You are here

Yeovil District Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 27 July 2016

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 15 and 17 March 2016. We also carried out an unannounced inspection on 24 March 2016. We carried out this comprehensive inspection at Yeovil District Hospital Foundation Trust as part of our comprehensive inspection programme. The trust has one main location.

The hospital opened in 1973 and was established as an NHS Foundation Trust in June 2006. The trust delivers services to a population of approximately 200,000 primarily from the rural areas of South Somerset, North and West Dorset and parts of Mendip. The trust provides outpatient and inpatient consultant services for a range of specialties primarily from its main site Yeovil District Hospital. It also provides outpatient and diagnostic services in a number of hospitals in the surrounding area, including the Yeatman Hospital in Sherborne and Wincanton, Crewkerne, Chard and South Petherton community hospitals. We did not review the care at the community hospitals at this inspection. At previous inspections the trust had been found to be compliant with the regulations we reviewed.

At this inspection we found that the trust was working hard with other stakeholders to improve the services offered to the local community. We found a highly committed workforce who put the patient at the centre of care. We saw some examples of very good practice which included the stroke buddying group and the ways in which maternity staff were involving vulnerable young women in maternity care. However we also found an emergency department which when under pressure was not responsive to the needs of patients. We struggled to understand the rationale for placing adult patients on the children’s ward and had to formally request information and reassurances from the trust around the safety of doing this. We found that the trust were responsive to the concerns we raised on and after the inspection and put in place actions to address these.

Our key findings were as follows:

  • Staff were caring in delivering care to patients. We observed many examples of compassionate care which staff delivered to patients with respectful and considerate approaches.
  • Feedback from patients, relatives and carers was positive throughout our inspection.
  • Staff were proud to work at Yeovil District Hospital. We found staff were part of a hospital based community in which staff worked together to try to meet the needs of patients.
  • In many areas staff felt well supported by their line managers and were aware of the trust’s vision and strategy. Many staff were aware of the trust’s iCARE strategy which incorporates the values of communicate, attitude, respect and environment.
  • We saw most staff complied with infection prevention and control best practice in relation to hand washing and remaining bare below the elbow. However, this was not consistent throughout the hospital.
  • Most areas of the hospital were visibly clean however we found equipment was not always stored appropriately and in a way which controlled and reduced the risk of infection.
  • Protected meal times were in place and staff offered patients food and drinks. Most areas assessed patients for their risk of malnutrition however we found nutritional screening assessments on surgical wards were not always completed in line with trust policies.
  • We found that whilst most patients received appropriate and completed risk assessments, on admission, the trust did not use individualised care plans to document on-going care, treatment and actions taken to mitigate risks to patients.
  • There were a greater proportion of middle grade and junior doctors employed at the hospital compared to the England average. We found emergency consultant cover in the Emergency Department did not meet the Royal College of Emergency Medicine standard for senior clinical cover in a listed trauma unit.

We saw several areas of outstanding practice including:

