Yeovil District Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of children and young people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection we rated this key question Good. At this inspection the rating has changed to Inadequate. This meant there was widespread and significant shortfalls in service leadership and governance which did not assure the delivery of high-quality care. The service was in breach of legal regulation in relation to governance of the service.

This service scored 46 (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 have a clear vision, and strategy based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. However, not many staff knew what the vision and strategy were, and their role in achieving them.

Yeovil District Hospital merged with the former Somerset NHS Foundation Trust that also managed Musgrove Park Hospital on 1 April 2023 and services were integrated. Leaders of the service had to re-prioritise their plans to incorporate Yeovil District Hospital. There had been the need to focus on immediate operational pressures and staffing arrangements. Leaders recognised staff had been working under enormous amounts of strain and demand at Yeovil District Hospital.

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There was a level of resentment felt by some staff groups. Some medical staff told us the key leadership roles had been appointed and therefore felt new ways of working had been imposed upon them. The trust acknowledged and outlined its duty of care to colleagues who were working in a culture that had evidence of inappropriate hierarchies, division and low morale.

This was partly because of a physical environment that fostered division, workloads that were unrealistic, and a history of behaviours that had not been addressed.

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There was not a culture of continuous improvement. The service did not have a strong learning culture. There was not a focus on learning from significant incidents in a timely way. Not all safety events were investigated and reported in a timely way, and lessons from safety incidents or complaints were not learned to continually identify and embed good practices and improve care for others. Some medical staff told us they perceived a culture of individual blame.

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A lack of consultant presence during the service's busiest times and during the night shift's 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 or to express their needs and have their voices heard. This impact was felt by staff at all levels of the service. Medical staff told us they felt "tired" and "overwhelmed" with their workload. However, the trust was developing a plan to address staffing issues and concerns around civility and culture, to ultimately create a work environment underpinned by the values of trust, kindness, respect and teamwork.

Incident reporting was now in line with NHS England which changed the way patient safety incidents were reported and the outcomes. There had been a drop in the number of patient safety incidents reported which was being monitored closely. The change to the way data was collected meant a lot more detail was provided, and this was helping to build a clearer theme around what was impacting patient care.

In September 2022, the Board approved the People Strategy 2023-2028. The strategy set out five commitments: (care of our people; develop our people; compassionate & inclusive leadership; retain & attract talent and learning & transforming) and alongside each commitment there were high-level ambitions used to describe the focus and direction of travel for the next five years. Furthermore, these commitments were aligned to the NHS People Promise.

Somerset CAMHS and Paediatric services aimed to work together to create an integrated and inclusive paediatric service that delivered holistic care. Long term strategic aims for the service included improvements to the workforce numbers, workforce wellbeing, environment, patient pathways and joined governance across the hospitals. There was a direction and vision for the service.

Some staff felt supported, respected and valued, and were positive and proud to work in the service. There were cooperative, supportive and appreciative relationships among some staff. It was clear their work was important to them, and they felt passionate about their contribution to care and were committed to improving the health of children and young people.

Leaders understood the context in which the service delivered care, treatment and support. They had the knowledge, experience and credibility to lead effectively. However, agreed actions to address issues and mitigate risks to patients had not been timely to drive improvement in the quality and safety of the services provided.

Yeovil District Hospital merged with the former Somerset NHS Foundation Trust that also managed Musgrove Park Hospital on 1 April 2023 and services were integrated. Leaders of the service had to re-prioritise their plans to incorporate Yeovil District Hospital. There had been the need to focus on immediate operational pressures and staffing arrangements. The leaders understood the need for substantive staff and a recruitment campaign was successful to fill these roles.

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The acute paediatric leadership structure for children, young people and families included 2 medical directors, one for `obstetrics, gynaecology and maternity' and another for `paediatrics and child and adolescent mental health services (CAMHS)'. These were newly appointed in 2023/2024 as part of the merger of the 2 trusts. They were the first medical director roles across acute site service group for children, young people and families instead of site specific. A service group director, a director of midwifery and an associate director of patient care. The service group director had been in post for 6 days on the day of our onsite inspection.

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Under the medical director for paediatrics and CAMHS was a clinical director for each hospital. Under the service group director was the head and deputy head of CAMHS and paediatrics.

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There had been some improvements to the learning culture, but challenges remained. There was not a focus on learning from significant incidents in a timely way. Some medical staff told us they perceived a culture of individual blame and there was a culture of feeling threatened by critical feedback and scrutiny. Leaders had empathy for their colleagues and accepted the work to improve the culture was in its infancy. Leaders recognised doctors in training were important in the future culture of the service. However, a lack of consultant presence during the service's busiest times and during the night shift's handover resulted in a lack of supervision, support and in missed training opportunities to those doctors.

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There were also decisions made surrounding the medical workforce. For example, the foundation year 1 doctors needed to be supernumerary and not hold the clinical bleep. The clinical bleep system is designed to contact key personnel to communicate information in relation to a patient's condition that cannot wait until the next scheduled visit to the clinical area. However, the service's medical workforce staffing did not meet the Royal College of Paediatrics and Child Health (RCPCH) Facing the Future standards.

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General Medical Council survey results for doctors in training highlighted challenges the service had faced 5 years ago, and the results had progressively declined in the last few years. The service had also been in discussion with the Deanery regarding the report. This was challenging for the medical workforce who felt they were working hard under pressure and resulted in defensiveness.

