal centres to discuss learningand trends from other centres.




Outstanding practice

• The surgery wards had identified link roles for staff invaried and numerous relevant subjects. A nurse and ahealthcare assistant had been assigned together tothe link role.

• The surgery and musculo-skeletal directorates hadregular specialty meetings. A member of the care staffwho would not otherwise attend these meetingsjoined the meeting each time to provide a‘sense-check’. They listened to the content, decided ifit made sense and properly described the state of theirservice.

• There was an outstanding level of support from theconsultant surgeons to the junior and trainee doctorsand other staff including the student nurses.

• The maternity services strived to learn frominvestigations in order improve the care, treatmentand safety of patients. This was evident with therobust, rigorous and deep level of analysis andinvestigation applied when serious incidents occurred.For example, the reopening of a coroners case as aconsequence of the maternity service investigations.Further evidence of this was available in meetingminute records. In addition, a wide range of staffdemonstrated that learning from incidents was a goalwidely shared and understood.

• The Benson bereavement suite facilities, and sensitivecare provided to patients experiencing loss wereoutstanding. These services had been developed withthe full involvement of previous patients and theirpartners. The facilities were comfortable andextensive, enabling patients and their families’ privacyand sensitive personalised care and support.

• In the services for childrenand young people a mobileAPP was produced in conjunction with a regionalneonatal network to provide information and supportfor parents taking their babies home.

• Sarum Ward staff worked across the hospital workingwith a variety of teams to improve services for childrenand young people. Examples were of developing a DVDfor pre-operative patients, using child friendly surveysin other areas of the hospital, supporting any staff withexpertise on the needs of children and young people.

• Nurse led pathways were being used. In one example anurse led pathway was in place for early arthritis, this

pathway had been ratified by the Royal College ofNursing. The pathway was evidence based thatshowed the quicker patients were diagnosed witharthritis, the quicker treatment could be started andthe quicker patients could go into remission. Thisservice came top in a national audit for patients withearly arthritis. Staff had presented their service atnational an international conferences including theBristol Society of Rheumatology conference in 2015.

• We observed excellent professionalism from staff inoutpatients during an emergency situation. Staffattended to the patient that needed immediate helpand support. Staff also cared and supported the otherpatients who had witnessed the emergency. Patientswere moved away from the emergency into anotherdepartment and kept informed of what washappening and offered lots of reassurance. When theemergency was over, patients were shown back intothe waiting area with explanations on the subsequentdelay to the clinic.

• The outpatients departments monitored how oftenpatients were seen in clinics without their medicalrecords. From January to July 2015 123,548 sets ofpatients notes were needed for the various clinicappointments across the trust. Out of these, 115 setsof notes could not be located for the appointment.The department identified that this was because thenotes had been miss-filed, staff had not used the casenote tracking properly or the notes were off site foranother appointment. Overall, patients’ medical noteswere found for 99.91% of appointments, which was asmall increase from the previous two years. Thisshowed that there was an effective system in place formaking sure patients’ medical notes were available fortheir outpatient’s appointments. Where they were notavailable, a reason was identified to try and reduce thelikelihood of the issue happening again.

• In the spinal centre there were examples of care wherestaff went above and beyond the call of duty. Oneexample of this was where a patient got married in thespinal centre. Staff went with the patient’s partner to

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


collect and prepare food and on the wedding day waspicked up by a member of staff in their classic car. Thecouple were then allowed the use of the dischargeaccommodation after the wedding.

• The ‘live it’ and ‘discuss it’ sessions were fullyintegrated into the spinal treatment centre. Weobserved one session where patients and relatives

were given opportunities to discuss their concerns as apeer group as well as to professionals and ex-patients.It was clear that patients and their carers were beingsupported through a difficult time and were beingeducated on important topics preparing mentally andphysically them for discharge.

Areas for improvement

Action the hospital MUST take to improveAction the hospital MUST take to improve

• Review nurse staffing levels and skill mix in the areasdetailed below and take steps to ensure there areconsistently sufficient numbers of suitably qualifiedand experienced nurses to deliver safe, effective andresponsive care. This must include:▪ a review of the numbers of staff and competencies

required to care for children in the emergencydepartment,

▪ a review of the arrangements to deploy temporarynursing staff in the emergency department,

▪ a review of arrangements in the emergencydepartment to ensure that nursing staff receiveregular clinical supervision, education andprofessional development.

