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Inspection Summary


Overall summary & rating

Good

Updated 5 December 2017

Our inspection of the trust covered only this hospital. What we found is summarised in the Overall summary under the sub-heading Overall trust.

Inspection areas

Safe

Requires improvement

Updated 5 December 2017

Effective

Good

Updated 5 December 2017

Caring

Outstanding

Updated 5 December 2017

Responsive

Good

Updated 5 December 2017

Well-led

Good

Updated 5 December 2017

Checks on specific services

Maternity and gynaecology

Good

Updated 25 May 2016

Overall, maternity and gynaecology services at Musgrove Park Hospital were rated as good.

The safety of maternity and gynaecology services were rated as requires improvement, with effectiveness, caring, responsiveness and leadership rated as good.

The maternity service provided an average ratio of one whole time equivalent (WTE) midwife to 31 births, which was below the national standard of one midwife to 28 births.

Anaesthetic staffing out of hours did not meet the guidance of the Association of Anaesthetists of Great Britain and Ireland (AAGBI); this states that a duty anaesthetist must be immediately available on Labour Wards 24/7 and that there should be a minimum of 12 consultant anaesthetist sessions per week.

Where daily checks were required for cleaning and checking of emergency and resuscitation equipment, staff had not always signed to indicate this had been done.

Rates of compliance with appraisals, safeguarding and mandatory training including skills and drills training for midwives were below the trust targets.

Frequently occurring incidents were not always reported.

Midwifery staff had not received training in the care of the critically ill woman and anaesthetic recovery in line with current guidance, however systems were in place to ensure women having general anaesthetic received suitable care during recovery.

Some maternity guidelines were not compliant with current evidence based guidance, however plans were in place to address this.

The normal birth, home birth, overall caesarean section and instrumental delivery rates were all better than the national average. The average waiting time for women waiting for epidurals was less than 30 minutes. The maternity service had achieved UNICEF Baby Friendly stage three accreditation, and breastfeeding statistics for initiation within 48 hours of birth were higher (better than) the trust target. The service had introduced a range of care initiatives that had been successful in reducing the still birth rate.

The care provided to patients in maternity and gynaecology services was good. Without exception, patients and their families said they had been treated with kindness and respect and described staff as caring.

Women were given a choice of place of birth in line with national guidance. Services were arranged to meet women’s needs with a range of specialist clinics and midwives to support them.

There was no dedicated elective caesarean section list which could lead to patients facing delays.

The emergency gynaecology service was fragmented.

There was a clear vision and strategy in place for the development of the service. A staff leadership programme was available and staff worked well together.

The Head of Midwifery was not visible to more junior staff.

Senior midwives in maternity were aware of a difference in status to other staff of the same grade in the other parts of the hospital. Band seven staff were not always supernumerary in comparison to other hospital staff of the same grade.

Medical care (including older people’s care)

Good

Updated 25 May 2016

Overall, we rated medical care services, including care of older people at Musgrove Park Hospital as good, but safety requires improvement. We rated caring as outstanding.

We found:

Patients received evidenced based care and treatment and we saw policies based on national guidance. Staff assessed and managed patient’s hydration, nutrition and pain appropriately.

The trust took part in local and national audits to assess patient outcomes and the quality of care. Results from these audits were mostly positive. There was evidence of some seven day working particularly from diagnostic imaging and reporting.

The service had very positive friends and family test results with an average of 100% and 98% for HOPE and Acute Medicine directorates respectively. This meant almost all patients were would recommend the service to others.

Staff treated patients with compassion, dignity and respect and we saw staff going the extra mile for patients. Patients were positive about their care and we saw that they were involved in their care and treatment.

There was a proactive approach to bed management and discharge planning began from the moment the patient arrived in hospital. Services were responsive to patient needs and medical outliers (medical patients placed on surgical wards) received appropriate care and treatment that reflected their condition.

There were positive stroke and cardiac pathways to improve access to treatment times and discharge.

There were systems and processes to manage risk and quality assurance, including local and clinical audits. Staff at all levels took ownership and responsibility for quality assurance.

Leadership was visible at all levels of the service. Leaders were aware of issues affecting service delivery and passionate about their staff. Staff felt supported and there was an open, honest patient centred culture.

There was a robust incident reporting procedure. Staff knew and demonstrated how they could report incidents. We saw that there was learning from incidents.

Nursing and medical staffing levels were safe. Nursing and medical staff received support from managers and senior clinicians and received regular supervisions.

However, we also found:

Staff did not assess all patients appropriately on their arrival to hospital. We saw evidence of risk assessments not completed or dated, and deteriorating patients not treated in a timely manner.

Staff compliance with infection control policies and procedures were inconsistent, particularly on the acute medical unit (AMU). Hand hygiene audits for AMU were poor and staff did not always ensure a safe environment for patients.

The environment presented a challenge to staff and service delivery. Despite the trust having a bed escalation plan additional beds were kept open in the clinical decisions unit while patients waited for medical beds.

Staff did not always follow procedures around assessing patient capacity and applying for deprivation of liberty safeguards (DoLS) authorisation.

Urgent and emergency services (A&E)

Good

Updated 5 December 2017

Urgent care centre

Updated 21 November 2013

The A&E department provided effective care and staff were caring and responsive. Most patients were seen and treated within the national waiting time limit of four hours and plans were put in place for discharge or transfers for further care and treatment. However, there were not always enough senior doctors present at night and weekends. Children were seen by appropriate child care specialists but there were concerns that not enough staff in the A&E department had up-to-date qualifications in emergency child care.

