Salisbury District Hospital

Salisbury NHS Foundation Trust provides care to over 240,000 people across Wiltshire, Dorset and Hampshire. This includes general and acute services at Salisbury District Hospital with specialist services including burns, plastics, cleft lip and palate, genetics and rehabilitation serving over three million people. In addition the Duke of Cornwall Spinal Treatment 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 around 240,000 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 partner organisations. Against this the trust was judged as a low risk, at level six (the lowest level) which it had been at since 2013.

We inspected this trust as part of our programme of comprehensive inspections of acute trusts. The inspection team inspected 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 responsive to 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 guidelines or 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 such as wearing of gloves and aprons. In a minority of areas equipment was found to be dusty and in one area a commode 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 healthcare practitioner 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 raise concerns, record safety incidents and near misses and to report these appropriately. Staff received feedback and lessons were learnt to improve care. There was a culture of being open and the duty of candour was well understood.

Effective

• 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 the national average.

• Mortality rates were as expected at 107 as measured by the Hospital Standardised Mortality Ratio (July 2015) and 107 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 and theatres could do more to improve multidisciplinary working.

• The majority of staff received an annual appraisal. Improvements were needed to ensure the records about who had 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 were examples 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 the friends and family tests were below the national average the number of patients who would recommend Salisbury Hospital exceeded the national average.

Responsive

• Patient’s individual needs were not consistently met. In spinal services there was disparity between the experiences of 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 appointments and 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 mental health needs, particularly children and adolescents who required assessment by a mental health practitioner, did not 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 the adult 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. These related to working with other organisations to provide a single response when required, the development of action planning and learning after the investigation.

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

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

Well led

• The trust had a governance framework which supported the delivery of care although there were some areas of weakness. The trust had recently undertaken a self- assessment against Monitor’s quality governance framework however this had not clearly identified weaknesses or areas for improvement. A review had been undertaken to support board development. Additionally, an externalreview of the board assurance framework had beencompleted 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 always been 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 for decisions and actions.

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

• There was an extremely positive culture in the trust, staff felt respected and valued. Many staff had worked in the trust for a considerable number of years and knew each other well. They frequently referred to themselves as being like 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 staff survey 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 and supported 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 when issues were raised.

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

• Innovation and improvement was encouraged and rewarded. There were award ceremonies at which innovative and caring practice was shared and recognised, this was well publicised and appreciated by staff who were proud of 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 a healthcare 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 who would not otherwise attend these meetings joined the meeting each time to provide a ‘sense-check’. They listened to 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 other staff including the student nurses.

• The maternity services strived to learn from investigations in order improve the care, treatment and safety of patients. This was evident with the robust, rigorous and deep level of analysis and investigation applied when serious incidents occurred. For example, the reopening of a coroners case as a consequence of the maternity service investigations. Further evidence of this was available in meeting minute records. In addition, a wide range of staff demonstrated 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 facilities were comfortable and extensive, enabling patients and their families’ privacy and sensitive personalised care and support.

• In the services for children and young people a mobile APP was produced in conjunction with a regional neonatal network 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 and young people. Examples were of developing a DVD for pre-operative patients, using child friendly surveys in other areas 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, this pathway had been ratified by the Royal College of Nursing. The pathway was evidence based that showed the quicker patients were diagnosed with arthritis, the quicker treatment could be started and the quicker patients could go into remission. This service came top in a national audit for patients with early arthritis. Staff had presented their service at national and international conferences including the Bristol Society of Rheumatology conference in 2015.

• We observed excellent professionalism from staff in outpatients during an emergency situation. Staff attended to the patient that needed immediate help and support. Staff also cared for and supported the other patients who had witnessed the emergency. Patients were moved away from the emergency into another department and kept informed of what was happening and offered lots of reassurance. When the emergency was over, patients were shown 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 across the trust. Out of these, 115 sets of notes could not be located for the appointment. The department identified that this was because the notes had been miss-filed, staff had not used the case note tracking properly or the notes were 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 for making sure patients’ medical notes were available for their outpatient’s appointments. Where they were not available, 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 example of this was where a patient got married in the spinal centre. Staff went with the patient’s partner to collect and prepare food and on the wedding day was picked up by a member of staff in their classic car. The couple were then allowed 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 session where patients and relatives were given opportunities to discuss their concerns as a peer group as well as to professionals and ex-patients. It was clear that patients and their carers were being supported through a difficult time 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:

• Review nurse staffing levels and skill mix in the areas detailed below and take steps to ensure there are consistently sufficient numbers of suitably qualified and experienced nurses to deliver safe, effective and responsive care. This must 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 clinical supervision, education and professional development.

• a review nursing staff levels at night on Amesbury ward, where the current establishment of one nurse for 16 patients, does not meet guidance and is not safe. Other surgery wards with a ratio of one nurse to 12 patients at night must be reviewed. Pressure on staff on the day-surgery unit, when opened to accommodate overnight patients, 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 the patients in the critical care unit.

• ensuring there are adequate numbers of suitably qualified, competent and skilled nursing and medical staff deployed 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 with national 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 appropriate steps to ensure that all patients who attend the emergency department are promptly clinically assessed by a healthcare practitioner. This must include taking steps to improve the observation of patients waiting to be assessed 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 or treatment in line with the hospital’s policy and best practice. This must include effective documentation with regard 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 emergency department’s risk register, that there are clear management plans to mitigate risks, regularly review them and escalate them where appropriate.

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

• 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 safety checklist. The audit of the checklist must be conducted as soon as an appropriate period of time has passed since its reintroduction. Results must be presented to and regularly reviewed at clinical governance.

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

• 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 and the impact this has on patients. Patients must not be discharged home from main theatres unless this cannot be avoided. Surgery must not be undertaken if there is clearly no safe pathway for discharging the patient. Operations must 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 and outpatient appointments.
• Ensure care and treatment are delivered in a way to ensure that all patients have their needs met which reflects their preferences. This includes the training of agency staff, the availability of physiotherapy and occupational therapy sessions, and the availability of suitable activities for patients in spinal services.

Professor Sir Mike Richards

Chief Inspector of Hospitals