▪ a review nursing staff levels at night on Amesburyward, where the current establishment of one nursefor 16 patients, does not meet guidance and is notsafe. Other surgery wards with a ratio of one nurseto 12 patients at night must be reviewed. Pressureon staff on the day-surgery unit, when opened toaccommodate overnight patients, and still runningfull surgical lists, must be addressed.

▪ ensuring there are appropriate numbers of, andsuitably qualified staff for the number anddependency of the patients in the critical care unit.

▪ ensuring there are adequate numbers of suitablyqualified, competent and skilled nursing andmedical staff deployed in areas where children arecared for in line with national guidance.

▪ ensuring there are sufficient numbers of midwiferystaff to provide care and treatment to patients inline with national guidance. Health and Social CareAct 2008 (Regulated Activities) Regulations 2014(part 3) Regulation 18(1)

▪ ensuring one to one care is provided in establishedlabour in order to comply with national safetyguidance (RCOG, 2007)

• Ensure staff across the trust are up-to-date withmandatory training.

• Ensure that all staff have an annual appraisal and thatrecords are able to accurately evidence this.

• Complete its review of triage arrangements in theemergency department without delay and takeappropriate steps to ensure that all patients whoattend the emergency department are promptlyclinically assessed by a healthcare practitioner. Thismust include taking steps to improve the observationof patients waiting to be assessed so that seriouslyunwell, anxious or deteriorating patients are identifiedand seen promptly.

• Ensure staff effectively document care delivered in thepatient’s healthcare record at the time of theassessment or treatment in line with the hospital’spolicy and best practice. This must include effectivedocumentation with regard to intravenous cannulasand urethral catheters and the recording of patients’weight.

• Strengthen governance arrangements ED to ensurethat all risks to service delivery are outlined in theemergency department’s risk register, that there areclear management plans to mitigate risks, regularlyreview them and escalate them where appropriate.

• Ensure that all actions are implemented and reviewedto reduce patients being cared for in mixed sexaccommodation.

• Ensure that daily and weekly check of all resuscitationequipment are completed and documentedappropriately.

• Ensure there is a hospital policy governing the use andaudit of the World Health Organisation surgical safetychecklist. The audit of the checklist must be




conducted as soon as an appropriate period of timehas passed since its reintroduction. Results must bepresented to and regularly reviewed at clinicalgovernance.

• Ensure there is a sustainable resolution to the issue ofholes or damage in the drapes wrapping sterilesurgical instrument sets, and all sets are processedand available for re-use to avoid delays orcancellations to patient operations.

• Ensure patient charts are kept secure and confidentialat all times.

• Must ensure there is effective management of theconflict between meeting trust targets for performingsurgery and the impact this has on patients. Patientsmust not be discharged home from main theatresunless this cannot be avoided. Surgery must not beundertaken if there is clearly no safe pathway fordischarging the patient. Operations must take place inthe location where staff are best able to care for theirrecovery.

• Ensure staff consistently adhere to the trust infectioncontrol policy and procedures.

• Ensure that patients are discharged from the criticalcare unit in a timely manner and at an appropriatetime.

• Ensure the process for booking patients an electivebeds following surgery is improved and reduce thenumber of cancelled operations due to the lack ofavailability of a post operative critical care bed.

• Ensure that the governance arrangements for criticalcare operate effectively, specifically that identifiedissues of risk are logged and that risk are monitored,mitigated and escalated or removed as appropriate.

• Ensure that care and treatment is provided in a safeway relating to the numbers of spinal patients waitingfor video uro-dynamics and outpatient appointmentsand reducing the risk of harm to these patients.

• Ensure that risks associated with the spinal service aremanaged appropriately with the pace of actionsgreatly improved. In particular, to the management ofthe numbers of patients waiting for videouro-dynamics and outpatient appointments.

• Ensure care and treatment are delivered in a way toensure that all patients have their needs met whichreflects their preferences. This includes the training ofagency staff, the availability of physiotherapy andoccupational therapy sessions, and the availability ofsuitable activities for patients.

