Musgrove Park Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation. 

At our last inspection we rated this key question Good. At this inspection the rating has remained Good. This meant people were safe and protected from avoidable harm. 

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

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The service managed patient safety incidents well. Staff knew what incidents to report and how to report them. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Every Tuesday, there was an `interesting conversation' where cases and learning were discussed.

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Staff understood the duty of candour. When things went wrong, staff apologised and gave children, young people and their families honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.

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During discussions with doctors in training we were told the induction was thorough and learning from incidents were discussed in a relaxed environment. The focus of the informal meeting was on learning from the decisions made and exploring what could have been done differently without blame. There was an open culture, staff felt supported and listened to and this was seen as a positive experience and not one to be feared. We were told by doctors in training that the teaching environment was the best they had experienced, above any other hospital they had worked in. Staff we spoke with said there was a very approachable, supportive and helpful team and they "have never felt alone or stressed".

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We saw evidence of improvements being made prompted by learning and feedback from families and patients. For example, there had been changes to governance structures and working patterns because of a serious incident. A case learning was presented on slides with differential diagnosis, differences in presentation and photos, and retrospective comprehensive analysis of perioperative care. Feedback from families was an integral part of business planning for the paediatric assessment unit.

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There had been no Never Events reported relating to Paediatrics.

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Staff made sure there was continuity of care, including when people moved between different services. The service worked with people and healthcare partners to establish and maintain safe systems of care. The service mostly managed and monitored safety, however the use of the electronic National Paediatric Early Warning system was taking time to embed.

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Staff kept detailed records of children and young people's care and treatment. Records were clear, up to date, stored securely and easily available to all staff providing care. We reviewed 3 patient records and found them all to be comprehensive and accessible to all staff.

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Shift changes and handovers included all necessary key information to keep children and young people safe. We observed a morning meeting and saw this was attended by a nurse manager, a consultant, a GP trainee, a night registrar, a night senior house officer (SHO), a day SHO and a child and adolescent mental health service nurse. Handover information was displayed electronically and updated in real time.

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There was a paediatric assessment unit staffed with a dedicated consultant paediatrician between the hours of 10am until 6pm from Monday to Friday, and during the winter months (October -March) also on Saturday and Sunday. Outside of these hours, the paediatric assessment unit was covered by the on-call paediatric team (three tier on call rota with consultant present until 10pm Monday — Friday and until 1pm Saturday and Sunday during the Summer months). This meant children and young people did not have to attend the emergency department and could access senior clinicians for advice and treatment and timely intervention during these hours in line with the Royal College of Paediatricians and Child Health "Facing the Future: Standards for Acute General Paediatric Services 2015".

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The National paediatric early warning system (PEWS) charts had been introduced in electronic form at the service. PEWS is a national standardised approach of tracking the deterioration of children in hospital. An audit of PEWS data showed observations and paediatric early warning scores were not being carried out in line with National guidance. The trust's `Patient Deterioration Audit' dated December 2024, showed 33% of records did not have a set of observations recorded on admission and 70% of all observations were found to be done late or were missing. The trust completed a review of the audit results and established patient observations were not being entered in the system at the time they were taken; the electronic system did not allow retrospective recording of observations. In addition, data showed escalation guidance was not always followed which had the potential to expose patients to risk of harm in the event of their condition deteriorating and not being identified and managed through effective escalation of their care for additional clinical support and treatment. However, this was partially due to problems with the system used to record observations which prompted staff to escalate patients when they were stable within a risk category. The trust's review of audit data showed due to these limitations in the electronic system, 64% of observations were showing as overdue when they were not. The trust developed a clear Patient Deterioration Audit (PEWS) action plan as a result of these audits with an identifiable lead person for each action, an achieve by date and progress to date to keep track of the solutions proposed to address these issues. The action plan detailed steps to address the issues highlighted by the audits. The action plan included liaising with their digital team and the developer to find digital solutions to the limitations posed by the electronic system, amongst others. The actions contained in the plan were ongoing at the time of our inspection. The due date for the plan to be completed was June 2025.

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In addition, a deteriorating child protocol had been devised but not yet ratified: "Observation and National Paediatric Early Warning System (nPEWS) Escalation — Recognition and Response to the Paediatric Deteriorating Patient". The guidance provided best practice around escalation and management of critically ill children. The trust had plans to implement this protocol at Musgrove Park Hospital.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.  

Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.  

Staff knew how to make a safeguarding referral and who to inform if they had concerns. Safeguarding clinics had been introduced. 

The service provided safeguarding training, but not all staff had completed it. Evidence submitted showed training compliance for safeguarding level 3 at 79%. This did not meet the expected compliance levels of the trust. However, a member of the safeguarding team contacted the on call paediatric registrar every weekday morning which provided an opportunity to promptly identify concerns. The safeguarding team ran a check of emergency department records for all attendances of anyone under the age of 18.

There were daily child protection clinics which see an average of 16-20 people per month. Leaders told us work is being done to promote the importance and use of professional curiosity. The service had some recent good examples of the use of professional curiosity in child protection, and these are acknowledged and recognised through excellence reporting. The service also counts with an established Safeguarding Advisory Service which provides Safeguarding Supervision to staff with support, advise and reflective learning trust wide. 