  • Snack box training had been set up to deliver specific and focussed small pieces of training to staff that can be accessed during their lunch break.
  • Development of a hospital garden for the use of patients, including patients living with dementia.
  • Development of an integrated care model supporting patients with three or more long-term conditions.
  • A ‘buddy system’ was used in critical care where nurses were paired to work together, this was to ensure adequate supervision of patients during staff meal breaks and for checking medicines.
  • Patient diaries in critical care were extremely well managed. The unit kept a copy of the diaries to ensure staff knew what the diaries contained; this enabled on-going support to be given to patients families after the diaries had been collected.
  • At the foot of every bed space in the critical care unit there was an analogue clock, with the date also displayed and a very clear sign which said, ’You are in intensive care, you are in Yeovil Hospital.’ This had been provided in response to patient feedback and helped to orientate patients to where they were being cared for and to the time and date.
  • The critical care outreach team had produced and implemented a patient assessment document to aid the early recognition and prompt treatment of sepsis. As part of the education package unit staff had produced a video. A staff badge had been introduced to acknowledge hospital staff who had used the tool to identify and manage a patient with sepsis.
  • In maternity and gynaecology services, the Acorn team provided specialist care for women who were vulnerable, were known to be at risk of domestic abuse, who smoked or were prone to substance abuse. Women under the age of 19 and women who had a learning disability could also be referred to the Acorn team.
  • The children and young people’s services’ community nursing team provided a range of different services to meet the needs of patients. The team included specialists or nurses with an interest in specific conditions such as cystic fibrosis, oncology and end of life care.
  • Services for children and young people had a school based within the children’s outpatients department. The school had a qualified teacher, working Monday to Friday, to provide education to patients who had been in hospital for long periods.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure systems and processes to prevent and control the spread of infection are operated effectively and in line with trust policies, current legislation and best practice guidance. The trust must work to improve standards of hand hygiene across children’s services.
  • Ensure equipment is stored appropriately and in a way that reduces infection risk. Ensure equipment used by cleaning staff is not stored in the sluice area and toilet rolls are not stored on commodes. Ensure commodes are completely clean before returning them to clean utility rooms. Ensure clean equipment is stored off the floor to prevent contamination. Ensure the covers on metal linen shelving units are kept closed when not in use to prevent cross infection. Ensure contaminated disposable items are not stored with clean disposable items. Ensure systems and processes to prevent and control the spread of infection are operated effectively and in line with trust policies, current legislation and best practice guidance within the maternity operating theatre.
  • The trust must ensure resuscitation equipment is routinely checked. The emergency department must ensure all resuscitation equipment is checked. Children’s resuscitation equipment must be available in the children’s assessment area in the emergency department. The trust must ensure all emergency lifesaving equipment, is sufficient and safe for use in maternity and gynaecology services and that there is evidence it has been checked in line with the trust policy.
  • The trust must ensure medical and nursing staffing is sufficient to meet the needs of patients. The emergency department must undertake a review of staffing levels using a recognised assessment tool. The trust must recruit sufficient medical and nursing staff to enable the operational and staffing standards for intensive care units to be met. Ensure sufficient medical staff are on duty in the medical business unit at night. The trust must ensure staffing levels reflect the acuity of patients in accordance with British Association of Perinatal Medicine (BAPM) standards.
  • Ensure that all patients receive appropriate and completed risk assessments, including those for dementia, on admission and an individualised care plan commenced to demonstrate the on-going actions taken to mitigate risk. The trust must also ensure nutritional screening assessments on surgical wards are completed in line with trust policies. Ensure the completion of documentation and of patient risk assessments on the gynaecology ward.
  • Ensure that controlled drugs are managed in accordance with trust policies, legislation and best practice in the discharge lounge. Ensure oxygen, when required for patients, is prescribed appropriately. Ensure medicines are always safely managed in line with trust policies, current legislation and best practice guidance in maternity and gynaecology services. The radiology department must ensure that guidance is in existence surrounding patient group directive medications.
  • Ensure that at least 90% of all staff receive an annual appraisal. Ensure nursing staff in specialist areas are trained on recruitment or placement to become efficient and competent members of their staff team. The trust must train all staff who have direct input into assessing, delivering, and intervening in the care of children and young people, in level three child safeguarding in line with intercollegiate guidance. The trust must improve the numbers of staff trained in European Paediatric Life Support (EPLS) to ensure they meet Royal College of Nursing guidance of at least one EPLS trained member of staff working every shift. Ensure all overseas staff are supported to achieve a good standard of the English language to reduce risks to patients.
  • The emergency department must put systems and processes in place to ensure patients receive initial assessment (triage) by an appropriately qualified clinical member of staff within 15 minutes of arrival to the emergency department.
  • The emergency department must take action to ensure the safety of children in the waiting area of the emergency department.
  • The emergency department must provide daily clinical and managerial leadership with oversight of capacity and demand. The emergency department must develop robust escalation processes.
  • Ensure that all patient records are kept securely and located away from the public to maintain confidentiality.
  • Ensure all wards have single sex accommodation including sleeping accommodation, bathroom and toilet facilities and do not need to pass members of the opposite sex to use the facilities.
  • Ensure the sepsis protocol is embedded with all staff groups to achieve and maintain high levels of compliance with sepsis identification and antibiotic administration.
  • The trust must ensure young adults (patients between the ages 18 to 24) meet the criteria for admission onto the Young Persons Unit.
  • The trust must review the physical environment of Ward 10 and explore options to separate the Young Persons Unit from Ward 10 to ensure patients over the age of 18 do not have access to children.
  • Ensure 'do not attempt cardio-pulmonary resuscitation' (DNACPR) forms are completed appropriately and in accordance with national guidance and best practice. The trust must also ensure DNACPR decisions are documented fully in accordance with the legal framework of the Mental Capacity Act 2005.
  • Radiology must continue to target the quality assurance backlog of equipment.
  • The radiology department must develop audits and action plans to address incomplete five steps to safer surgery checklists. The radiology leads must ensure guidance surrounding trauma computerised tomography (CAT) scanning is clear and not open to individual interpretation.
  • The outpatients department must continue to support improvements to meet the national referral to treatment times.
  • The trust must ensure that fewer appointments are cancelled by the hospital at short notice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 27 July 2016