Action the hospital SHOULD take to improve

• Continue to work with third party providers to ensurethat patients with mental health problems (adults,children and young people) who attend theemergency department out of hours do not experiencelong delays to be assessed by a mental healthpractitioner.

• Take steps to ensure that patients in vulnerablecircumstances, such as patients living with dementia,are appropriately supported in the emergencydepartment and the short stay emergency unit.

• Ensure staff receive sufficient training in the MentalCapacity Act in line with the trust’s targets so they areup to date with the relevant guidance.

• Ensure all staff implement policy and procedures inrelation to the isolation of patients with knowninfections and ensure staff are not isolating patientswho no longer require isolation

• Ensure all paper based care plans and records arelegible copies.

• Ensure urgent or unplanned medical patients are seenand assessed by a consultant within 14 hours ofadmission.

• Ensure patient flow within the hospital is managedappropriately so that patients are moved a minimalnumber of times during their stay. Ward staff and bedmanagement teams should work effectively to ensurethe need to move patients at night is minimised, in linewith the trust’s policy.

• Ensure that medical patients are cared for on wards tobest meet their medical speciality needs.

• Ensure patient records within surgery are clear to otherclinicians if there has been any issues they should beaware of, such as the risks of a retained swab, forexample.

• Ensure there is a professional standard of reporting formortality and morbidity reviews with actions beingdecided, recorded, monitored and improvementsrecognised. All high-risk deaths or those recognised ashaving less than optimum care or treatment should bereviewed.

• Recognise Duty of Candour within root-cause analysisreports following any serious incidents.

• Ensure there is sustained improvement inhand-washing audits for the medical staff withinsurgical services.




• Ensure all used surgical instruments are safelyremoved from operating theatres to prevent and risksfrom cross-contamination.

• The trust should ensure all policies are reviewed toensure they do not discriminate.

• Ensure the results of the consent audit are addressedas some areas within surgical services criticised in2014 had not improved in 2015.

• Ensure there is improved communication andexperience for patients who are delayed for theiroperation. Staff should ensure patients are not fastedinappropriately, and are given updates of theirprogress towards surgery as often as possible.

• The trust should improve access throughout thehospital to Wi-Fi.

• Should develop an approved strategy for the surgeryand musculo-skeletal directorate for the futureprovision of services, which should cover the visionand plans for a reasonable period into the future.

• Ensure there is consistency in reporting ofdepartmental clinical governance meetings within thesurgery directorates and all audits and reports arereviewed somewhere relevant within the governanceprocess.

• Ensure the acknowledgement and the documentationof risk and acting upon it in emergency laparotomyprocedures is significantly improved after it has beenidentified as poor for over a year. An integrated carepathway should be created for emergency laparotomyprocedures.

• Ensure that equipment such as commodes arecleaned after use.

• Ensure that patients cutlery and crockery aredecontaminated separately from staff items.

• Ensure that hand sanitising and personal protectiveequipment rules are consistently followed on the unit.

• Ensure that all patients with allergies are identifiedappropriately.

• Ensure that corridors emergency exits are always freefrom clutter.

• Ensure that health care records are maintained andcompleted contemporaneously.

• Maintain version control for documents used inhealthcare records.

• Ensure that there is a dedicated pharmacist solely forRadnor Ward meeting the core standards for criticalcare services.

• Consider auditing the use of the newly introduced minichecklists in critical care designed to improve thedocumentation if ward rounds in the medical notes.

• Review the sustainability of the consultant rota incritical care unit in light of the unit becoming busier.

• Ensure that all policies and procedures in use are indate.

• Ensure that patients within critical care are regularlyassessed regarding pain and document pain scores.

• Ensure that patients who are ventilated or sedatedhave their personal care needs attended to at anappropriate time.

• Ensure that there are systems in place to reassess staffcompetence in the administration of intravenousfluids and medicines in line with NICE guidelinesCG174.

• Ensure that equipment training for medical staff isrecorded.

• The trust should ensure that a minimum of six weekssupernumerary time is provided for newly qualifiedstaff joining the team in line with the Intensive CareCore Standards.

• Ensure that the communication record is completedfor all patients in the critical care unit and whereappropriate relatives communicated with in a timelymanner.

• Should ensure all medicines are dispensed and storedsafely and in accordance with national and localguidelines.