Surgery

Good

Updated 5 December 2017

Intensive/critical care

Good

Updated 25 May 2016

Overall critical care at this hospital was rated as good.

Safety of critical care was rated as requires improvement. There was limited assurance about safety. Overnight, we could not be assured medical assistance would be immediately available to provide advanced airway management before the consultant arrived. This did not meet Core Standards for Intensive Care 2013.

The environment did not meet national standards and this had not been highlighted on the critical care risk register. Guidelines for the Provision of Intensive Care Services (GPICS) state existing facilities that do not comply with HBN 04-02 should identify a program of work/time-line to establish when national standards will be met and, should note this as part of their risk register.

Infection prevention and control was not always given sufficient priority. During our inspection, we noted peeling paint, rust on radiators and broken and stained ceiling tiles in various areas across ITU and HDU.

Where daily checks were required for cleaning, storage of medicines and checking of resuscitation equipment, staff had not always signed to indicate this had been done.

However, patients were protected from abuse. Staff had an understanding of how to protect patients from abuse.

We judged that the effectiveness of this service was good. Patients received effective care and treatment that mostly reflected current evidence-based guidance, standards and best practice. Patients had a comprehensive assessment of their needs, which included pain management, nutrition and hydration and physical and emotional aspects of their care. Outcomes for patients were routinely collected and monitored, and were mostly positive.

The care provided to patients in critical care was outstanding. Patients were truly respected and valued as individuals and were empowered partners in their care.

We found the responsiveness of critical care to be good. Services were tailored to meet the needs of the individual patient with a proactive approach to understanding the needs of different groups of people.

The leadership of critical care was good. This was an innovative service with a clear vision and a strong focus on patient centred care. Staff were engaged and demonstrated commitment to delivering high quality patient-centred care.

Services for children & young people

Good

Updated 25 May 2016

Overall, the children’s and young people’s service was rated as good.

We found services for children, young people and their families were effective, caring, responsive and well led. However, improvements were needed for the service to be safe.

Staffing within the children’s service, although currently considered as being safe by the senior management, and reflecting both occupancy rates and the fluctuating number of children as inpatients, were recognised as not achieving Royal College of Nursing (RCN) (2013) guidance because they had two less staff per shift than recommended by national guidance.

A paediatric nursing community team of 10 children’s nurses supported the children’s and neonatal service throughout the Somerset region.

Shortfalls in trained nurse provision on the neonatal unit and within children’s services were managed through escalation pathways and through the support of an identified bleep holder.

The trust stated that funding for the two-bedded paediatric high dependency unit (HDU) was proportional to bed occupancy and monitored through the South West Specialist Clinical Network. The current 

funded staffing establishment was 4.7 whole time equivalent trained nurses. Eight band six nursing staff (not all of which were full time) worked in the HDU and were managed and supported by a band seven nurse who was HDU and advanced paediatric life support (APLS) trained. We were told that the majority of time the HDU was staffed by band six nurses who had completed the HDU course; however, there were occasions when an experienced band five nurse who did not have the HDU course would work in the HDU area.

The service was not compliant against the ‘Facing the Future’ standards because of a lack of permanent consultant cover between 5pm – 10pm. The trust identified that in accordance with ‘Facing the Future 2015’ funding was secured to provide additional senior paediatric consultant cover until later evenings (5pm until 10pm) to match periods of highest activity.

Neonatal staffing did not fully meet the British Association of Perinatal Medicine (BAPM) Guidelines (2011) (BAPM) because they could not always provide 1:1 and 1:2 care for babies who required intensive care or high dependency care. The staffing report (1 April 2015 – 26 January 2016) confirmed that 32% of shifts were not compliant against the neonatal staffing toolkit. Because of this the neonatal caseload has been reduced by 0.34%.The failure to comply with the neonatal toolkit in respect of staffing and the potential risk to the neonatal intensive care service had been recognised as a risk on the women’s and children’s risk register.

The failure to comply with the neonatal toolkit in respect of medical cover overnight and the potential risk to the neonatal intensive care service had been recognised as a risk on the women’s and children’s risk register.

The South West Neonatal Network recorded neonatal daily staffing levels across the South West and the trust was comparable in terms of levels of neonatal staffing with other units in the South West.

There was generally good access and flow within the children’s service. Patients received evidenced based care and treatment and good multi-disciplinary working existed between the children’s services, external providers and the child and adolescent mental health service (CAMHS).

Monitoring records of resuscitation equipment and neonatal transport systems showed that monitoring of this equipment had not taken place daily.

There were shortfalls in the management and storage of some medication in the neonatal unit and child development centre.

Training shortfalls existed in some areas, for example in mandatory training, advanced paediatric life support (APLS) and European paediatric life support (EPLS) training.

This meant that the service could not provide at least one nurse per shift in each clinical area trained in APLS or EPLS as identified by the RCN (2013) staffing guidance, although 79% of nursing staff did carry the PILS qualification for paediatric life support.

Staff were caring, compassionate and respectful. Staff were positive about working in the service and there was a culture of flexibility and commitment.

The service was well led and a clear leadership structure was in place. Individual management of the different areas providing acute children’s services were well led. A governance system was in place and we saw clinical risks were identified. Feedback from staff, parents, children and young people had resulted in changes to aspects within the service.

End of life care

Good

Updated 5 December 2017

A summary of this service appears in the Overall summary.

Outpatients

Good

Updated 5 December 2017

A summary of this service appears in the Overall summary.