You are here

Provider: Yeovil District Hospital NHS Foundation Trust Requires improvement

On 08 May 2019, we published a report on how well Yeovil District Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Inadequate  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Reports


Inspection carried out on 11 Feb to 2 March 2021

During an inspection looking at part of the service


CQC inspections of services

Inspection carried out on 4 December 2018 to 17 January 2019

During a routine inspection

Safe and well-led were requires improvement, with effective, caring, and responsive rated as good. The rating of well-led at core service level was good overall, but the rating for trust management, specifically around financial governance, was requires improvement. This led to a combined overall rating for the trust of requires improvement. Safe and well led remained as requires improvement, and caring remained good. The other key questions of effective and responsive improved from requires improvement to good. In maternity services, caring was rated as outstanding, and in urgent and emergency care (A&E) responsive was rated as outstanding.

We rated well-led at the trust as requires improvement because:

  • There was a significant failing of financial governance and the board collectively taking ownership of those areas of concern the trust could control and influence. There was a lack of assurance of financial scrutiny by the board. The board were unable to collectively or consistently articulate or explain the financial problems the trust was facing or the deterioration in the financial position emerging in the latter part of this financial year. The board assurance framework did not rate the financial risks at a sufficient level to match the degree of their seriousness. NHS Improvement rated the trust as inadequate for its use of financial resources.

However:

  • Beyond the significant financial challenge, the trust’s leadership team had the experience, capacity, capability and integrity to lead the organisation. Leaders were highly visible, approachable and supportive to their staff. The leadership team recognised there were challenges to high quality care and sustainability, although this did not extend to a resolution of the serious financial issues.

  • There was an interconnected vision and strategy for the quality of care and services for patients and the local population. The trust was working with local healthcare partners to achieve the priorities for delivering good quality sustainable care, but failing to make inroads and play its part in a system-wide solution to the financial problem.
  • The culture of the organisation was strong and centred on people who use services. Staff felt positive and proud to work for the organisation. The leadership team modelled and encouraged compassionate, inclusive and supportive relationships among staff, who felt respected, valued and supported. There was an emphasis in the trust on the safety and wellbeing of staff. Equality and diversity were promoted within the organisation. There were structures, processes and systems of accountability to operate a governance system designed to monitor the service and provide assurance of safe and quality care.
  • The operational performance at the trust was meeting most of the national targets or standards for treating patients. It was performing better than the England average in all measures. The trust engaged in a variety of ways with the public and local organisations to plan, manage and deliver services.
  • There was a strong culture of reporting incidents to learn and improve. There were systems to improve the service and performance with a focus on continuous learning and quality improvement projects. There was innovation and development through research.
  • Urgent and emergency services (also known as accident and emergency services or A&E) improved from requires improvement to good overall. Safe, effective and well-led improved from requires improvement to good. Caring remained as good, with responsive improving significantly from requires improvement to outstanding. In safe, we found people were protected from harm by sufficient numbers of staff, a safely run department, and a team willing to learn and improve. Care was delivered effectively to give patients good outcomes. The caring of patients was delivered with kindness and empathy. Our rating of responsive described the department’s service as outstanding. The service was one of the top in England at meeting the four-hour standard to see and treat patients. Patients were treated as individuals and meeting their needs was part of the values which drove staff. Well-led had improved with a renewed commitment to the service, it’s governance and improvement.

  • Medical care was rated overall as good overall. This improved from a rating of requires improvement at our last inspection in 2016. Safe remained as requires improvement but responsive and well-led improved to good. Effective and caring remained as good. In safe, we were concerned about risk assessments and responding to deteriorating patients. There were some issues with cleanliness, tidiness and equipment checking. Patients’ records were not always maintained well enough. However, other aspects of safe had seen improvements. Effective care was provided to give patients good outcomes. Caring was provided with kindness, and patients and those who cared for them were valued as central to the care provided. The service met the needs of people who used it, and responsive was rated as good. There had been considerable work to get people into and out of hospital in the best way possible, although some referral times needed to be improved. The service was well-led and this area rated as good. The management had the skills and experience to lead and govern the quality and safety of care.