• Should evidence, using a representative sample,compliance with, the World Health Organisation(WHO) adapted surgical safety checklist for obstetrictheatres.

• Should ensure the gynaecology mortality andmorbidity meeting minutes record attendees andcontain sufficient detail to evaluate how discussionshave led to learning or other actions.

• Should be aware of the processes regarding themaintenance of equipment in the maternity service.

• Should ensure all equipment used in the maternityservice has in date maintenance and service checks.

• Should review the number of computer on wheelsrequired for effective use within the delivery suite.

• Should ensure when clinical rooms are in use, thatpatient privacy is maximised and interruptionsminimised within the maternity services.




• Should provide assurance that all midwivesredeployed during busy periods have the necessaryskills and competencies to work in alternative clinicalenvironments.

• Should maximise opportunities within the maternityservices for multidisciplinary team working for thebenefit of patient care.

• Should consider and follow all aspects of thematernity escalation policy when there are insufficientmidwives.

• Should have defined future succession planning withinthe maternity and gynaecology services.

• Should have access to departmental quality,governance and improvement information, which canbe promptly accessed by all senior maternity staff.

• Should consider how a deteriorating patient’s needsare recognised, escalated and documented within thechildren's and young people’s service .

• Should ensure levels of safeguarding training andknowledge for medical staff is in line with nationalguidance within the children's and young people’sservice.

• Should consider the environment in which children arecared for and their exposure to adult behaviours.

• Should consider embedding the use of a staffingacuity tool within the children's and young people’sservice to monitor changes in staffing requirementsthroughout.

• Should ensure protocols are clear for staff andaccurately followed so that equipment is checked asbeing clean and ready for use within the children's andyoung people’s service.

• Review the arrangements for mortuary viewings atweekends and ensure clarity around staffunderstanding of the procedures in place.

• Ensure a trust wide policy and strategy for end of lifecare is developed.

• Have measures in place to make sure all outpatientareas achieve 100% in their hand hygiene audits.

• Review the haematology outpatients area to ensurepatients are as comfortable as possible whilst waitingfor their appointment, rather than standing in thecorridors.

• Review and revise the current system in outpatients forauditing outside prescription forms to make sure it isfit for purpose and a clear audit trail of prescriptionforms was available.

• Ensure that it has systems and processes in place tomeet the national waiting time targets including thetwo week cancer targets.

• Maintain one to one support and care for ventilatedpatients in the Spinal Treatment Centre by suitablestaff to continually provide safe care for this high riskpatient group.

• Alliterate the importance of call bells to all staffworking in the Spinal Treatment Centre and that theirroles and responsibilities to answer these calls areunderstood by all.

• Improve the practices of staff and processes tomaintain a clean environment to reduce the risk of andspread of infections.

• Improve how it collects patient outcomes in the spinalservices and use the data in a meaningful way to gainoversight of the effectiveness of care provided and toimprove the service.

• Improve how it manages competence of staff withinthe spinal services and assures itself that oversight ofstaff competence is obtained.




Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Diagnostic and screening procedures

Surgical procedures

Treatment of disease, disorder or injury

Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

(1)The provider had not taken appropriate steps toensure that the care and treatment of service users

(a)appropriate

(b) met their needs

(3) (a) the provider had not carried out, collaborativelywith the relevant person an assessment of the needs andpreferences for the care and treatment of the serviceuser.

Emergency services

Patients did not always receive an initial clinicalassessment by a healthcare practitioner within 15minutes of arrival in ED. Guidance issued by the Collegeof Emergency Medicine (Triage Position Statement, April2011) states that a rapid assessment should be made toidentify or rule out life/limb threatening conditions toensure patient safety. In addition observation of patientswaiting to be assessed was not adequate which reducedthe opportunity to identify seriously unwell, anxious ordeteriorating patients and ensure they were seenpromptly.

Surgery

The trust was not effectively managing the conflictbetween meeting surgery targets and providing patientswith a service that safely met their needs and gave thema good quality experience. (9(b))

Critical care

Patients in Radnor Ward were not discharged in a timelyway from the unit onto wards when they were ready toleave or at an appropriate time. Five patients (betweenApril and June 2015) had been moved after 22.00hours.

