Salisbury District Hospital

Updated 8 December 2021

Our rating of services improved. We rated it them as good because:

• Staff treated people with the kindness, dignity and respect. Individualised, person centred care was delivered by a workforce who recognised and valued their responsibilities towards people using the hospital.
• There was a strong culture of doing what was right for patients, for keeping them safe and involving them in decisions which affected their treatment and care. Patients and relatives spoke highly of staff and the standards and quality of care. They were informed of investigations and treatment plans, and how these would affect them.
• Services were planned and arranged to meet the general and specific needs of local people. Staff carried out a range of risk assessments and safely managed these in line with national and professional guidance. The trusts safeguarding arrangements assisted in keeping vulnerable people safe and protected them from avoidable harm.
• The systems and processes available to support staff in their clinical practices were well organised and structured. Professional guidance was easily accessible and used to inform decision making around patient needs.
• The arrangements for reporting, investigating and learning from incidents was supported by a positive culture of improving patient care.
• The hospital environment was generally visibly clean. Most staff followed infection prevention and control procedures and routine standards of cleanliness and hygiene were maintained.
• Leaders had the skills, knowledge, experience to oversee services. We found improvements had been made in the leadership of the accident and emergency department and critical care services since the last inspection.
• Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff were encouraged and supported to access training and development opportunities.
• Departments planned and reviewed staffing levels and skill mix so people received safe care and treatment.
• The trusts vision and values were understood by staff. Local service objectives had been developed and staff committed to achieving these.
• There were effective governance arrangements within departments and information was communicated upwards through various committees to the board. Information was shared with staff in an open and transparent manner, which helped staff to feel valued and respected.

Updated 7 April 2016

We rated medical services as good overall. Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them. Learning from incidents was evident and care and treatment within the hospital protected patients from avoidable harm.. Medical cover, nursing levels and skill mix were appropriate to the needs of the patients on the eight medical wards we visited, which included the acute medical assessment unit, the endoscopy suite and the cardiac catheter laboratories.

We did however identify a breach in regulation in relation to record keeping, and specifically to the documentation of cannulas, catheters and patients’ weight.

Care was effective and was delivered in accordance with evidenced-based guidelines and current best practice. Staff managed patients’ pain well and feedback from patients reflected this. The trust ensured staff were adequately trained and competent to carry out their role.

Staff provided compassionate care and patients were treated with kindness, dignity and respect. Patients spoke positively about their experience of being cared for at Salisbury hospital. They felt included in their care and were kept informed about their care and treatment throughout their stay.

The provider planned services and coordinated care well for patients living with dementia. The layout and appearance of wards provided a suitable environment for these patients. Patients accessed care and treatment in a timely way.

Services were not always responsive to patients’ needs and required improvement. The provider could not always assure adequate patient flow within the hospital. This meant that mixed-sex accommodation breaches frequently occurred and patients were moved during their stay, sometimes late at night. The hospital could not always provide a bed for care and treatment of medical patients on a medical ward. These patients were called medical outliers and were admitted to surgical wards. However, staff and patients were always aware of which doctors were providing specialist medical care and treatment to them and nursing staff were competent to deliver their care.

The medical services were well led. Staff were aware of the hospital’s vision and values spoke of the family atmosphere of working in the hospital. The leadership, governance and culture promoted the delivery of high quality care. There was a clear set of values driven by quality and safety and staff were familiar with these. The trust engaged its patients and visitors regularly to obtain feedback in order to improve the patients’ experience in the hospital. Staff spoke highly of their managers and felt their views and concerns were listened to and acted upon. The staff survey showed staff recommended the hospital as a place to work.

Updated 7 April 2016

Overall we found the services for children and young people to require improvement.

Staff were clear they wanted to provide the best care they could for children and young people but there was no clear vision for how the service wanted to be performing in the coming years.

Staffing levels for both medical and nursing staff did not meet the nationally recommended guidelines for the acuity of children cared for in the hospital. Risks to patient safety regarding nurse staffing levels had been raised as a concern but no permanent arrangement had been put into place to maintain safe staffing levels. High dependency patients were nursed on the ward but there was no funding available for the extra nursing staff needed to care for these patients.