  • Maternity services were rated overall as good. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. Safe, effective, responsive and well-led were rated as good. Caring was rated as outstanding. In safe, training, safeguarding, infection risk and medicines were managed safely. Equipment and premises were generally well-maintained, although the premises were ageing and some areas not ideal. The windows were susceptible to leaking in the rain and the lift was at risk from breaking down at times. There were mostly safe levels of staff as recommended by national guidance. Care was effectively provided in line with national guidance and women had good outcomes. Staff were competent and their performance was monitored. Caring was rated as outstanding as feedback from women and their partners was consistently excellent. Women were treated with dignity and respect and emotional support. The service was responsive to the needs of women and their partners. Services were planned to give choice and were available when needed. Managers in the service had the skills and experience to provide a good, high-quality service. There was a positive culture and staff were well supported.

  • Services for children and young people improved from requires improvement at our last inspection in 2016 to good overall. Safe stayed as requires improvement. Effective remained good as did caring and responsive. Well-led improved from requires improvement to good. Safe remained as requires improvement as we were concerned about the overall safety of the environment with the necessary admission of children with mental health problems where there were no beds available to them in specialist mental health services. Not all staff had updated their mandatory training and some patient records needed to be better. However, staff knew how to protect children from abuse and there were enough staff to support them. Incidents were managed well and the service was willing to learn. Care was effective and children and young people had good outcomes. Caring was provided with kindness and compassion to both children, young people and their families. The service was responsive to meet the needs of the population. Well-led had improved with managers who had the skills to run a service with a recognised commitment to children and young people. There was a positive culture and shared values.

  • End of life care was rated overall as good. This improved from a rating of requires improvement at our last inspection in 2016. Safe dropped one rating to requires improvement due to issues with recording of mental capacity assessments and decisions around resuscitation. Not all risk assessments were being completed and there was no policy or standard operating procedures for the use of syringe drivers. However, staff were well-trained, kept patients safe, most patients’ records were good, and there was a safe level of staff. Effective remained good with patients receiving good outcomes and care and treatment based upon national guidance. There was good multidisciplinary working. Caring was good, with staff providing compassionate and emotional support. Responsive remained as good with the service committed to meeting the needs of the population and caring for them as individuals in the last phase of their lives. Well-led had improved to good with renewed leadership. The governance of the service had improved, although there remained some work to do.

  • On this inspection we did not inspect surgery, critical care, or outpatients. The ratings we gave to these services on the previous inspection in 2016 are part of the overall rating awarded to the trust this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website – www.cqc.org.uk/provider/RA4/reports.

Inspection carried out on 15 – 17 March 2016 and 24 March 2016

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 15 and 17 March 2016. We also carried out an unannounced inspection on 24 March 2016. We carried out this comprehensive inspection at Yeovil District Hospital Foundation Trust as part of our comprehensive inspection programme. The trust has one main location.

The hospital opened in 1973 and was established as an NHS Foundation Trust in June 2006. The trust delivers services to a population of approximately 200,000 primarily from the rural areas of South Somerset, North and West Dorset and parts of Mendip. The trust provides outpatient and inpatient consultant services for a range of specialties primarily from its main site Yeovil District Hospital. It also provides outpatient and diagnostic services in a number of hospitals in the surrounding area, including the Yeatman Hospital in Sherborne and Wincanton, Crewkerne, Chard and South Petherton community hospitals. We did not review the care at the community hospitals at this inspection. At previous inspections the trust had been found to be compliant with the regulations we reviewed.

At this inspection we found that the trust was working hard with other stakeholders to improve the services offered to the local community. We found a highly committed workforce who put the patient at the centre of care. We saw some examples of very good practice which included the stroke buddying group and the ways in which maternity staff were involving vulnerable young women in maternity care. However we also found an emergency department which when under pressure was not responsive to the needs of patients. We struggled to understand the rationale for placing adult patients on the children’s ward and had to formally request information and reassurances from the trust around the safety of doing this. We found that the trust were responsive to the concerns we raised on and after the inspection and put in place actions to address these.