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


The process the process for booking patients an electivebeds following surgery did not consider the limit as tohow many beds could be booked each day. In the threemonths to March 2015 11 elective cases were cancelleddue to a lack of available post operative critical carebeds.

The two corner bed spaces were restrictive. These didnot provide:

• an unobstructed circulation space at the foot of eachbed space to maintain the required bed separation forinfection control reasons and aid positioning ofequipment

• space to allow staff to manoeuvre the patient,themselves and equipment safely due to the closeproximity of neighbouring bed spaces

• space to allow five members of staff to attend to thepatient in an emergency situation

• space to accommodate the specialised beds thatwere used for the other critical care patients.

A consultant explained that the two bed spaces inquestion were adequate, especially for level one and twopatients. However, during the inspection an intensivecare (level three) patient was admitted into one of thebed spaces. A risk register was developed for therefurbishment. Insufficient space to meet current bedspace recommendations was included and stated that 12beds could be used during periods of escalation if riskassessments were undertaken to reduce risks topatients. However the issue of risk assessments was notincluded in the draft operational policy; neither wasthere a documented risk assessment for a patient caredfor in one of these beds during the inspection.

Regulated activity

Treatment of disease, disorder or injury Regulation 10 HSCA (RA) Regulations 2014 Dignity andrespect

10(2)

The provider must ensure the privacy of the service user.

Regulation




Compliance was not consistently achieved for single sexaccommodation.

Regulated activity


Surgical procedures


Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

12(1) Care and treatment must be provided in a safe wayfor service users.

12(2) Without limiting paragraph (1), the things which aregistered person must do to comply with thatparagraph include:

(f) where equipment or medicines are supplied by theservice provider, ensuring that that there are sufficientquantities of these to ensure the safety of service usersand to meet their needs.

Surgical services

There had not been a sustained resolution for theincidence of damage to or holes in the sterile surgicalinstrument packs so they were rendered unusable. Notall instrument packs were available when they wereneeded.

Care and treatment was not consistently provided in asafe way for patients.

12(h) assessing the risks of and preventing, detectingand controlling the spread of, infections including thosethat are healthcare associated

Staff on Radnor ward were not consistently adhering tothe trust infection control policy and procedures:

• Commodes when found to be dirty and there was nostandard cleaning procedure in pace for these on theunit

Regulation




• There was not a hand basin for every bed space asrecommended by Health Building Note 04-02 and thiswas not documented on the risk register.

• Staff were not consistently using personal protectiveclothing such as gloves and aprons appropriately, forexample, not removing and replacing these whenrequired, or not using them at all when required.

Patients and staff crockery were being washed together.There was dishwasher in place but it had not beenplumbed in due to water pressure problems.

Trust wide

Regulation 12 (2) (e) care and treatment must beprovided in a safe way for service users and withoutlimiting paragraph one the things which a registeredperson must do to comply with that paragraph include –ensuring that the equipment used by the serviceprovider for providing care or treatment to a service usedis safe for such use and used in a safe way.

The provider must make sure that equipment is suitablefor its purpose, properly maintained and used correctlyand safely. We found that resuscitation equipment wasnot being checked appropriately or within nationalguidance.

Regulated activity

Treatment of disease, disorder or injury Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

17(1) Systems or processes must be established andoperated effectively to ensure compliance with therequirements in this Part.

17(2) Such systems or processes must enable theregistered person, in particular, to:

Regulation




(a) assess, monitor and improve the quality and safety ofthe services provided in the carrying on of the regulatedactivity (including the quality and experience of serviceusers in receiving those services); and

(b) assess, monitor and mitigate the risks relating to thehealth, safety and welfare of services users and otherswho may be at risk which arise from the carrying on ofthe regulated activity, and

(c) maintain securely an accurate, complete andcontemporaneous record in respect of each service user,including a record of the care and treatment provided tothe service user and of decisions taken in relation to thecare and treatment provided.

The emergency service risk register did notsystematically capture the range or severity of knownrisks to safety and quality.

Within the emergency department there was a lack ofassurance that identified risks were regularly reviewed orappropriately escalated within the organisation.

The surgery services did not have a policy or any auditdata yet produced following the recent reintroduction ofthe surgical safety checklist. The safety of the checklistwas not considered by the theatre management clinicalgovernance.