Safeguarding training did not meet national guidelines at the time of our visit but we were shown a plan was in place to provide this training and a timeline for meeting the guidelines.

There were times when children and young people were cared for in areas used for adults such as some outpatient appointments, main theatre and day surgery unit. Some provision had been made to protect children from adults in these shared areas. We found the screens to protect a child were not always used.

Learning from examples of past practice was encouraged and medical staff felt well supported by their senior colleagues. Staff were able to access training that would add to their skills and the majority of nurses in the neonatal unit were trained in their specialty. Children and young people’s needs were cared for and responded to by competent staff. Policies and protocols were based on national guidelines ensuring that best practise was observed. Audit programmes were contributed to both internally and nationally to demonstrate how well the department performed against other trusts.

All staff worked flexibly to support the needs of children, young people and their families. Staff worked together and shared information appropriately with community staff to ensure the safety and wellbeing of children who were being discharged home.

Staff were compassionate in their treatment of patients and their families and privacy and dignity was respected at all times. Children and young people’s views were listened to and their consent was always sought in a way they could understand. Facilities were provided and used flexibly for parents to spend time with their children and at times included the accommodation for the patient’s whole family.

Staff had developed methods of gaining feedback from children of all ages and had made changes to facilities in response. Patient and parent feedback we saw was positive with comments including “unconditional support and care”, “cheerful, even at the end of a long shift” and “patience and honesty”.

Staff from the children’s unit were supporting those areas where adults were also nursed with projects designed to improve a child or young person’s experience when they visited that area.

Updated 1 March 2019

Our rating of this service improved. We rated it as outstanding because:

• During the 12 months preceding our inspection, the critical care team cared for five patients admitted to the unit via the emergency department with a condition later diagnosed as nerve agent poisoning. These admissions were categorised as major incidents, lasting 5 months in total. The team’s response to these major incidents was outstanding in terms of their commitment to provide effective care, their collaborative working and their focus on the safety and well-being of all staff and patients on the unit during this time. There was no precedent for treatment of nerve agent poisoning. Four of the five patients survived.
• There were comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training now exceeded the trust target. The team had improved practices around infection prevention and control. There were now more effective systems for cleaning equipment and staff now used personal protective equipment consistently. Staff consistently checked safety equipment and recorded they had done so. All staff proactively anticipated and managed patient risks including the risk resulting from two bed-spaces that did not comply with best practice guidelines for critical care facilities. The service had improved patient records and nursing staffing numbers now met recommended staffing ratios. Mortality and morbidity reviews had embedded and were well attended.
• Care and treatment was delivered in line with current best practice. Policies and procedures had been updated. The team had introduced care bundles and a new pain assessment tool. The pharmacist reviewed all patients daily in collaboration with the medical staff. Best practice in relation to consent to care and treatment was evident. The service had improved training around medical equipment. Nursing appraisal rates had improved and now exceeded the trust target.
• The team still cared for patients with compassion and continued to involve patients and their loved ones in decisions about their care and treatment. The team had gone to extraordinary lengths to protect the privacy of patients during the period of the major incidents. The service included input from a psychologist.
• The number of surgical operations that were cancelled due to a lack of an available bed in critical care had reduced (improved). The number of discharges form the unit that were delayed had reduced (improved). Staff made every effort to fulfil patient’ wishes and all decisions were centred on the patient experience and how it could be improved.
• Governance arrangements had been recently reviewed. These now reflected best practice and mirrored the trust wide reporting protocols. The risk-register was updated and now included all evident risks. There was compassionate, inclusive and effective leadership at all levels. Staff at all levels were empowered and encouraged to be leaders. Staff engagement had improved. Monthly governance meetings were now well attended.

Updated 7 April 2016

We have judged the overall end of life service as being good.

The trust could organise rapid discharges effectively but there were delays due to funding of care packages in the community. The trust had not recently completed an audit of patients achieving their preferred place of dying.

