8 May 2019
Yeovil District Hospital has 320 beds, 14 inpatient wards, and an integrated private patients’ wing (profit from which is reinvested into the trust). The trust provides full emergency department services for adults and children, and critical care for adults. Patients are admitted for emergency and planned surgery, and a full range of medical care services. There are a range of outpatient services, services for older people, acute stroke care, cancer services and a full pharmacy service. Yeovil District Hospital is an accredited trauma unit as part of the Severn Trauma Network.
The hospital provides comprehensive maternity services, including a midwife-led maternity unit, community midwifery antenatal care, postnatal care, and home births. The trust has a special care baby unit and children’s services including emergency assessment, inpatient and outpatient care.
Diagnostic services include fully accredited pathology, CT scanning, MRI scanning, ultrasound, cardiac angiography and a respiratory laboratory. There are a wide range of therapy services, a frailty assessment unit, and an integrated service working with GPs and social services.
8 May 2019
Our rating of services improved. We rated it them as good because:
- There were systems and processes to keep patients safe and safeguarded from abuse. There was a proactive approach to safeguarding and prevention of harm. Staff had received up-to-date training. Staffing levels were planned and with staff with the right skills to keep patients safe. There were effective handovers so staff knew about the patients they were caring for. Medicines were used and provided safely. They were well managed. Lessons were learned when things went wrong, and staff were confident about reporting incidents.
- Patients had good outcomes, and there was a strong culture of doing what was right for patients. Care was delivered in line with national guidance and legislation. There were good assessments of patients’ needs, including pain relief, hydration and nutrition. Staff were trained and their performance regularly reviewed. They were supported to gain new and improved skills to develop their practice and experience. Staff worked together to ensure care and treatment was effective.
- Patients and relatives spoke highly of staff and the standards and quality of care. Feedback was positive, and patients we met said they had been treated with dignity and respect. Patients could make their own decisions, and the right people were involved if a patient was not able to do so. Patients’ emotional needs were recognised and supported.
- Services were planned and arranged to meet the general and specific needs of local people. The needs and preferences of different people were accounted for to give patients the best outcomes. The hospital was treating most patients on time and within national targets and standards.
- The staff leadership had the skills, knowledge, experience to oversee services. High-quality and patient-centred care was promoted. There was a clear set of values for staff which were based on the experience for the patient. Staff were well supported and there was good morale and a strong culture. Staff were willing to challenge poor practice and support each other. There was a strong culture around innovation, research, development and improvement. Staff had good systems to assure themselves they were providing a good, safe and quality service.
- Some staff had yet to update their mandatory training in line with trust targets. Not all resuscitation equipment was checked as required. There were some areas where infection prevention and control were not as strong as they should be.
- Not all patients’ medical records were completed as well as they should have been. There were gaps around assessing patients’ mental health, risk assessments and responding to the needs of deteriorating patients. The paperwork documenting resuscitation discussions was not always completed in line with trust policy.
- There were issues with the environment in the children’s ward which impacted on patients. A business plan to resolve much of this had yet to be approved. Some specialist training around eating disorders for staff looking after children had yet to be provided. There was limited access to therapy for children over the weekend. The processes for safe administration of medicines through a syringe driver were not sufficient to guide staff.
8 May 2019
Our rating of this service improved. We rated it as good because:
- We rated safe as requires improvement and effective, caring, responsive and well-led as good. Overall, we rated the service as good.
- The effectiveness of the service continued to be good. People received care and treatment that reflected current evidence-based guidance and achieved good outcomes. Performance in national audits met national standards most of the time.
- The care provided by staff continued to be good. People were supported, treated with dignity and respect, and were involved as partners in their care.
- The responsiveness of the service had improved. There were innovative services to meet the needs of the population. Staff cared for patients with additional needs well and care for patients living with dementia had improved.
- The management of the service had improved. We found the leadership, governance and culture supported the delivery of high-quality care. There were clear governance processes from ward level up to the trust board. The trust worked well with the local authority and external providers to deliver high quality services. Staff were engaged with quality improvement projects.