There were potential breaches of patient confidentialityin surgery services from patients’ charts on wards notbeing held securely at all times.

In the medical wards there was ineffectivedocumentation with regard to intravenous cannulas andurethral catheters and the recording of patients’ weight.




Some charts were illegible.

Trust wide

The governance arrangements across the trust were notconsistently operating effectively. Not all identified riskswere entered onto the risk register therefore they werenot appropriately assessed, monitored and action takento remove or mitigate the risk.

Risks that were on the risk register were not allreassessed and monitored, with some past their reviewdate.

Regulated activity



Regulation 18 HSCA (RA) Regulations 2014 Staffing

18(1) Sufficient numbers of suitably qualified,competent, skilled and experienced persons must bedeployed in order to meet the requirements of this Part.

18(2) Persons employed by the service provider in theprovision of a regulated activity must –

(a) receive such appropriate support, training,professional development, supervision and appraisal asis necessary to enable them to carry out the duties theyare employed to perform.

There were not always sufficient numbers of suitablyqualified, skilled and experienced nursing staff in theemergency department.

There were insufficient numbers of staff employed in theemergency department who had received appropriatetraining to equip them to care for children.

Regulation




Compliance with mandatory training in the emergencydepartment was well below the trust’s target rate of85%.

There was a lack of assurance that nursing staff in theemergency department had sufficient opportunities forclinical supervision, education or professionaldevelopment.

Arrangements for the deployment of temporary staff inthe emergency department were not sufficiently robustto ensure that these staff were suitably skilled orexperienced.

Nursing staffing levels in surgery services had not beenadequately reviewed and, although were improving,were not yet established to safe levels. There were someareas where staff anxiety and stress were high due tofeeling unable to carry out their duties to a highstandard.

Staff employed in surgery services had not met trusttargets for updating mandatory training. Non-medicalstaff in surgery services had not met the trust targets forbeing provided with an annual performance appraisal.

Occasionally due to staffing shortages, the unit did notmaintain safe nurse staffing levels in accordance with theNHS Joint Standards Committee (2013) Core Standardsfor Intensive Care. The details of these occasions werenot documented. However, the electronic reportingsystem was used to highlight shifts that were shortstaffed. There were16 flagged short staffed shiftsbetween August 2015 and November 2015.

There were not sufficient numbers of midwifery staff toprovide care and treatment to patients in line withnational guidance.




There was a lack of assurance that there was sufficientstaff in maternity services to provide one to one care inestablished labour 100% of the time. This was requiredto be compliant with national safety guidance (RoyalCollege of Obstetricians and Gynaecologists, 2007)

There were not enough Registered Nurses (child branch)available to meet the changing dependency needs ofpatients in the children’s services at all times.

There were not enough junior doctors in the children’sservices to cover the needs of all areas caring for childrenat evenings and at weekends, according to the BritishAssociation of Perinatal Medicine guidelines.

Trust wide

Staff were not receiving annual appraisals and thedocumentation to support the number of staff who hadwas poor.

Staff were not all up to date with mandatory training.




Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity



Section 29A HSCA Warning notice: quality of health care

Care and treatment are not being provided in a safe wayfor service users.

Systems or processes have not been established and arenot operating effectively to:

a) assess, monitor and improve the quality and safety ofthe spinal services provided;

b) assess, monitor and mitigate the risks relating to thehealth, safety and welfare of spinal service users.

Patients in spinal services were frequently andconsistently unable to access services including videoruro-dynamics and outpatients in a timely way fordiagnosis, follow up and treatment and experiencesunacceptable waits for these services. There were 467patients on a waiting list for video uro-dynamics and1,024 patients on a waiting list for an outpatientappointment with no clear understanding from the trustas to how the risks to these were assessed. There wereno clear and detailed actions with timescales to reducethese lists.

Effective measures to reduce or remove the risks relatingto the wait for video uro-dynamics had not beenintroduced. In addition there was a lack of processes tominimise the likelihood of risks and the risks of anyimpact on patients.

Regulation


Enforcement actionsEnforcementactions


Salisbury District Hospital NewApproachFocused Report ... · LetterfromtheChiefInspectorofHospitals...

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