There was an improvement plan in place for end of life care that was being overseen by a strategy steering group. There had been a number of changes put into place in the previous twelve months. These were initiated following the results of the National Care of the Dying Audit that was completed in 2014 and also to respond and implement national directives such as the NICE Quality Standard on End of Life Care. These included a new personalised care framework, to replace the discontinued Liverpool Care Pathway, improved rapid discharge processes and the appointment of two end of life care facilitators to roll out the new documentation and provide training. Whilst some of the changes were not fully imbedded the staff were committed and motivated to provide an improving service and embraced the initiatives that were being developed by the end of life steering group.

There was evidence of leadership in both the palliative care team and at board level however despite the work undertaken to deliver the improvement plan there was no trust wide strategy or policy on end of life care. This was combined with limited representation at the strategy steering group from board members.

Staff understood their responsibilities to raise and report concerns, incidents and near misses. They were clear about how to report incidents and we saw evidence that learning was shared across the teams.

Equipment was readily available and properly maintained for the use of patients. Anticipatory medicines were always available and patients being discharged home had their medicines provided promptly.

There were processes in place to assess and respond to patient risk. Staff were able to contact members of the palliative care team for advice about deteriorating patients and this team was responsive and supportive to urgent requests for input. The palliative care team were staffed sufficiently to provide the advice and support that was requested.

The trust was providing a seven day service from members of the palliative care team but this was only currently being funded until the end of March 2016.

There was a range of training that was provided for members of the palliative care team and also training that was available to other staff if they could be released from their duties but there was currently no mandatory end of life training for staff trust wide.

Patients received compassionate care and were treated with respect and dignity by staff. Patients were communicated with sensitively and kept informed about their diagnosis and prognosis.

Staff worked in a positive and open culture and felt supported by their colleagues and line managers. Staff felt valued by the trust and were engaged with the trust objectives.

The end of life service rated poorly in the 2014 National Care of the Dying survey. New paperwork and processes were being introduced and every member of staff on every ward was receiving a two-week training package in end of life care. There were no audits to evidence how the service was achieving rapid discharge or if patients were supported with their preferred place of care. The leadership needed to develop a trust wide strategy and policy for end of life care.

Updated 9 July 2021

Updated 7 April 2016

Salisbury NHS Foundation Trust outpatient and diagnostic services were overall rated as good.

There were good systems in place for incident reporting and learning from when things did not go as planned. Systems were in place for the safe administration of medicines and for the prevention of infection. The outpatient and medical records department achieved a high standard in making sure medical notes were available for 99.91% of appointments. Staff were knowledgeable about safeguarding and their responsibilities to vulnerable adults and children. During our inspection we observed an emergency situation in the outpatients department. The way in which this was handled showed staff were aware of the health of their patients and responded quickly and appropriately to any deterioration in a patient’s health.

Staff were very competent in the roles they were being asked to perform. There were some outstanding areas of practice including the nurse led pathways within the rheumatology outpatients clinics and one stop clinics within urology outpatients. There was good multidisciplinary working both within the trust and with other external organisation such as other health care providers and the Ministry of Defence.

Staff communicated in a professional but friendly manner with patients and their families. Comments from patients and relatives were very positive about the staff and how they provided their care and treatment. Patients were involved in their care and treatment and always put them first.

The departments provided a good service to make sure people were not waiting long periods of time for either outpatients or diagnostic services. The trust was working with other local hospitals and looking at capacity demand in order to make sure waiting lists did not increase. We saw that the trust was achieving 92.94% for its cancer two week waiting time against a standard of 93%. Outpatients departments operated a ‘patient initiated follow-up’ appointment which meant for a three month period patients could arrange a follow-up appointment if they felt they needed it. We saw evidence that complaints were discussed at departmental meetings and changes were made where necessary to help prevent further complaints.

Staff were supported at all levels from their immediate manager through to the trust executive team including the chief executive. Good governance systems were in place across outpatients and diagnostics. Whilst some staff described the culture as a ‘them and us’ we did not see this view shared by the majority of staff. The majority of staff we spoke with felt the culture was open and that staff strived to make sure the experience for patients was outstanding in line with the trust vision.