- Systems and processes to keep people safe were not always followed in relation to the risk assessments for patients, responding to deteriorating patients and the quality of nursing records. Records were not always up-to-date in a way that kept people safe.
- Staff did not always understand their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Staff did not always follow the trust policy and procedures when a patient needed a mental capacity assessment.
8 May 2019
- The trust provided an effective, caring, responsive and well led service for children and young people.
- Staff safeguarded children and young people and were knowledgeable regarding the action to taken where abuse was suspected.
- The control of infection was managed well and staff were knowledgeable about the prevention of cross infection and health related infectious diseases. Staff had access to appropriate equipment to meet the care and treatment needs of children and young people. The ward was decorated in a style to appeal to children and young people.
- The service had enough nursing staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. Staff worked well together as part of multi-disciplinary teams to meet the needs of children and young people and provide them with a seamless service.
- The service followed best practice when prescribing, giving, recording and storing medicines.
- The service managed patient safety incidents well. Staff recognised and were confident in reporting incidents.
- The care, treatment and support of children and young people promoted a good quality of life and was based on national guidelines and recommendations. The nutrition and hydration needs of babies, children and young people were assessed, monitored and met. Staff used appropriate tools to assess, monitor and manage the pain experienced by babies, children and young people. Parents and carers were included in the assessment of their child’s pain.
- Staff were competent and skilled within their roles, they worked together well as a multi-disciplinary team to meet the needs of babies, children and young people admitted to the wards. The staff supported and encouraged patients and their families to live healthier lives and provided health promotion information and practical assistance. For example, the provision of leaflets and nicotine replacement therapy.
- Children and young people were consulted regarding their care and treatment. Parents and carers were included in discussions regarding care and treatment plans and their views listened to.
- Children, young people and their families and carers were treated with compassion, kindness, dignity and respect. There was a happy atmosphere on the ward and children and young people were engaged in activities relevant to their interests and ages. Staff offered emotional support and reassurance to children, young people and their relatives and carers to minimise their distress.
- We rated safe as requires improvement. There were identified issues with the environment which impacted on the safety of children and young people who were admitted to the ward. These had not been addressed although the senior leaders had submitted a business plan which would reconfigure the layout of ward 10 and mitigate against many of the risks. This had yet to be approved.
- Not all staff had completed their mandatory training. For example, a number of medical staff had not completed safeguarding children training.
- Treatment and care plans were not always easy to locate within medical records.
- Staff were due to be provided with update training and guidance regarding the programme for the treatment of eating disorders in children and young people. This was because it had been identified that staff had not always followed the strict and complex regime for children and young people admitted for this care and treatment.
- There was a limited therapy service to the ward at weekends, for example from the physiotherapists.
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.
8 May 2019
Our rating of this service improved. We rated it as good because:
We rated effective, caring, responsive and well-led as good and safe as requires improvement.
- There were some concerns about infection prevention and control in the ageing mortuary estate, and the completion of risk assessments and documentation of decisions about resuscitation. However, the specialist palliative care team responded well to changes in patients’ conditions.
- End of life care was delivered in line with national guidance. There were systems to monitor performance and there was good multidisciplinary care and support for the benefit of the patient. However, there was an inconsistent approach and documentation to support patients’ mental capacity assessments.
- Care for patients approaching the end of their life was provided with compassion and respect. Staff sought to involve patients’ next of kin. The bereavement service and chaplaincy services continued to support relatives after the death of a loved one.
- The specialist palliative care team were responsive and reviewed referrals promptly, although they were only available during the week in normal working hours.
- Leadership and governance processes had strengthened since our last inspection. The service had a vision and a strategy to achieve this. However, processes to identify risks and incidents relating to end of life care needed to be improved. The governance processes did not have sufficient structure.
8 May 2019
We previously inspected maternity jointly with gynaecology, so we cannot compare our new ratings with previous ratings. We rated it as good because:
- We rated the caring key question as outstanding, and the safe, effective, responsive and well led key questions as good.