Effective

Requires improvement

Updated 27 July 2016

Caring

Good

Updated 27 July 2016

Responsive

Requires improvement

Updated 27 July 2016

Well-led

Requires improvement

Updated 27 July 2016

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 27 July 2016

Overall, maternity and gynaecology services at Yeovil District Hospital were rated as requires improvement.

The safety of maternity and gynaecology was rated as requires improvement. Infection prevention and control was not always given sufficient priority within the maternity operating theatre. Where daily schedules were required for cleaning, these were not available for staff to sign indicate cleaning had been done and where the environment did not comply with national standards we did not see a long term plan to address this. We saw that the maternity theatre was in a state of disrepair and that medicines were not stored securely. The theatre refurbishment was on the trusts risk register but funding was not currently available. We were so concerned that we immediately informed the trust senior management team. The trust closed the theatre to make repairs and undertake a deep clean. We saw on our unannounced inspection that these had been undertaken.

Where daily checks were required for the checking of emergency and resuscitation equipment, staff had not always signed to indicate this had been done in either gynaecology or in maternity.

There was a heavy reliance on agency and bank staff on the gynaecology ward and there were times when the skill mix did not meet the care requirements of women undergoing gynaecological procedures. Staffing was planned to provide a ratio of one qualified nurse for every eight patients; however, one nurse we spoke with had been responsible for overseeing the care of fifteen patients at the time of our inspection. However, staffing levels and skill mix on the maternity and labour ward were planned, implemented and reviewed to keep patient’s safe at all times. Staffing shortages were acted upon appropriately. There was adequate consultant obstetric cover in the delivery suite at 40 hours a week which was in line with Royal College of Obstetricians and Gynaecologists RCOG guidelines (2007).

We rated the effectiveness of maternity and gynaecology services as good. The maternity service had achieved full UNICEF Baby Friendly accreditation and breastfeeding rates for initiation were good. Women said that they were able to access pain relief in labour and after they had had their babies, and this was provided to them in a timely manner. Midwives were qualified and had the skills they needed to carry out their roles effectively and in line with best practice. They were supported to deliver effective care and treatment through clinical supervision, the appraisal process and peer to peer support.

There was an enhanced recovery programme for women undergoing gynaecology surgery. However we also found that patients on the gynaecology ward did not always have a comprehensive assessment of their needs, which included nutrition and hydration and physical and emotional aspects of their care.

The care given to women using maternity and gynaecology services was good. Feedback about midwifery services was positive, staff were well motivated, dedicated to their roles and women told us they felt safe and well cared for. Women were treated with dignity, respect and kindness during all interactions.

The responsiveness of maternity and gynaecology services required improvement. The gynaecology ward was being used as an escalation ward and the gynaecology day-case unit was being used for patients to stay overnight because of bed capacity issues throughout the trust, which meant elective gynaecology surgery was being cancelled. The operating table in the gynaecology theatre was not suitable for women who had a high body mass index (BMI). Women with a weight above 140kg had to have their surgery performed in the main operating theatre in the main hospital. This led to difficulties in arranging surgery for these women at a time that was convenient for the gynaecologists. Because of bed capacity issues, women who were undergoing a termination of pregnancy, either because of an unwanted pregnancy or because of fetal abnormalities at times were nursed in bays with elderly women, some of whom were living with dementia.

