Yeovil District 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 Requires Improvement. At this inspection the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to need for consent, safeguarding service users from abuse and improper treatment, premises and equipment and staffing.

This service scored 38 (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 did not have a strong learning culture. There was not a focus on learning from significant incidents in a timely way. Safety events were investigated and reported, although lessons from safety incidents or complaints were not learned to continually identify and embed good practices and improve care for others.

Some staff told us they perceived a culture of individual blame. This resulted in ways of working where not everyone felt they could express their needs and have their voices heard. There was resistance to feedback and a lack of encouragement to speak up. Some staff told us they felt some rules had been imposed on them.

Some medical staff we spoke with did not feel supported after serious incidents. Although leaders debriefed and felt they supported staff, some medical staff felt this was done from a point of view of blame and not focused on learning.

A lack of consultant presence during the service’s busiest times and during the night shift handover resulted in a lack of supervision and in missed training opportunities. Some members of staff told us they did not feel comfortable to challenge medical decisions. Staff said there was not a culture of leaders open to feedback. A lack of mentorship resulted in very few opportunities to discuss safety more informally.

Prior to the merger, a centralised team had responsibility for liaising with children, young people, carers and their families when things went wrong. The service was in the process of delegating the responsibility of duty of candour to the medical team. This meant the discussions between the medical team and the children, young people, carers and their families were taking time to embed. However, staff we spoke with understood the duty of candour.

Staff we spoke with knew what incidents to report and how to report them. Staff raised concerns and reported incidents and near misses in line with trust policy. Nursing and medical staff we spoke with did not always receive feedback from investigation of incidents.

There had been no Never Events reported relating to Paediatrics.

The service did not establish and maintain safe systems of care. Staff did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. However, the service worked well with healthcare partners when patients moved between different services.

There was only 1 consultant led handover on 13 January 2025, and therefore 1 consultant led ward round in 24 hours. Staff and leaders told us this was often the case. This was not in line with standard four of the Royal College of Paediatricians and Child Health “Facing the Future: Standards for Acute General Paediatric Services 2015”. At least 2 medical handovers every 24 hours should be led by a consultant paediatrician or associate specialist. The lack of regular consultant reviews meant there was a risk to the quality of care children and young people received, including risk of an increased length of stay in hospital.

Not every child who was admitted to the paediatric department with an acute medical problem, or those who attended the Emergency Department, were seen by a consultant paediatrician or associate specialist within 14 hours of admission. This was not in line with standard two of the Royal College of Paediatricians and Child Health “Facing the Future: Standards for Acute General Paediatric Services 2015”.

There was 1 Registrar covering all paediatric areas after 5pm. The paediatric areas of the hospital included:

• Ward 10, which was located on Level 10 of the hospital

• The maternity ward and special care baby unit, which were in the maternity hospital (a separate building but accessed via Level 2)

• The Emergency Department, which was located on Level 3.

These areas were a significant distance away from each other. There was a risk of delays to the triage and treatment of children and young people, especially out of hours due to the geographical spread and lack of medical staff available.

National paediatric early warning system (PEWS) charts had been introduced in paper form at the service. PEWS is a national standardised approach of tracking the deterioration of children in hospital. An audit of PEWS data was planned but had not yet been collected. Therefore, the trust were not assured observations and paediatric early warning scores were being carried out in line with National guidance and escalation guidance was followed. Since our inspection, the service had developed their own audit tool, and audits have been undertaken by the nursing team since January 2025.

There was a “Deteriorating Patient Policy” dated 1 November 2019. 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 Yeovil District Hospital.

The service did not have a paediatric assessment unit or level 2 critical care beds. Level 2 critical care is for patients requiring more detailed observation or intervention, also known as ‘high dependency units’ (HDUs). If a child required this level of care they were either; intubated and stabilised on the ward until transferred to another hospital or taken to theatre or the adult intensive care unit (ICU) and cared for by adult nurses. A member of the paediatric nursing team would be sent to accompany and care for the child if staffing allowed.

However, staff kept records of children and young people's care and treatment. Records we reviewed were clear, up to date, stored securely and easily available to all staff providing care.

We observed handovers and they included all necessary key information to keep children and young people safe. Handovers took place each day. We observed a morning meeting and saw this was attended by a consultant, a registrar, 2 senior house officers and 1 medical student and a senior nurse.

Referral letters were read daily by paediatric consultants and there was an aim to get responses to GPs within 24-48 hours.

The serviced worked well with healthcare partners when patients moved between different services. Transition pathways had been established based on medical conditions. Staff were proud of the relationships with the neighbouring tertiary hospital.