- Feedback from women and their families was consistently positive. We saw numerous examples where staff had ‘gone the extra mile’ and exceeded the expectations of women and their partners. Women told us they had formed a bond with their midwives and saw them as friends and advocates. Without exception, all the staff we spoke with, were most proud of the relationships they formed with women and their families.
- Support to women and families who experienced the loss of a baby was exceptional. There was a specialist midwife who provided emotional and practical support to bereaved families. There was an excellent, self-contained bereavement room, sensitively located, decorated and furnished, where women and their partners could stay for as long as they needed to come to terms with the loss of their baby. We heard moving accounts from a number of bereaved parents, who had written to express their gratitude for the support they received, which far exceeded their expectations.
- Care was centred on women and their needs and preferences. Women were empowered to make choices, based on good quality and unbiased information. The service supported women, identified as being at low risk of complications in labour, to give birth at home; feedback from women who chose this was very positive and the rate of homebirths was increasing.
- The service was committed to providing continuity of care, and women’s feedback confirmed that this was valued by them. Staffing levels mostly supported this; the service operated an integrated model of midwifery care, where staff worked flexibly in hospital and community settings, according to workload, and to ensure, where possible, women received continuity of care. Midwives operated an on-call system so that they could respond to peaks in demand.
- Women in vulnerable circumstances and those with complex needs were well supported throughout their pregnancy and postnatal period, by multidisciplinary specialist teams. This included teenagers, women with mental illness or a learning disability, women who were alcohol or substance-dependant, and women in difficult social circumstances.
- Women were encouraged and supported to look after their own and their babies’ health. This included help to stop smoking, advice on healthy eating and exercise, and advice and practical support with breastfeeding. Women were supported to have skin to skin contact with their babies as soon as possible. The service monitored this and performed well.
- Women told us staff supported them to manage their pain in childbirth and they were provided with information and choice. Women who chose to have epidural pain relief in labour received this in a reasonable time.
- The service identified women at risk of complications in pregnancy and childbirth and monitored them closely. This included women with diabetes, women who had previously had a caesarean section and women who had previously lost a baby.
- High risk women received consultant-led care, with input from other specialist teams, including anaesthetists. Multidisciplinary handovers took place every day on the labour ward and women admitted as emergencies received prompt medical input. Midwives told us if they needed a medical opinion they could get this without delay.
- There were good working relationships between obstetricians and anaesthetists. Anaesthetists attended multidisciplinary ward rounds and assessed women for planned caesarean section in pre-assessment clinics. Women who underwent planned caesarean sections followed an enhanced recovery programme. There was excellent documentation, including a patient diary, to record each stage of the patient pathway.
- The service was committed to ensuring women had a voice in the way services were planned and delivered. They used a range of methods and media to connect with women, share information, educate them, and seek their views. Where the standards of care did not meet women’s expectations, their views and feedback were listened to, learning was shared with them and they were invited to participate in that learning.
- The service used safety monitoring information and audits to provide assurance of patient safety and good patient outcomes. The service used a maternity dashboard to continuously monitor and benchmark its performance against national and local standards.
- When incidents occurred or patient experience or outcomes were not positive or as expected, the service took appropriate actions to address shortfalls and continued to monitor performance.
- There were effective structures and processes to support quality and safety. Processes interlinked to provide managers with a holistic view of safety and quality, including patient experience. There was a meetings structure, supported by a system of regular audit, which reported from ward to board. There were robust risk management arrangements and the maternity risk register was used appropriately and dynamically to monitor risk and its management.
- There was a learning culture, where safety was paramount and mistakes were openly discussed and seen as opportunities to improve safety. Staff were encouraged to speak up about concerns and improvement was everybody’s responsibility. Staff’s views were listened to and they were encouraged to participate in quality improvement projects and audits.
