Royal United Hospital Bath

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 learning culture, safe environments, safe and effective staffing, and medicine optimisation quality statements for the safe key question. We rated these quality statements good.

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.

The trust monitored patient experience and complaints to improve its service offering. In Quarter 1 of 2024, 97% of the feedback received was positive.

Staff and leaders were trying to encourage a learning culture. We saw evidence wards had access to clinical nurse practice educators (CNPE). The CNPE were there to support and train mainly newly qualified nursing staff with their educational and clinical skill requirements. Staff understood how to report incidents and stated learning from clinical incidents was shared through safety briefings and electronic communication, such as emails. However, the service had a large number of open incidents which required investigation. Incident investigations were not happening in a timely manner. For example, in December 2023 there were 1500 open incidents on the incident reporting system that may have required investigation. Post inspection we have received information showing this has reduced to 416 open patient safety incidents as at the end of May 2024. The leadership team were aware of the issue and were working at clearing the backlog and improving what information they reviewed when undertaking a patient safety investigation. Patients could be at risk of unsafe care if the service hasn’t investigated all safety incidents and identified required learning.

The trust had processes to foster a good learning culture. We reviewed 3 incident reports at random and all 3 incidents showed the Duty of Candour process was followed. Duty of Candour is a legal requirement which requires staff to be open and honest with patients and families if treatment or care causes, or could cause, harm or distress. We saw examples of ‘improvement boards’ where staff could raise any issues along with any suggested solutions. These suggestions were taken to ward meetings to be discussed. We saw the leadership team were given information on trends in incident reporting such as pressure ulcers and delays in medicines when patients were discharged. We also saw evidence that an e-learning package was developed to address educational needs around the use of malnutritional universal screening tools and that this was then granted mandatory status in October 2023. Mandatory training is training which staff members must complete and repeat on a cyclical basis.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

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.

People we spoke with were positive about the way they were cared for in the ward environment.

Staff we spoke with were happy with the working environment provided by the trust. However, space on wards was limited and we were told that nurse safety briefings were carried out outside of patient bays on Forrester Brown ward. This was a problem due to confidentiality as patients were able to overhear information about other patients on the ward. We received a patient complaint which raised patient confidentiality as an issue.

We visited 3 surgical wards during our site visit. We found these wards were in the main calm and well organised. We sample checked equipment in each ward and found that these were within servicing and expiry dates. We saw evidence that the wards used the ‘I am clean’ green stickers to indicate which equipment was clean and ready to use.

The trust had processes to control potential risks in the care environment. We saw there were processes to check equipment. We saw evidence the service carried out regular fire risk assessments, however, we were not assured that the actions that arose from these assessments were completed in a timely manner. We reviewed 9 risk assessments and saw 2 assessments where risk was classed as substantial. This meant “considerable resources might have to be allocated to reduce the risk. If the premises are unoccupied, it should not be occupied until the risk has been reduced. If the premises are occupied, urgent action should be taken.” The remaining 7 risk assessments reviewed were classed as ‘moderate’. We received information from the trust on the actions it had already taken to mitigate the risk in the 2 wards where the risk was classed as substantial and have asked for an action plan from the trust to ensure that all actions on the plan are completed. New fire risk assessments are due in July 2024.

Surgical patients said staff kept them informed. Patients described nurses as “lovely”, “great”, “brilliant” and “doing their best”.

Staff had training in key skills, and we saw information showing 91.36% of staff had completed mandatory training. We requested information on competency training and were told this was currently recorded at ward level; however this process was being moved so that staff competency skills could be viewed on the electronic learning management system. We found on Pulteney ward, a surgical acute ward which received patients from the intensive care unit, not all nurses had received training in airway management. We were told by staff and it was confirmed that this was on the surgical risk register. We have requested an action plan from the trust to address this risk. The number of staff in the surgical department receiving a regular annual appraisal had been increasing month by month but was still short of the trust target of 90% at 79.69% as at February 2024. The trust were working on improving the number of staff receiving an annual appraisal and we saw evidence that this was discussed at senior management meetings. The medical staffing for the surgical division was close to establishment with 3 gaps in registrar positions being covered by locum shifts. We were told that any gaps in the rotas that were not filled were covered by enacting the ‘acting down policy’ where senior staff worked to cover the junior positions.