Colposcopies took place in a room off the gynaecology ward. There was one consulting room with a couch where the women were consulted and colposcopies were performed. There was no recovery area and women who had undergone the procedure were required to recover in the day room with women who were waiting to be seen. The colposcopy room was small and there was no separate changing area for women to get changed, so women had to get changed in the colposcopy room. There were plans to upgrade this service. Plans were in place and had been approved. However, we also found that women were given a choice of birth in line with national guidance and services were mostly arranged to meet the needs of women and there were a range of specialist midwives and clinics to support them.

The leadership of maternity and gynaecology services required improvement. There was no established strategy or vision for maternity and gynaecology services, although there was evidence of staff being involved in the future development of a vision and strategy. There was a maternity and gynaecology risk register and senior staff at governance meetings had discussed the risks but there was little evidence that the risk register had been recently updated or that there were any action plans for the risks identified. The risks relating to the maternity operating theatre had been on the risk register since 2014 and no action had been taken to mitigate the risks.

At ward level we observed examples of good leadership principles; however, business unit managers had not addressed the issues which were known to them such as the poor maintenance, long standing repair issues and infection control issues in the maternity theatre and did not have plans in place to ensure that women were cared for safely and in a responsive manner. However, we also found there was a positive culture throughout the service. Staff reported positive working relationships and there was good public and staff engagement.

Medical care (including older people’s care)

Requires improvement

Updated 27 July 2016

Overall, we found the medical services at Yeovil District Hospital required improvement; however we did find that effective and caring were good. We found that safe, responsive and well led required improvement.

There was a significant breach of patient information and confidentiality within one ward, which, despite the inspection team bringing this to the attention of the trust, did not act immediately to rectify this. We also found isolated cases throughout the medical wards where medical record trolleys were left open or notes were left open and accessible to the public at nurses’ stations.

Patient risk assessments were generally completed on admission with the exception of a few isolated incidents where we found incomplete assessments. However, the medical business unit did not use individualised care plans for patients, making it difficult to identify if staff were taking action to mitigate any risks found in the initial assessments.

Medicine management within the medical business unit was generally good. However the recording of controlled drugs (CDs) in the discharge lounge caused concern. It was not possible from the records available to identify if patients had received their CD medicines to take home with them.

Staff were following relevant National Institute for Health and Clinical Excellence (NICE) guidance. Staff regularly assessed patients for pain and provided pain relief in a timely manner for those who required it. All new staff attended a corporate induction programme which was supplemented with a local induction to their ward or department.

Patients we spoke with during our inspection told us they received care, which was dignified and respectful, and were complimentary about the staff providing the care. We saw examples where staff provided care that was compassionate and kind and reflected feedback from the patients themselves.

The trust had been experiencing high demand with high levels of bed occupancy, which reached 100% for the medical business unit during our inspection. The escalation ward, which was often opened to care for patients of both sexes at times of high demand, was not equipped to accommodate patients for long periods and could not meet the personal hygiene needs of patients. During our inspection, patients had been admitted onto the ward for periods from 48 hours to several days. The area was not meeting the single sex requirements with patients of the opposite sex often having to walk past other patients to get to the toileting facilities.

With high demand and high bed occupancy, we saw large numbers of medical outliers throughout the hospital. The consultants from the medical business unit had made improvements to how some patients in non-medical specialty wards were cared for; however this was not consistent throughout the hospital. Younger adults, between the ages of 18 and 23 were being cared for on the children’s ward and we found staff on both the children’s ward and the gynaecology ward were experiencing difficulties when trying to access doctors from the medical business unit to care and review outlying medical patients.

Overall, the trust had mechanisms in place where they would try to meet the individual needs of patients, which included the use of activities to occupy patients living with dementia. However this was not consistent across the wards in the medical business unit and was reflected in the Patient-Led Assessment of the Care Environment (PLACE) score for the provision of care for patients living with dementia.

There was a mixed response as to whether the executive managers were visible on a regular basis; some staff had not seen any of them in their areas before. Although there was a business unit risk register, we were not assured that governance processes were in place to appropriately reduce and manage risks. However, staff spoke positively of their immediate managers and matrons. They also added there was an open and honest culture in the business unit and managers had an ‘open door’ approach.