Updated 9 July 2021

Updated 1 March 2019

• The service had made a number of improvements in response to the concerns we raised at our last inspection.
• Staff made sure that equipment needed for emergency situations were checked frequently as per trust policy and records made to demonstrate this.
• Changes had been implemented to sterile drapes on equipment used in theatre to reduce the risk of damage and to prevent cancelled operations. Whilst these risks had not been totally eradicated, arrangements were in place to continually monitor and review the situation.
• The service had improved compliance with The World Health Organisation (WHO) surgical safety checklist. Recent audits demonstrated that compliance for the general theatres was running at 100%.
• Staffing levels had improved following several initiatives which had been introduced to help aid recruitment of registered nurses across all wards. Recruitment was ongoing and additional staff had been recruited from different disciplines to support registered nurses.
• The service provided effective care, with patients receiving evidence-based care and treatment. Staff from different services, both internal and external, worked well together. Staff were competent in meeting the assessed needs of patients.
• The trust participated in national audits to monitor patients’ care and treatment outcomes, and to compare with other similar services. Reviewing data from audits, the trust was generally performing well or as expected, when benchmarked nationally.
• Staff took the time to interact with patients, and those close to them, in a respectful, compassionate and considerate way. Patients and their relatives/carers, where required, were actively involved in their treatment and care.
• The service had taken steps to improve the experience of patients discharged home following surgery by reconfiguring facilities.
• The service had improved patient flow in order to prevent unnecessary cancelled operations. Since the last inspection the trust had completely re configured its wards creating a short stay surgery unit, along with a chaired area for patients pre discharge. In addition, the trust had also changed its theatre timetable to maximise throughput for patients. These were components of larger Patient Flow and Theatre transformation programs. These actions had seen the number of elective cancellations due to bed pressures reduce dramatically and discharges from recovery, which was highlighted at the last inspection, no longer occur. Patients mostly received care and treatment when they needed it. Referral to treatment times were mostly in line with the England average. The percentage of cancelled operations was similar to the England average and all cancelled operations were rearranged within the required 28 days, which was better than the England average.
• Leaders had the right skills and commitment to improve the quality of the service. The culture was centred around the needs and experience of patients. There were structures, processes and systems of accountability to support the delivery of good quality services.

However:

• Storage of some equipment in the day surgery unit on the floor and fabric chairs in several areas were potential infection control risks.
• Rooms where medications were being stored were not routinely having the temperature monitored to make sure they were being stored at the manufacturers recommended temperature.
• There was some confusion about the resources available to staff when caring for patients with a learning disability.

Updated 1 March 2019

Our rating of this service improved. We rated it as good because:

• Staff had the right skills and knowledge to provide safe care and treatment for patients. Clinical education was used to support staff and patients.
• Policies and guidelines had been developed in line with national policy including the

National Institute for Health and Care Excellence (NICE) guidelines.

• All patients had their nutrition needs and hydration needs met and staff assessed and managed patients’ pain effectively.
• Staff had a good understanding of consent, mental capacity act and deprivation of liberty safeguards and had access to guidance through the intranet.
• Doctors, nurses and allied healthcare professionals supported one another to provide holistic care to patients.
• The service supported patients by promoting healthier lifestyles. The service had managers at all levels with the right skills and abilities to run the service, providing high-quality sustainable care.
• The service had a vision for what it wanted to achieve and we saw evidence of actions to achieve it.
• Managers promoted a positive culture that supported and valued staff, free from bullying, harassment or discrimination, creating a sense of common purpose based on shared values.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• Staff were kind and supportive to patients and their relatives. We observed staff providing emotional support to patients on many levels. Patients told us that they felt involved and included in decisions about their care.
• Learning from complaints were shared across the emergency department through daily safety huddles and regular team meetings. Complaints were reviewed through the emergency department governance meetings.
• Leadership at departmental level was considered by staff to be supportive and effective.
• Departmental staff were aware of the departments values and the values of the trust.
• There were assurance systems implemented to ensure the identification and management of risks was undertaken and appropriate action taken.

However:

• There were not always sufficient numbers of staff employed by the service. This had contributed to a sense of low morale within the department.
• Staffing challenges meant dedicated areas of the department designed for children and young people could not be opened. This resulted in children being treated in the main emergency department which may not always promote the best experience for children.
• A lack of a standard operating procedure for the short stay emergency unit meant there was ambiguity over who should be referred to the unit.