We assessed 3 wards during our site visit and spoke to staff working on these wards. We noted on Pulteney ward, it was a registered nurse short for the shift and that the ward had 3 patients who required enhanced 1 to 1 care. Following the inspection, we were informed the ward was only one nurse short between 7am and 12pm because that member of staff was attending a preceptorship study session and that the staffing level were reviewed by the duty matron on the day and it was assessed as being at a safe level. We observed on Philip Yeoman Ward that the planned numbers did not meet the actual numbers at the time of inspection, however, at the date of the site visit the ward wasn’t being fully utilised to its maximum occupancy level. Staffing on Forrester Brown ward at the time of the site visit met with the planned numbers.

The trust used electronic systems to calculate safer staffing levels. There had been a review of the system to ensure this did not include optional duties (for example supernumerary shifts) which should not be contributing to the overall fill rate. This work was due to be completed in June 2024. Prior to this being implemented, the director of nursing for surgery and matron team reviewed prospective rosters 10 days in advance to highlight any foreseeable staffing gaps and look at the requirement for temporary staffing. There were twice daily staffing meetings where a review of staffing gaps was discussed and triangulated with the use of the electronic system, professional judgement and agreed safe staffing levels. During the site visit we looked at 6 recruitment files for 2 members of staff from each ward we visited. All the records reviewed complied with Regulation 19(3)(a) of the Health and Social Care Act (Regulated Activities) Regulations 2014. We saw evidence that staff had been checked by the Disclosures and Barring service. There was a process to check staff were on the appropriate professional registers. The trust had clear induction policies and procedures; however, the induction policy was due for review which had not been completed at the time of the inspection. The trust had a performance management policy which had been reviewed within the set timescales.

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.

All the patients we spoke with were happy with the care they were receiving and were happy with the support staff gave them to take their medicines. One patient told us that they didn’t like the taste of paracetamol, but that the staff “couldn’t do more even if they tried”. Another patient told us they were well informed about changes that were made to their prescribed medicines. We spoke with patients who were self-administering their prescribed inhalers and they were able to tell us when they needed to be taken which reflected the directions on the dispensing labels.

We spoke with the senior nurses on all wards, who were able to tell us in detail how they managed medicines using the medicines administration system. Staff told us they receive medicines training online, as well as a competency assessment that were completed on an annual basis. Staff told us they were well supported by clinical pharmacists who visited the wards daily and the wider pharmacy team for the supplies of medicines.

We looked at medicine records for 14 patients across 3 wards. In all cases allergies were recorded where needed. We observed staff using these records to give medicines at the right time. However, we observed that the Controlled Drugs register was being completed to confirm patients had received these medicines before these medicines had been given to the patient. This was not in line with the trust policy. There was one patient’s record where their body weight was not recorded, despite being prescribed a medicine (anti–coagulation) that requires the patients weight to ensure the correct dose is prescribed. Discharge medication counselling (and prescribing on one ward) was nurse led. There was 1 patient with a 5-day delay in the completion of their venous thromboembolism (VTE) risk assessment. Patients' medicines were securely stored and at an acceptable temperature.

An electronic prescribing and medicines administration system was used to record the prescribing and administration of medicines. The process for medicines administration appeared to be effective with safety features in place to prevent the inadvertent administration of the same medicine, if prescription is in different formulations. Medicines were given as prescribed and were accurately recorded. Medicines storage areas were monitored to ensure medicines were stored at the correct temperature. Fridge temperatures were monitored centrally by the pharmacy department and there was a system to alert the pharmacy to out-of-range temperatures. Medicines for patients to be discharged with were appropriately labelled and dated. Controlled Drugs (CD) were audited on a regular basis; however, this monitoring had failed to identify an expired Controlled Drug which had not been separated from the current stock available to patients. One CD register had not been carried over appropriately , a new one having been started before the old one was closed. We were told there was a daily presence of a ward pharmacist although none were present when we carried out the site visit. A couple of bottles of liquid morphine did not have date of opening recorded. On 1 ward there were 2 controlled drugs cabinets which were not bolted to the wall appropriately and in accordance with legislation. Room temperatures where medicine was stored were recorded. Normal stock medication date checks took place every three months. There was one CD entry for morphine sulphate injection ampoules where the strength was not recorded. We were able to see the medicines report where details of medicines incidents were recorded, and this was shared with the multidisciplinary teams.