Urgent and emergency services (A&E)

Requires improvement

Updated 27 July 2016

Safety in the emergency department was found to require improvement for the following reasons. There were not robust systems in place to ensure patients were protected from infection. Nurse-staffing levels were not adequate with a reliance on bank and agency nurses. Patients experienced waiting times of up to 75 minutes for initial clinical assessment (triage), meaning there was a risk of unobserved patient deterioration. For children the designated children’s waiting area did not ensure their safety and the children’s examination room was not fit for purpose due to limited space and access to emergency equipment. Specialist consultant on-site cover did not meet the college of emergency medicine recommendation of 16 hours on-site presence in each 24 hours.

During an unannounced inspection, ten days after the initial inspection, the trust had taken action to address areas of concern. This included an increased nursing establishment, reducing triage time and to support patients waiting in the corridor. The trust also increased specialist registrar cover during the evening and improved security for the children’s waiting area. We saw these improvements on our unannounced inspection.

There was a positive reporting culture and staff were knowledgeable about major incident procedures.

The emergency department was rated as requires improvement for effective for the following reasons. There were gaps in support arrangements for junior medical staff and no local induction programme. There was a range of treatment pathways available for use in the emergency department however; these were not always applied effectively, putting patients at risk. Nursing and non-clinical staff appraisal rates were below the trust target of 90%. However, we found the department had received a positive outcome following peer review for trauma unit status. Nurses had access to external advanced practitioner training and there was an effective multidisciplinary steering group.

Caring was rated as good with staff showing compassion and respect for privacy and dignity when patients and visitors attended the emergency department. Parents told us they were kept fully informed of their children’s condition and treatment whilst in the department. Volunteers provided excellent support to patients and visitors. However we found patient’s privacy and dignity was compromised when they were being cared for in the major’s area corridor and patients were not kept informed of waiting times or provided with updates on their treatment plan whilst in the department.

Responsive in the emergency department was rated as requires improvement because the emergency department did not meet the needs of the local population. During the inspection, the department was experiencing a period of high demand for which there was a lack of effective escalation and management. The department did not meet the department of health (DOH) targets for initial clinical triage and time to treatment or discharge. The department did not meet the Health Building Note (HBN 15-01) for the provision of emergency care. However there was good facilities provided by the trust for patients and visitors in the waiting area and there was ready access to translation services.

For well led we considered the emergency department to require improvement. We found there was a lack of active leadership or continual monitoring of capacity and demand. This resulted in crisis rather than proactive management of escalation situations. Staff in the emergency department were not aware of the emergency department vision for the future. However, we did see a copy of the department’s vision document, which was part of the trust’s vision and business strategy 2016/17. The trust had supported the development of a nurse led acute ambulatory care unit in the emergency department.

Surgery

Good

Updated 27 July 2016

Overall, we rated surgical services as Good.

Staff were not aware of current infection prevention and control guidelines, particularly in relation to documentation of water testing for legionella. Cleaning schedules and logs were not available. However equipment was available, which appeared visibly clean, safe and well maintained. Controlled medicines were managed and stored correctly, however we found some documentation relating to intravenous medication to be out of date.

Staff attended mandatory training. We found staffing levels were within establishment boundaries, the ward teams were not able to provide the trust recommended 1:8 nurse to patient ratio. Patients were on the whole risk assessed appropriately although were not provided with individualised care plans. Patients were assessed individually for pain relief and for their nutritional requirements. However the Malnutrition Universal Screening Tool (MUST ) was not used consistently across all areas.

Safe systems were in place for reporting incidents, duty of candour and safeguarding issues. However, there had been one never event in the reporting period. We found that the five steps to safer surgery checklists were completed consistently.

Staff provided care and monitored compliance in line with national best practice guidelines. Surgical wards received a relatively high number of medical patients, for whom the medical wards did not have sufficient capacity. This impacted on the quality of care for all patients.

Patients, carers and families were positive about the care and treatment provided. They felt supported, involved and staff actively engaged with patients whilst providing kind, compassionate care. We observed positive interactions when staff obtained consent. Staff supported patients and relatives with their emotional and spiritual needs.

The surgical care group participated in a number of local and national clinical audits and acted upon any recommendations. Data from the audits was positive and the trust had action plans in place.

Staff were competent and supported by managers. Multidisciplinary team working was established and effective within the surgical wards and theatres.