- There were safety systems and processes and staff were mostly up to date with training in these systems and processes. This included multidisciplinary training in maternity and neonatal emergencies. There were systems to identify and respond to changing risk, deteriorating health and medical emergencies. Systems to ensure the safety of patients in theatre were excellent, with clearly documented pathways, checklists and prompts.
- Premises were accessible, comfortable, clean and bright, well equipped, and on the whole, well-maintained. Premises, as far as possible, supported women’s choices in childbirth; there was a birthing pool on the labour ward, and labour rooms were equipped with birthing aids. Babies born in hospital were cared for in a secure environment, where access was restricted.
- Staff felt positive and proud to work for the maternity service. We observed good team working and respectful communication. Leaders were visible and supportive, highly respected and liked. Staff were supported to maintain their professional competence and to progress in their careers.
- The trust was an outlier for postpartum haemorrhage in the National Maternity and Perinatal Audit 2017. An action plan was developed and included a review of the methods to measure blood loss, a review of clinical guidelines and staff education. We reviewed the records of a woman on the labour ward at the time of our inspection, who experienced postpartum haemorrhage. We judged this was managed appropriately and in accordance with the protocol.
- There had been a recent spike in postpartum haemorrhage and perineal trauma (third and fourth degree tears).
- In the 2017 MBRRACE audit, the trust’s stabilised and risk-adjusted extended perinatal mortality rate (per 1,000 births) was up to 10% higher than the comparator group. The service had developed and completed an action plan in response to this concern and confirmed that all elements of NHS England’s Saving Babies’ Lives were in place. Internal audits continued to monitor performance.
- There were some maintenance issues in the women’s hospital, which had the potential to cause disruption to the service or risk to patients. There were two maintenance issues, which were recorded on the maternity risk register. Lifts in the women’s hospital had failed on a number of occasions and there was a risk of patient and/or staff entrapment. Leaking windows on the labour ward meant that some rooms may be taken out of use.
- Staff on the postnatal ward did not always follow guidance in relation to the recording of physiological observations for women who had undergone low risk vaginal deliveries. This was not routinely audited.
- Poor record keeping had been identified on the maternity risk register; recent audits and case notes reviews had identified some inconsistent practice. The service had established a documentation improvement group and produced new guidelines, with auditable record keeping standards. Staff education and regular audits had commenced to embed these standards.
- The maternity risk register identified there had been a significant number of policies and guidelines which were overdue for review. This had largely been addressed. However, there remained a few issues with version control and duplication of policies and guidelines, which meant staff could potentially refer to incorrect guidance.
- There had been three information governance breaches in the maternity service, which were classified as serious incidents, over the last year.
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.
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.
8 May 2019
Our rating of this service improved. We rated it as good because:
- We rated responsive as outstanding, and safe, effective, caring and well-led as good.
- The service had improved in providing safe care. Patients were risk assessed and triaged in a timely manner. Changes had been made following our previous inspection to address safety concerns.
- To be effective, services were provided in line with evidence-based practice. Staff were competent and induction and competency frameworks had been introduced. Patients suffering pain were well managed within guidelines and protocols.
- There was good care provided to patients. Staff were committed to giving the best care to patients, and frequently went above and beyond. The emotional needs of patients and relatives were recognised and addressed.
- The department was outstanding in its response to delivering its services. Services were planned and developed based on demand and patient need. The organisation was achieving the national targets for seeing, treating and discharging patients. People were treated as individuals and their needs were met.
- The leadership team for the frontline service had the skills and experience to carry out their roles. There had been improvements with governance arrangements to bring this closer to staff in frontline leadership roles. There was good engagement with stakeholders and partners to improve and coordinate services. There were no barriers to innovation and development.
- We were not assured the service was meeting the requirements to provide safe care at all times in all areas. There were issues with cross infection processes and the environment for ambulances on arrival at the department.
- The service was not achieving all national patient outcomes.
- There were areas of the governance structure which needed to mature and become embedded in the department. The governance arrangements and vision and strategy were under review and development at the time of our inspection.
- The department needed to strengthen their audit and risk management processes.