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them. Emergency situations were managed well. Staff told us patients were presenting to the service with increased acuity and required more intensive interventions. The service had a level 2 local neonatal unit.

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Staff completed and updated risk assessments for each child and young person and removed or minimised risks. Staff identified and quickly acted upon children and young people at risk of deterioration.

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Shift changes and handovers included all necessary key information to keep children and young people safe. The service had 24-hour access to mental health liaison and specialist mental health support (if staff were concerned about a child or young person's mental health). The psychiatric team sat within the paediatric ward, including at weekends and attended patient handovers. There was a joint child and adolescent mental health service and paediatric service with a clear goal for medical and mental health integration. The trust had implemented Martha's Rule. Martha's Rule is a major patient safety initiative providing patients and families with a way to seek an urgent review if their or their loved one's condition deteriorated, and they were concerned this was not being responded to. However, this was in its infancy and was being embedded across the trust.

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The service detected and controlled potential risks in the care environment. Staff carried out daily safety checks of specialist equipment. There were no gaps in the daily checks. All items were in date and tamper proof. The service had enough suitable equipment to help them to safely care for children and young people. Children, young people and their families could reach call bells and staff responded quickly when called. Teenagers were nursed in separate areas from young children when possible. Staff disposed of clinical waste safely. The ward was secure with swipe card access required to gain entry. Staff made sure equipment and technology supported the delivery of safe care. The paediatric ward faced environmental challenges due to an ageing estate that had the potential to negatively impact patient care and family experiences. The key issues identified involve the lack of an education room, insufficient family meal space, absence of outdoor areas and inadequate temperature control. The areas covered by medical bleep holders was a significant distance away from each other, increasing the risk of delays to the triage and treatment of children and young people during out of hours. Staff on call overnight supported both services and had to walk between the two buildings to attend when called and time was lost in making this journey. We were told of an example where a member of staff had to walk outside in the rain and had to deliver difficult news to a family when they were soaking wet which they felt was unprofessional. 

However, people we spoke with during our assessment told us staff responded quickly when called and reported no delays in their care.  

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs. The service had enough medical staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix and gave locum staff a full induction. The service also had enough nursing and support staff to keep children and young people safe. Managers accurately calculated and reviewed the number and grade of nurses and healthcare assistants needed for each shift, in accordance with national guidance. During the day there were 6 registered nurses and 2 healthcare assistants (HCAs) and at night and weekends there were 5 registered nurses with 2 HCAs. In the paediatric assessment unit, there was 1 registered nurse and 1 HCA from 9am to 9.30pm.

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The mandatory training was comprehensive and met the needs of children, young people and staff. Evidence submitted as training compliance for the paediatric service showed staff were up to date with most of their mandatory training. Staff felt nurtured and wanted to work at Musgrove after completing their training at the hospital. However, Mental Capacity Act Level 2 and Safeguarding Level 3 did not meet the trust target for compliance.

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The trust was pioneering an innovative supervision model that was designed to provide paediatricians with access to restorative supervision, provided by a clinical psychologist. The model aimed to support their emotional and professional well-being. Furthermore, the well-being lead paediatrician, also an Associate Medical Director for Well-being, offered one-to-one coaching, supervision, and general well-being support, ensuring a holistic approach to staff care. The general expectation for frequency of supervision for medical colleagues was monthly.

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However, there were concerns about the numbers of trained specialist oncology nurses due to recent turnover levels. A lack of availability in training courses near the service and long time to complete and be deemed competent also had an impact on the amount of staff with the adequate oncology training. The service has created a series of e-learning modules in Oncology Emergencies, available to staff at all levels which was aimed at improving trainees' skills in assessing and managing these patients.

The service assessed and managed the risk of infection. However, we identified some areas where infection control needed improvement. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff used equipment and control measures to protect children, young people, their families, themselves and others from infection. They mostly kept equipment and the premises visibly clean. The service generally controlled infection risk well. Ward areas were clean and had suitable furnishings which were well maintained. The service generally performed well for cleanliness. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. We reviewed cleaning audits for September, October and November and they showed 94% and above compliance. Staff followed infection control principles including the use of personal protective equipment (PPE). Hand hygiene audits were introduced from October 2024 and results showed compliance of 91% and above. All staff we observed adhered to `bare below the elbow' practice. Staff disposed of clinical waste safely. Sharps boxes were dated, closed for safety, and placed out of reach.

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However, curtains in the single rooms were made of linen and there was no date identified to know when they needed to be changed or cleaned. Staff said they were changed when patients were discharged, or if there was an infection control issue. The layout of the wards with individual cubicles caused difficulty in managing viruses and infections. There was also a shower cubicle used by parents and patients which had black mould at the bottom of the shower tray. We raised this during our inspection and staff said they would rectify this.

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The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. The service used systems and processes to safely prescribe, administer, record and store medicines. All medicines were labelled correctly and stored in locked cupboards. Entry to the room was by keypad. We checked medicines in all cupboards, and all were in date. Controlled drugs were stored securely in double-locked cupboards. There was a controlled drugs recording book which showed daily checks were completed with no gaps. Fridge items were stored appropriately, and temperatures were within range. There was a fridge temperature checklist and there were no gaps in its completion.