UHBW Bristol Campus

On this page

• 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 safe systems, pathways and transitions, safe and effective staffing and medicines optimisation for the safe key question. We found 2 breaches of legal regulations in relation to safe care and treatment and safe staffing. We found areas of concern in medical staffing and the safety of the environment in relation to overcrowding in the department and availability of trained fire wardens. There was a risk patient safety would be impacted by the reduced number of medical staff at weekends and that the service wouldn’t have access to a trained fire warden to manage an evacuation of the building in the event of a fire. We identified areas for improvement in relation to monitoring of the quality of handovers from the emergency department to wards and compliance with venous thromboembolism (blood clot) risk assessments. There was a risk to the continuity of patient care and safety when patients moved areas and an increased risk of blood clots if risk assessments were not always completed on the observation unit. Use of information technology to support safe pathways and transitions was limited. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

In the feedback we reviewed, some people raised concerns about the triage and the clinical care they received. However, most people were positive about the care they received from staff despite some long waits they had experienced.

Leaders had a collaborative and joined-up approach to safety. Leaders had a strong awareness of the risks of managing patient flow through the department and surges in demand. Nursing staff were positive about the processes for clinical escalation and told us medical staff were approachable and supportive. However, use of information technology to support safe pathways and transitions was limited. Patient records used in the department were a mix of paper and electronic. Junior medical staff commented that the hybrid notes system led to a significant duplication of work and made them less efficient at seeing new patients. We discussed the use of the patient information main whiteboards in majors with the nurse in charge. The system relied on staff updating the whiteboard manually and cross-referencing information with multiple electronic systems. This led to an increase in duplication of work and whiteboard information was not always up to date.

The service had processes for identifying and responding to deteriorating patients but, tools used to monitor patient’s signs of deterioration were not always used in a consistent and timely way. Recent audit data for NEWS2 (a standardised tool to support staff to detect and respond to clinically deteriorating patients) and the sepsis 6 pathway (a set of 6 tasks to be completed within 1-hour to improve clinical outcomes for patients diagnosed with sepsis). Audit data showed staff did not always identify and manage sepsis in line with trust guidelines. Sepsis is a life-threatening infection. If sepsis is not identified and managed effectively, there is a risk of patients becoming more unwell. The trust’s Patient Safety Improvement Team had identified management of the deteriorating patient as an area of focus to improve staff education on this topic. The service did not monitor the quality of staff handovers from the emergency department to the wards, so there were missed opportunities for learning as the service did not consistently monitor if patients were safely handed over to inpatient wards. However, the service had improved processes to reduce ambulance handover delays. This included 2 immediate triage assessment areas where senior nurses would accept patients into majors from ambulance crews to ensure patients were safely received into the department. The service had developed a ‘nudge’ system to ensure timely medical review and ordering of time critical tests. The service had rolled out an ‘Every Minute Matters’ campaign with support from another organisation to support staff to improve the patient journey from the emergency department, through to admission and discharge. Staff we spoke with were positive about the impact of this campaign.

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.

Feedback from people using the service was that there were not enough toilets for the number of people in the waiting room. People told us the seats in the waiting room were uncomfortable, especially when waiting for long periods.

Staff worked to control risks in the care environment, especially in relation to mitigating the risks of overcrowding in the department. The service had recently made improvements to an area to make it safer for people intending to harm themselves. Senior leaders told us there were plans to improve the environment of 1 cubicle in majors to make it more suitable for adolescents in mental health crisis who may be waiting for an inpatient bed in the community.

The size and layout of the emergency department was no longer fit for purpose for the increasing numbers of patients that needed to be seen to support the delivery of safe care. In times of extreme escalation, the service had to use clinical areas that were not designed to be used as inpatient areas such as the same day emergency care unit and the corridor outside the observation unit. This potentially impacted the experience of patients in relation to access to toilets and their privacy and dignity. We observed the midday daily flow meeting. Senior leaders across the hospital supported the coordination of discharges to identify inpatient beds for patients who had been assessed in the emergency department as needing to be admitted.

The service last completed a departmental fire risk assessment in March 2024 and at the time of the site visit, did not have enough staff trained and signed off as competent to act as fire wardens. This was a breach of regulation 12, safe care and treatment due to the potential impact on patient safety in the event of a fire. However, the service had developed a system of ‘reverse queues’ to manage patients who had a decision to admit and were awaiting a bed on a hospital ward. The service had risk assessed all these areas in relation to patient safety and staffing to ensure these areas were as safe as possible. This system improved patient safety by ensuring there was space available to receive patients arriving by ambulance and to differentiate between patients whose condition meant they needed emergency clinical treatment and those who had been assessed as needing ongoing secondary care in other areas of the hospital. The service had standard operating procedures for safe use of escalation areas (clinical areas that could be adapted for inpatient beds in times when the demand for the service exceeded the number of available inpatient beds).

Most people using the service were positive about the care and treatment they received from staff, despite some long waits they had experienced.

Medical staff told us that medical staffing was adequate during the week but inadequate at weekends. We discussed medical staffing with senior leaders in the emergency department. They told us weekend medical staffing was a challenge due to the limitations of the junior doctor contracts and as the trust had not provided additional funding for locum doctor cover. Nursing staff told us the numbers of nursing staff had improved but the skill-mix of nursing staff could be a challenge due to the number of band 5 nurses and newly arrived internationally educated nurses. Staff we spoke with were consistently positive about the opportunities for learning and development in the department.

The service had 22 emergency medicine consultants, working 16.75 WTE The Royal College of Emergency Medicine (RCEM) recommends (RCEM Workforce Recommendations 2018: Consultant Staffing in Emergency Departments in the UK, February 2019) consultants are on duty in the department from 8am to midnight in all medium and large systems. With usually more than 60,000 but fewer than 100,000 patient attendances each year, the adult emergency department at the Bristol Royal Infirmary would be classed as medium sized. Despite activity levels in the department significantly increasing, consultant staffing levels had not increased significantly since the last Care Quality Commission inspection in February 2021. This increased delays for patients waiting to be reviewed by a doctor and reduced the amount of senior clinical decision makers available to support more junior staff. This was a breach of regulation 18 safe staffing as staffing was not always sufficient to meet the demand for the service. However, the service had enough nursing staff to meet the needs of the service. The service was completing a review of staffing capacity and demand at the time of the assessment. to assess where the gaps in staffing were and the impact on patient safety.

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 reviewed the storage and management of medicines in the majors and fast flow areas of the department. There were appropriate arrangements for the safe management, use and oversight of controlled drugs. Managers shared learning from medication incidents with staff. For example, learning in relation to ensuring blue dots to prompt staff a patient was on time critical medication was shared with staff in a recent ‘message of the week.’ However, data showed venous thromboembolism risk assessments were not always completed on the observation unit.