Service planning and delivery took into account the needs of local people. Discharges were planned with the multidisciplinary team, however due to community pressures these were not always timely.

NHS England data showed that the national 18 week referral to treatment time targets were not being met. The number of cancelled elective operations as a percentage of elective admissions was consistently above the England average. However, of the 101 cancelled operations between October 2015 and January 2016 all but six have been rebooked within 28 days which was consistently lower than the England average.

There were clear governance structures in place and lines of accountability. Leaders were visible and staff were positive about local leadership. Trust values were understood by staff and embedded in appraisal documentation. Information on how the public could provide feedback was displayed in some departmental areas.

Intensive/critical care

Good

Updated 27 July 2016

The overall rating for the critical care services was good.

We rated the safety of critical care as good. Patient safety was given sufficient priority. An effective system was in place for the reporting and investigation of incidents, and this had led to improvements in the delivery of patient care and outcomes. There was sufficient equipment for the delivery of patient care and the environment was clean.

The unit had nursing and medical staff vacancies and recruitment was a challenge. Additional intensive care consultants were needed to enable the care of all patients on the critical care unit to be led and managed by an intensive care consultant at all times.

Senior nurses supported the critical care outreach service on a rotational basis which provided a good development opportunity but also impacted on the number experienced staff on the unit. Senior staff continually monitored staffing levels to ensure patient safety was maintained. The outreach service assisted in the early recognition of patients who were at risk of deterioration throughout the hospital and the follow up of patients who had been discharged from critical care.

We rated the effectiveness of critical care as good. Patients received evidenced based care that was based on comprehensive patient assessments and regular evaluation. Patient outcomes were monitored and were good.

Despite not having a dedicated clinical educator staff overall were supported in their personal development and training. Access to the critical care post registration qualification however was limited to two staff per year and less than 50% of the nurses currently held this critical care qualification as required by the Core Standards for Intensive Care. Although the multidisciplinary team (MDT) was an integral part of the patient care, a daily MDT ward round involving all members of the team did not take place.

We rated caring on the unit as good. Patient and relative feedback was very positive and care was patient centred. Staff understood the impact critical illness had on both patients and their relatives and this was reflected in the care that was delivered and how it was delivered. Patient diaries were well managed and assisted patients to recover and relatives to feel supported following a period of critical illness.

We rated the responsiveness of critical care as good. Critical care was delivered in a way that met the individual needs of critically ill patients. Patients were not always discharged from the unit within four hours of the decision being made to discharge them or before 10pm. Whilst this was not in line with the Core Standard for Intensive Care requirements, the timeliness of discharging patients was influenced by the availability of beds within the hospital. This was not in the direct control of the critical care unit. There was no evidence to suggest that bed availability was leading to non-clinical transfers of critically ill patients to other hospitals however elective operations had been cancelled due to critical care beds being available. Patients were offered the appropriate support with their rehabilitation following a critical illness, and a clear rehabilitation pathway was in place which included a follow up clinic visit.

Senior nursing staff were visible and accessible to patients, visitors and staff. The senior sister provided clear and professional leadership. There was an open and honest culture and staff were passionate about patient care. The senior leadership team were clear in their objective of wanting to meet the Core Standards for Intensive Care and have a closed unit model of care; with care being led by a consultant in intensive care medicine. At present any consultant can admit a patient to the unit without review by an intensivist. They were actively recruiting medical staff to enable this objective to be met.

Services for children & young people

Requires improvement

Updated 27 July 2016

Overall, we rated services for children and young people as requires improvement. We found:

The environment on Ward 10 presented a potential risk to young patients and children. The ward included a young person’s unit, which cared for adult patients up to the age of 24 years of age. There was no barrier between the different areas and no way of preventing adults from potentially having access to young children. This also presented safeguarding risks to patients. We raised this immediately with senior managers at the trust. Senior managers said they were assured that patients were safe. However, we also wrote a letter outlining our serious concerns to the trust shortly after the inspection. Following our letter, the trust ensured through its senior team that the admission criteria for the young person’s unit was followed i.e. that only patients in transition or those who have specific vulnerabilities were admitted. The trust have also commissioned a review of the area by the Royal College of Paediatrics and Child Health and have committed to implement their findings. Post inspection, the trust reported all admissions to this unit so stakeholders could monitor actions taken.