Staff did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service provided safeguarding training, but not all staff had completed it. Evidence submitted showed training compliance for safeguarding level 3 at 65.4%. This did not meet the expected compliance levels of the trust.

Staff knew how to identify children at risk of, or suffering significant harm. They knew how to make a safeguarding referral to the local authority. Support was available from a designated safeguarding team within the trust. A member of the safeguarding team contacted the paediatric ward 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. However, staff said they did not feel they had the same level of support they used to. During out of hours, they also knew to contact the local authority emergency duty team.

We reviewed patient records. These showed some areas of safeguarding where it was unclear how these had been followed up by staff on the ward. For example, a patient had been admitted, and it was unclear whether the overdose had been reported to the local authority as a safeguarding concern. This may have been done by the emergency department but had not been confirmed or checked. Therefore, there was little evidence to demonstrate professional curiosity. However, the safeguarding team were able to show how they kept track of these.

Child protection medical assessments were not being completed by a consultant paediatrician. Child protection medical assessments should be started within 24 hours. Data for the period from March 2023 to February 2024 showed only 89% of children were seen within the expected timeframe and not all of those by a paediatrician with child protection experience and skills. This was not in line with the Royal College of Paediatricians and Child Health “Child Protection Service Delivery Standards 2020”. The trust anticipated child protection medical assessments would be completed by a consultant paediatrician from 1 March 2025.

The service did not always work well to manage risks. Emergency situations were not always coordinated. However, staff completed and updated risk assessments for each child and young person. They worked with people to understand risks by thinking holistically so that care meets their needs.

Emergency situations were not always managed well. There were some systems and processes to ensure risks were managed. A daily emergency safety huddle had been introduced. This was attended by the resus team, outreach team, anaesthetist on call, nurses and Consultant Paediatricians. The aim of this meeting was to discuss the acuity of the ward, intensive care unit, bed availability and to delegate roles in case of emergency situations. However, this occurred at the morning handover only.

Staff told us patients were presenting to the service with increased acuity and required more intensive interventions. The lack of medical staff and high dependency beds meant there was more pressure to provide safe care.

Records showed a lack of understanding of the Mental Capacity Act, Mental Health Act, restraint and consent. Staff were not confident and lacked demonstrable legal compliance knowledge. For example, staff referred to actions taken in a patient’s best interest but had not completed a mental capacity assessment or best interest decision. There were no restraint care plans, despite being a regular aspect of care provision. Since our inspection, the service had identified gaps in recording and had agreed to provide staff with additional training and development.

We reviewed patient safety incidents. There was a recurring theme that parents did not feel listened to and staff did not communicate with them. 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.

However, staff completed risk assessments for each child and young person on admission, using a recognised tool, and reviewed this regularly.

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 child and adolescent mental health service (CAMHS) liaison 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.

Shift changes and handovers included all necessary key information to keep children and young people safe.

The service was not always able to control potential risks in the care environment due to an ageing estate. However, staff made sure equipment, and technology supported the delivery of safe care.

The slowness of the lifts contributed to delays for staff in moving around the hospital. We observed delays in patient safety information being handed over to members of staff during the night shift. There was a risk of delays in triaging patients. This was due to the distance between SCBU, the emergency department and the ward, and the need for one member of staff to cover these areas. The environment was not suitable for patients requiring high dependency. Staff gave us an example where they decided to hold an online meeting as they were struggling to get a lift from level 1 to level 10 for a face-to-face meeting.

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The paediatric ward faced environmental challenges that negatively impacted patient care and family experiences. Key issues included an ageing estate which resulted in inadequate temperature control, no suitable bereavement environment and insufficient family meal space. There was limited space available for parents and carers to eat with children and young people with eating disorders. There was an absence of outdoor areas.

A risk had been identified around staff being unable to assist a young person in the toilet cubicle due to the confined space and limited access, particularly when only one staff member was present. The service had a plan to combine the shower cubicle and toilet to create a large wet room to mitigate this.

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However, children, young people and their families could reach call bells and staff responded quickly when called. Staff carried out daily safety checks of specialist equipment. The service had enough suitable equipment to help them to safely care for children and young people. Staff disposed of clinical waste safely. Newly purchased paediatric transfer bags were available for inter-hospital transfers, and these were checked regularly. The ward was secure with swipe card access required to gain entry.

The service did not have enough medical staff. There were not enough suitably qualified, skilled and experienced persons deployed during the busiest period of the service, out of hours and weekends to meet the requirements of the paediatric service at Yeovil District Hospital.

