Southmead Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed the learning culture, safeguarding and safe and effective staffing quality statements for the safe key question: Learning Culture: There was a culture of safety and learning. This was based on openness, transparency and learning from events that had either put people and staff at risk of harm, or that had caused them harm. Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. Safe systems, pathways and transitions: There was joined up multidisciplinary working to maintain safe systems of care. Continuity of care was ensured when patients moved between specialities. Safe and effective staffing: There were enough qualified, skilled and experienced people who received support, supervision and development. They worked together effectively to provide safe care.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were open, transparent and honest about reporting incidents. Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses in line with the organisation’s policy. Staff said they were encouraged to report incidents promptly. Staff felt confident these would be investigated appropriately. We saw evidence learning from incidents was shared with staff. We observed good examples of staff’s positive attitudes towards safety. Current risks were regularly discussed and safety to both patients and staff was prioritised. Staff understood the duty of candour and gave patients and families a full explanation and apology when things went wrong. The duty of candour requires registered providers and registered managers (known as ‘registered persons’) to act in an open and transparent way with people receiving care or treatment from them.

The service had a clear process to ensure staff monitored patient’s physiological observations in a timely way to ensure patients were safe. Senior staff completed weekly audits to check staff compliance with this. Senior staff shared the results with staff at team huddles and they discussed where improvements were needed. Incidents were investigated internally. We reviewed 1 patient safety incident investigation and associated action plan. The action plan contained 9 safety recommendations with clear dates for implementation to ensure learning was embedded and to prevent recurrence of this type of incident. In addition to this, the trust had committed to 5 areas of focus organisation wide in response to the recognition, escalation and treatment of the deteriorating patient. The learning from this had been shared with staff. Senior staff shared learning throughout the service and ensured actions were implemented in line with national guidance. The trust had instigated a new training package which included deteriorating patient, sepsis, acute kidney injury and national early warning score (NEWS2) training. This was being implemented trust wide but had not yet been fully launched. This was due to the National Institute for Health and Care Excellence (NICE) updating guidelines on suspected sepsis: recognition, diagnosis and early management (NG51) which was expected to be published in January 2024. The trust planned to amend the training to reflect the latest NICE guideline update before the launch. There was a clear policy to guide staff to identify and report incidents. Managers investigated incidents and shared lessons learned with the whole team and the wider service. The trust had also shared learning with neighbouring trusts. When things went wrong, staff apologised and gave patients and families honest information and suitable support.

Staff held regular and effective multidisciplinary meetings to discuss all patients and improve their care. Patients had their care pathway reviewed by relevant consultants dependant on their care pathway. Consultants led daily ward rounds on all wards, including at weekends. Staff worked across all bandings in surgical and medical wards. They were knowledgeable and understood their responsibilities for assessing and reporting patients’ observations and national early warning scores (NEWS2). We attended nursing and medical handovers and ward safety huddles where we found patient escalation was discussed and managed appropriately. Nursing staff across the 3 different wards we visited told us their focus had been on making observations in a timely manner and to ensure escalation occurred promptly. This had been supported by training on NEWS2 and the deteriorating patient learning module and refresher sessions when the need arose.

There was a business case for a 24 hour care rapid response team to support ward care, with the addition of a critical care outreach service. This was progressing through the business planning process for 2024/25. The trust were in the process of implementing Martha’s Rule which is the rapid review initiative which will support families to raise concerns to a critical care outreach team independently of a ward team. The trust had updated 3 key policies in response to patient deterioration. The acute kidney injury care policy had been approved in September 2023 and the sepsis and NEWS2 policy had been approved in October 2023. Patient’s observations were recorded on tablets in the digital system. This provided a live dashboard view of NEWS2 scores, pain scores, and observations which were due and overdue. This dashboard was located near the nurse’s desk so they were continuously available for the nurse in charge of the ward to monitor and respond to deterioration or delays. Nursing staff told us if a patient’s NEWS2 score was high, this was also recorded on paper to ensure continuity in case of digital system failure. We were shown compliance results of the latest patient observation audit. The aim of this audit was to oversee patient observation timings, NEWS2 scores and patient risks. This was audited weekly; the results were shared with senior nursing staff and their teams. Audit results were displayed on the compliance board for all staff to see. The trust planned to complete annual audits of compliance with NEWS2 and evaluate through divisional review. Divisions planned to routinely monitor and report compliance data for NEWS2 through monthly executive divisional reviews to support continuous improvement. This will also include management of sepsis and fluid balance charts. The audit results will be reviewed by the patient safety group. During our site visit to the Intensive Care Unit, there were 4 patients who had been escalated to Intensive Care from various wards over the weekend before our visit. We checked the records of 2 of these patients and in both instances, the details of the escalation indicated they were escalated and assessed safely.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service had enough nursing and medical staff with the right qualifications, skills and training to keep patients safe and provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix. We were told bank staff had access to NEWS2 and deteriorating patient training and more explicit targets and ongoing monitoring arrangements had been established to strengthen this area. We were told the Chief Nursing Officer had written to external agencies to reinforce the expectations of staff working at the trust. Internationally trained nurses received support from UK trained nurses. They initially escalated patients to senior nursing staff before escalation to medical staff. Staff were able to clearly demonstrate the escalation process for a deteriorating patient. Staff we spoke with reported they had attended recent NEWS2 training and showed clear professional ability to apply their learning. Staff reported they could override a low NEWS2 score with clinical judgement and escalate if they were concerned about a patient, however they were not able to override a high score. On some of the wards, the deteriorating patient training was highlighted as training of the month. There was easy to read information on wards for staff. Teams had organised training sessions based on the learning shared from cases where staff had not monitored deteriorating patients effectively. The service had practice development nurses who were able to deliver further training to staff who had either been identified to have refresher training requirement or who had requested more support. Junior doctors were on rotation every 4 months; therefore, deteriorating patient training was arranged for the intake of the new cohort. Nursing staff had support for rib fracture patients from the geriatric peri-operative care (GPOC) team.

Staffing levels for this service had been significantly increased since 2022. The trust had employed 250 internationally educated nurses in 2022 and they had undertaken deteriorating patient training as part of their objective structured clinical examination (OSCE) preparation. The trust had created 335 senior healthcare support worker roles, with 70% having completed additional mandatory training in patient observations and caring for the deteriorating patient. There was a plan for this to be 100% by the end of April 2024. There was a weekly audit to oversee compliance with patient observation timings, NEWS2 scores and risks. The results were shared with senior nursing staff and they told us they held weekly meetings where they relayed these results to their teams. The executive team reviewed these audits each month, and the divisional leadership team were held to account for improvement which was scrutinised by the trust board. NEWS2 training was now mandatory for registered nurses, nursing associates and healthcare support workers. Staff told us there was face-to-face simulation training available in observations and caring for the deteriorating patient. Senior staff members requested another staff member attend the training when knowledge gaps were identified or when a staff member needed a refresher. Knowledge gaps were identified by senior nursing staff as internationally trained nurses initially escalated high NEWS2 scores to them. The in-ward face-to-face training was provided by the Practice Development Nurse (Band 6, in training to Band 7). The Senior Leadership team told us the biggest win came from changing how consultants work. They had 4 new posts in the trauma service, and now had a consultant on the ward round which facilitated identifying problems at an earlier stage. However, the trust was unable to provide up to date staff training compliance figures for sepsis, NEWS2 and management of deteriorating patients.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.