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The joint paediatric and CAMHS leadership started at Musgrove Park Hospital 3 months prior to the merger. The CAMHS team had worked closely with the local authority and children and young people, to change the patient pre-admission pathway. The service partnered with the local council and employment charity to create a new service development for looked after children. We were told of an example where a child from Somerset had been placed in Manchester for 3 months on an acute ward. The child's needs were not met in this environment. The service worked hard with the partnership, and listened to the child's views, to flex the offer available. They were able to offer daily community visits with a paediatrician and nurse at the child's home. This helped improve the emotional and mental wellbeing of the child.

People did not always feel they could speak up and that their voice would be heard.

Staff were aware they could raise concerns about patient care and safety with the Freedom to Speak Up Guardians (FTSUG), but some staff said they were not encouraged to speak up and felt uncomfortable about raising any concerns. They did not feel listened to and did not feel encouraged to make suggestions within the service.

We spoke to the Freedom to Speak up Guardians. There had been 19 concerns raised to the FTSUG since April 2024 regarding the paediatric service at Yeovil District Hospital. Themes amongst the concerns raised with the team included management, timeliness and communication style, and the impact this can have on colleagues.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The service promoted equality and diversity in daily work and provided opportunities for career development.

Governance systems were not operating effectively to ensure risk and performance issues were addressed with timely action to drive improvement in the quality and safety of the services provided. Staff did not always act on the best information about risk, performance and outcomes. However, the service had clear responsibilities, roles and systems of accountability.

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After the merger, leaders were mindful not to merge governance arrangements immediately. The service had recently appointed a senior governance lead. Prior to this, leaders felt they did not have the capacity to review themes around learning from patient safety incidents. The senior governance lead had prioritised this work with a focus on a thematic review. The review collated information from review meetings, themes, actions and the top 3 were given focus. This review was due to be presented to the Patient Safety Board and Integrated Care Board (ICB) and the findings would be taken to Yeovil District Hospital governance. However, there had been some disagreement from senior medical colleagues in the findings and recommendations within the report which caused delays.

There was a lack of record keeping to provide the trust with assurance that training had been completed and there were sufficient staff trained in paediatric advanced life support in the hospital at all times. Some medical staff had completed external paediatric life support training. There was a lack of assurance of the quality of this 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.

Not all policies were regularly reviewed. The trust had a "Deteriorating Patient Policy" dated 1 November 2019 which was in use at Yeovil District Hospital. 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". This was due for approval at the Yeovil Paediatric Clinical Governance meeting in February 2025. 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. An audit of PEWS data was planned but had not yet been collected. Therefore, the service was not assured observations and paediatric early warning scores were being carried out in line with National guidance and escalation guidance was followed.

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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 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 the child if staffing allowed. Not all paediatric staff were trained to provide this level of care and support to patients. The service had no mitigation for the risk of children being cared for in an adult environment with adult trained nursing staff.

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The service did not have a paediatric assessment unit. This meant children and young people had to wait in ED until they could be reviewed. Out of hours the registrar was providing cover to ED, SCBU and ward 10 by themselves. The risk of delays to triage and treatment had not been mitigated.

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We reviewed the risk register for the service. The risk of the geographical area to be covered by the registrar was not on the register. The service did not have an up to date policy for the deterioration of children and young people. The lack of deteriorating child policy and clinical observations and deterioration audit was not on the risk register.

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Governance systems of the Paediatric Service at Yeovil District Hospital were not operating effectively to ensure risk and performance issues were addressed with timely action.

The issues above had been recognised by the trust but agreed actions to address these issues and mitigate the risk to patients had not been timely to drive improvement in the quality and safety of the services provided.

The service did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for children and young people.

Medical staff did not always share information and learning with colleagues at Musgrove Park Hospital. There had been strained relationships between the service and critical care and the emergency department.

However, there had been improvements in the relationships between these departments. Staff told us examples about collaborative working between other NHS hospitals in the South West, for example when liaising patients transfers to higher level hospitals.

There was an onsite child and adolescent mental health service (CAMHS) liaison team which provided weekend support and were included in handovers. The CAMHS team had worked closely with the local authority and children and young people, to change the patient pre-admission pathway. The service partnered with the local council and employment charity to create a new service development for looked after children.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Staff did not always encourage creative ways of delivering equality of experience, outcome and quality of life for children and young people.

Not all staff were committed to continually learning and improving services. They did not always have a good understanding of quality improvement methods and the skills to use them.A lack of mentorship and senior medical presence resulted in very few opportunities for learning and the improvement of junior colleagues.

However, some staff contributed to effective practice and participated in appropriate research. This included a wide range of studies and trials relating to vaccine, diabetes, respiratory, abdominal surgery and orthopaedics.

Staff also contributed to international research and publications including topics such as the usefulness of blood tests in patients with re-feeding syndrome for paediatric inpatients with anorexia nervosa, telementoring initiative for newborn care providers in Kenya, Pakistan and Tanzania and exploring new models of care to help children who had stopped eating to remain in the community.

A consistent process for reviewing paediatric deaths had been agreed. All expected and unexpected paediatric deaths were subject to the Medical Examiner process. In addition to the trust bereavement services, specialist support from a bereavement charity was also offered. The Medical Examiner and the bereavement team had been asked to automatically refer all paediatric deaths.