Whilst staff had been trained in safeguarding procedures there was not enough staff appropriately trained in child safeguarding as per intercollegiate guidance. A lack of appropriate training presented a risk to patients and a risk of staff not recognising signs of abuse.

We saw there was a lack of specialist beds for young people with mental health conditions. This meant that staff on Ward 10 cared for patients who required specialist mental health support rather than medical care. Staff and patients were at risk of harm from some patients who needed specialist mental health support. Staff had not had appropriate training to manage patients with aggressive behaviour.

There were not enough members of staff trained in European Paediatric Life Support (EPLS) training to meet Royal College of Nursing guidance of one EPLS trained member of staff on each shift. Medical staff were trained in EPLS and were available 24hours per day.

Data from the trust showed staff observing policies on hand hygiene had consistently been below trust standards

We saw managers did not always change staffing levels to reflect the acuity of patients on Ward 10. We saw from rotas provided by the trust the service did not always have access to a senior children’s nurse at all times during a 24-hour period in accordance with British Association of Perinatal Medicine (BAPM) standards.

The service had not reviewed guidelines for staff since 2013. Four out of seven guidelines we reviewed did not have review dates meaning there was no assurance trust guidelines met the latest national guidance.

There were a limited number of transitional services available for young people.

The trust did not have a play service or play specialist. Hospital play specialists work with children, and their parents and carers, to help them cope while being treated in hospital or at clinics.

The environment presented a challenge to services. For example, parts of the building needed additional work and repair and patients could not use an outside play area due to it requiring further development. In addition, some facilities on Ward 10 were not suitable for disabled patients.

Outpatient clinics used a ‘full booking’ system for follow up appointments. The system provided patients with an appointment date upon leaving the clinic. This meant clinics could be booked up months in advance reducing the flexibility to manage appointments and contributing to higher cancellation rates.

The service could not assure the inspection team they had addressed risks presented to children and young people on Ward 10. There was a lack of oversight of ward admissions and a lack of progress against recommendations identified in a review of the service in 2012.

The governance and management of children’s outpatients meant there was a lack of supervision, performance management and delays to allocating appointments. This led to some staff in outpatients feeling unsupported and a lack of leadership visibility on occasion.

However we also found:

Staff knew how to report incidents and when they had done so. We saw incidents investigated in accordance with trust policy and staff gave us examples of learning from incidents. We saw staff observed the Duty of candour in incident investigations. Staff had received training on the Duty of candour and could demonstrate how they had used it when things went wrong.

Equipment, including resuscitation equipment was suitable for patients of all ages. We saw staff checked and tested equipment regularly.

Medicines were stored in locked rooms, cupboards, and fridges. Staff monitored fridge temperatures using an automated monitoring system. Staff recorded and clearly documented key patient information on drug charts.

Staff worked together to assess and plan ongoing care and treatment in a timely way when patients were due to move between teams or services, including referral, discharge and transition.

Staff demonstrated through discussion their understanding of Gillick competence and understood the consent process. We saw staff ask parents about consent to treat patients and where parents were not present staff telephoned parents to gain consent.

There were appropriate assessments of patient nutrition and hydration. Where required, children, young people and baby’s care plans included comprehensive nutrition and hydration requirements.

We saw strong and positive relationships between staff and patients, in particular regular users of children’s services. Staff spent time getting to know patients and understanding their needs.

Staff involved patients, carers, and parents in care and treatment and ensured they understood their treatment and conditions. Staff in the Special Care Baby Unit encouraged parent involvement in their baby’s care and treatment wherever possible.

Staff were compassionate and caring towards patients. Patients and their relatives/carers were positive about their care and treatment. The service had positive patient feedback results on the care and treatment they delivered.

The community nursing team provided a range of different services to meet the needs of patients. The team included specialists or nurses with an interest in specific conditions such as cystic fibrosis, oncology and end of life care.

Services for children and young people had a school based within the children’s outpatients department. The school had a qualified teacher working Monday to Friday to provide education to patients who had been in hospital for long periods.

The trust had specialist staff to support and care for patients with learning disabilities and diabetes. Services could access translators, translation materials and interpreters.