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There was no paediatric consultant or associate specialist present during times of peak service activity, 7 days a week. There were 8 substantive consultants, 6 full time, 2 part time and 1 long term locum. This meant there was a consultant on call for 1 in 7 days and this was not in line with standard one of the Royal College of Paediatricians and Child Health "Facing the Future: Standards for Acute General Paediatric Services 2015". Facing the Future standards outline how to provide a safe and sustainable service that meets the needs of every child and young person. The trust recognised the rota needed to be expanded and an additional 2 consultants were required. These posts were currently out for advert but had not been filled. A long-standing recruitment strategy, for both national and international consultant colleagues, had been unsuccessful despite offers being made to individual candidates following interviews.

A lack of consultant presence during the service's busiest times and during the night shift handover resulted in a lack of supervision and missed training opportunities. The most experienced doctors were not present during the busiest times and there was a risk children and young people were not seen in a timely manner by a suitably experienced doctor. This meant patients may be exposed to the risk of harm from the lack of senior clinical oversight.

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At Yeovil District Hospital, neonatal and paediatric services were part of the same service group and operated under a shared medical workforce rota. Although there was a shortfall of 2 full-time resident doctors in training, this was mitigated by the employment of Trust Grade doctors. A dedicated rota coordinator was in place to ensure appropriate and consistent rota cover. After 5pm, one registrar provided cover across all paediatric areas. These areas were a significant distance away from each other. There was a risk of delays to the triage and treatment of children and young people, especially out of hours due the geographical spread and lack of medical staff available at that time. Staff we spoke with told us they felt "overwhelmed and exhausted".

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The special care baby unit (SCBU) was covered with medical presence until 3pm, after which time it was covered by the bleep holder. The British Association of Perinatal Medicine issued "Optimal arrangements for Local Neonatal Units and Special Care Units in the UK". SCBUs should provide at least an on-call registrar (tier 2) to support the foundation year 1 (tier 1) doctors in SCBUs admitting babies requiring respiratory support, or of very low admission weight. The on-call doctor was not continuously immediately available as they were also covering paediatrics and ED.

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Evidence submitted as training compliance for paediatric advanced life support showed compliance at 36.8%. Some medical staff completed life support training externally and the manual update to the trust electronic system resulted in a delay of confirmation of compliance. Verbal confirmation of advanced paediatric life support training for medical staff was 100%. There was a lack of record keeping to provide the trust with assurance training had been completed and there were sufficient staff trained in paediatric advanced life support in the hospital at all times. There was also a lack of assurance of the quality of the external training and whether those undertaking that training followed the same procedure/process in an advanced life support scenario as those who undertook training provided by the trust.

If a child deteriorated and required support in adult intensive care, a paediatric nurse would accompany them, this depleted the nursing team on the ward. The additional training required to support children with high dependency was offered to interested staff. There were only 2 places offered per year from the training provider, therefore not all staff were trained to this level. The trust stated Yeovil District Hospital were a priority if a patient required retrieval.

However, the service had enough nursing staff with the right qualifications, skills, training and experience to keep children, young people and their families safe and to provide the right care and treatment. There were 4 trained staff on each shift. Managers regularly reviewed and adjusted staffing levels and skill mix. There was very little bank and agency use. Medical and nursing staff met the trust compliance rate for their annual appraisal.

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Regular simulation training had been introduced and alternated between paediatrics and the SCBU. The training included both medical and nursing staff, although we were told not all medical staff working on the ward were encouraged to attend. Staff told us this was positive and lessons learned were discussed.

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There was a play assistant on the ward. They were in the process of completing their training course to become a play therapist.

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The service assessed and managed the risk of infection. Some audits had only recently been introduced or were due to be implemented. 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 kept equipment and the premises visibly clean.

The service generally performed well for cleanliness. Cleaning records were up-to-date and demonstrated all areas were cleaned regularly. We reviewed cleaning audits for September, October and November 2024 and they showed 97% 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 93% and above. All staff we observed were adhering to ‘bare below the elbow’ practice. However, ‘bare below the elbow’ and ‘decontamination’ audits had yet to be implemented, but there was a plan to do so.

Curtains were reuseable, however 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.

Staff disposed of clinical waste safely. Sharps boxes were dated, closed for safety, and placed out of reach.

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.

Staff followed systems and processes to prescribe and administer medicines safely. All medicines and prescribing documents were managed and stored safely. The senior sister's office was located within the drug preparation unit and this meant they were often available to double check medicines. Staff completed medicines records accurately and kept them up to date.

However, during our inspection we were informed a child had received medication meant for another child. The service reviewed the incident, including duty of candour for the family, and supported further training for staff. They also introduced system changes to reduce the chance of a similar incident occurring.