Our key findings were as follows:

  • Staff were caring in delivering care to patients. We observed many examples of compassionate care which staff delivered to patients with respectful and considerate approaches.
  • Feedback from patients, relatives and carers was positive throughout our inspection.
  • Staff were proud to work at Yeovil District Hospital. We found staff were part of a hospital based community in which staff worked together to try to meet the needs of patients.
  • In many areas staff felt well supported by their line managers and were aware of the trust’s vision and strategy. Many staff were aware of the trust’s iCARE strategy which incorporates the values of communicate, attitude, respect and environment.
  • We saw most staff complied with infection prevention and control best practice in relation to hand washing and remaining bare below the elbow. However, this was not consistent throughout the hospital.
  • Most areas of the hospital were visibly clean however we found equipment was not always stored appropriately and in a way which controlled and reduced the risk of infection.
  • Protected meal times were in place and staff offered patients food and drinks. Most areas assessed patients for their risk of malnutrition however we found nutritional screening assessments on surgical wards were not always completed in line with trust policies.
  • We found that whilst most patients received appropriate and completed risk assessments, on admission, the trust did not use individualised care plans to document on-going care, treatment and actions taken to mitigate risks to patients.
  • There were a greater proportion of middle grade and junior doctors employed at the hospital compared to the England average. We found emergency consultant cover in the Emergency Department did not meet the Royal College of Emergency Medicine standard for senior clinical cover in a listed trauma unit.

We saw several areas of outstanding practice including:

  • Snack box training had been set up to deliver specific and focussed small pieces of training to staff that can be accessed during their lunch break.
  • Development of a hospital garden for the use of patients, including patients living with dementia.
  • Development of an integrated care model supporting patients with three or more long-term conditions.
  • A ‘buddy system’ was used in critical care where nurses were paired to work together, this was to ensure adequate supervision of patients during staff meal breaks and for checking medicines.
  • Patient diaries in critical care were extremely well managed. The unit kept a copy of the diaries to ensure staff knew what the diaries contained; this enabled on-going support to be given to patients families after the diaries had been collected.
  • At the foot of every bed space in the critical care unit there was an analogue clock, with the date also displayed and a very clear sign which said, ’You are in intensive care, you are in Yeovil Hospital.’ This had been provided in response to patient feedback and helped to orientate patients to where they were being cared for and to the time and date.
  • The critical care outreach team had produced and implemented a patient assessment document to aid the early recognition and prompt treatment of sepsis. As part of the education package unit staff had produced a video. A staff badge had been introduced to acknowledge hospital staff who had used the tool to identify and manage a patient with sepsis.
  • In maternity and gynaecology services, the Acorn team provided specialist care for women who were vulnerable, were known to be at risk of domestic abuse, who smoked or were prone to substance abuse. Women under the age of 19 and women who had a learning disability could also be referred to the Acorn team.
  • The children and young people’s services’ community nursing team provided a range of different services to meet the needs of patients. The team included specialists or nurses with an interest in specific conditions such as cystic fibrosis, oncology and end of life care.
  • Services for children and young people had a school based within the children’s outpatients department. The school had a qualified teacher, working Monday to Friday, to provide education to patients who had been in hospital for long periods.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure systems and processes to prevent and control the spread of infection are operated effectively and in line with trust policies, current legislation and best practice guidance. The trust must work to improve standards of hand hygiene across children’s services.
  • Ensure equipment is stored appropriately and in a way that reduces infection risk. Ensure equipment used by cleaning staff is not stored in the sluice area and toilet rolls are not stored on commodes. Ensure commodes are completely clean before returning them to clean utility rooms. Ensure clean equipment is stored off the floor to prevent contamination. Ensure the covers on metal linen shelving units are kept closed when not in use to prevent cross infection. Ensure contaminated disposable items are not stored with clean disposable items. Ensure systems and processes to prevent and control the spread of infection are operated effectively and in line with trust policies, current legislation and best practice guidance within the maternity operating theatre.
  • The trust must ensure resuscitation equipment is routinely checked. The emergency department must ensure all resuscitation equipment is checked. Children’s resuscitation equipment must be available in the children’s assessment area in the emergency department. The trust must ensure all emergency lifesaving equipment, is sufficient and safe for use in maternity and gynaecology services and that there is evidence it has been checked in line with the trust policy.
  • The trust must ensure medical and nursing staffing is sufficient to meet the needs of patients. The emergency department must undertake a review of staffing levels using a recognised assessment tool. The trust must recruit sufficient medical and nursing staff to enable the operational and staffing standards for intensive care units to be met. Ensure sufficient medical staff are on duty in the medical business unit at night. The trust must ensure staffing levels reflect the acuity of patients in accordance with British Association of Perinatal Medicine (BAPM) standards.
  • Ensure that all patients receive appropriate and completed risk assessments, including those for dementia, on admission and an individualised care plan commenced to demonstrate the on-going actions taken to mitigate risk. The trust must also ensure nutritional screening assessments on surgical wards are completed in line with trust policies. Ensure the completion of documentation and of patient risk assessments on the gynaecology ward.
  • Ensure that controlled drugs are managed in accordance with trust policies, legislation and best practice in the discharge lounge. Ensure oxygen, when required for patients, is prescribed appropriately. Ensure medicines are always safely managed in line with trust policies, current legislation and best practice guidance in maternity and gynaecology services. The radiology department must ensure that guidance is in existence surrounding patient group directive medications.
  • Ensure that at least 90% of all staff receive an annual appraisal. Ensure nursing staff in specialist areas are trained on recruitment or placement to become efficient and competent members of their staff team. The trust must train all staff who have direct input into assessing, delivering, and intervening in the care of children and young people, in level three child safeguarding in line with intercollegiate guidance. The trust must improve the numbers of staff trained in European Paediatric Life Support (EPLS) to ensure they meet Royal College of Nursing guidance of at least one EPLS trained member of staff working every shift. Ensure all overseas staff are supported to achieve a good standard of the English language to reduce risks to patients.
  • The emergency department must put systems and processes in place to ensure patients receive initial assessment (triage) by an appropriately qualified clinical member of staff within 15 minutes of arrival to the emergency department.
  • The emergency department must take action to ensure the safety of children in the waiting area of the emergency department.
  • The emergency department must provide daily clinical and managerial leadership with oversight of capacity and demand. The emergency department must develop robust escalation processes.
  • Ensure that all patient records are kept securely and located away from the public to maintain confidentiality.
  • Ensure all wards have single sex accommodation including sleeping accommodation, bathroom and toilet facilities and do not need to pass members of the opposite sex to use the facilities.
  • Ensure the sepsis protocol is embedded with all staff groups to achieve and maintain high levels of compliance with sepsis identification and antibiotic administration.
  • The trust must ensure young adults (patients between the ages 18 to 24) meet the criteria for admission onto the Young Persons Unit.
  • The trust must review the physical environment of Ward 10 and explore options to separate the Young Persons Unit from Ward 10 to ensure patients over the age of 18 do not have access to children.
  • Ensure 'do not attempt cardio-pulmonary resuscitation' (DNACPR) forms are completed appropriately and in accordance with national guidance and best practice. The trust must also ensure DNACPR decisions are documented fully in accordance with the legal framework of the Mental Capacity Act 2005.
  • Radiology must continue to target the quality assurance backlog of equipment.
  • The radiology department must develop audits and action plans to address incomplete five steps to safer surgery checklists. The radiology leads must ensure guidance surrounding trauma computerised tomography (CAT) scanning is clear and not open to individual interpretation.
  • The outpatients department must continue to support improvements to meet the national referral to treatment times.
  • The trust must ensure that fewer appointments are cancelled by the hospital at short notice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.