Staff had access to specialist support for patients with mental health conditions. Staff could also access out of hours psychiatric advice and support for patients.

End of life care

Requires improvement

Updated 27 July 2016

Overall, we rated end of life care services as requires improvement. We rated safe, caring and responsive for end of life care services as good, with effective and well-led requiring improvement.

Risk assessments for patients were completed appropriately and were re-evaluated within the required time frame to ensure risks were minimised. The wards we inspected had appropriate systems for the safe storage of medicines. Medical notes were also safely stored in locked medical notes trolleys. We found care records were mostly maintained in line with trust policy. Staff understood their responsibilities in following safeguarding procedures.

Staff understood their responsibilities in following safeguarding procedures.

We also found that The National Council for Palliative Care recommends one WTE consultant for every 250 beds; the hospital had 345 beds and therefore the trust did not meet this, as the consultant staffing provision was not in line with recommended guidelines.

We looked at 26 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ orders (DNACPR) across the trust and found there were inconsistencies in how these were completed. We found that out of 26 DNACPR orders, nine were completed correctly (35%). We found staff had not always followed trust policy when they completed DNACPR orders.

The trust had participated in the National Care of the Dying Audit 2013/14 but had not developed an action plan to address four of the seven organisational indicators and the one clinical key performance indicator that had been missed. The trust participated in the National Care of the Dying Audit 2015. This was not published until after our inspection in March 2016. The trust had not had the opportunity to review or respond to the 2015 audit report at the time of the inspection.

However, we saw that care and treatment was delivered in line with recognised guidance and evidence based practice. The last days of life care plan had recently been rolled out throughout the trust. The trust had effective multidisciplinary working in place.

We observed patients being cared for with dignity and respect. Staff were seen to be compassionate and we observed them treating patients and their families with dignity and respect. Patients we spoke with told us that staff were caring and looked after them well.

A bereavement service was offered on site, with staff available to support family members with practical and support issues following bereavement. The chaplaincy service provided a 24 hour, seven days a week on call service for patients in the hospital, as well as their relatives, and aimed to see people within the hour. Patients who were referred to the specialist palliative care team were seen according to their needs.

During 2014/15 the specialist palliative care team (SPCT) received 564 referrals, 60% of these were patients with a diagnosis of cancer and 40% of patients with a non-cancer diagnosis. This indicated that specialist care was being provided for patients with other life shortening conditions. Ward staff said the SPCT normally responded within 12 hours of referrals.

The trust did not have a Rapid Discharge Home to Die Pathway. Discharge in these circumstances was arranged by the palliative care clinical nurse specialist and could be facilitated within a few hours for patients wishing to return home.

There was no written strategy for end of life care throughout the trust. The trust was an integral member of the Somerset Palliative Care and End of Life Programme Group and had been involved in developing the Somerset End of life Strategy which was due for final review in June 2016. This will subsequently inform the local strategy once ratified.

There was no internal audit results for end of life care services available at the time of our inspection. However a plan was in place to conduct audits in the coming year. . However, staff spoke positively about the service they provided for patients. High quality, compassionate patient care was seen as a priority. Staff within the specialist palliative care team spoke positively and passionately about the service and care, they provided for patients.

The trust’s iCARE strategy incorporates the values of communicate, attitude, respect and environment. The mortuary won iCARE team of the year in 2015.

Outpatients

Good

Updated 27 July 2016

We rated outpatients and diagnostic services (OPD) at Yeovil District Hospital as good overall.

Systems were in place for keeping people safe. Staff were aware of how to report incidents, safeguarding issues and the Duty of Candour process. Risks to patients using the service were assessed and appropriately managed.

Consent to care and treatment was obtained in line with legislation and guidance. Staff were suitably qualified and skilled to carry out their roles effectively. Staff described a good learning environment, with good role progression.

We saw good examples of the service being redesigned and improvements made to meet the needs of the patients.

Patients spoke positively of staff that they encountered, and the care they received. Staff were observed to be caring and compassionate in the way they cared for patients, their families and carers.

Changes made to appointment booking and reminder system were structured to target the clinics with highest did not attend rate. These changes were monitored before implementation throughout the department.

Staff felt included in the changes made in the unit. They described a supportive environment in which to work.