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Provider: Taunton and Somerset NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 5 December 2017

Our rating of the trust stayed the same. We rated it as good because:

Safe was requires improvement, effective, responsive and well-led were good, and caring was outstanding.

Our inspection of the core services covered only Musgrove Park Hospital.

  • Urgent and emergency care improved from requires improvement to good overall. The question of safety improved from inadequate to requires improvement. Well-led improved from requires improvement to good. We recognised there had been significant improvements in the emergency department, particularly around paediatric nursing. The integrated front door model was being used to improve both the efficiency of the service and respond to patients. However, some areas of sepsis treatment needed to improve, along with triage times for patients.
  • Surgery services remained rated as good overall. Safety improved from requires improvement to good. There had been action taken to address and resolve issues with theatre safety and surgical site infections. However, there were some patients not being treated within the national target for their referral to treatment. An improvement trajectory around RTT times had been presented to commissioners, and was being monitored for progress.
  • End of life care improved from requires improvement to good overall. Responsiveness improved from requires improvement to good, but effective stayed the same as requires improvement. Delivery of the service and outcomes for patients had been improved. Patients’ needs were met and treatment delivered by well-trained competent caring staff. Services were flexible. However, not all patient records were completed well enough. There were shortfalls in the recording of consent and patients who were subject to the Mental Capacity Act. Staff were not always involving patients who had the capacity to make their own choices in decisions about their care. There was a variable approach from the wards to making referrals to the palliative care team.
  • Outpatients was rated as good overall. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. Responsive dropped from good to requires improvement. Staff felt the culture in the various departments had improved over the last year. There were good improvement projects planned for the future. However, the referral to treatment times for a large proportion of the specialties were not meeting NHS England’s targets.
  • On this inspection we did not inspect medicine (including older people’s care), critical care, maternity, and services for children and young people. The ratings we gave to these services on the previous inspection in May 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/RBA/reports

Inspection areas

Safe

Requires improvement

Updated 5 December 2017

Our rating of safe stayed the same. We rated it as requires improvement because:

  • Urgent and emergency care improved for safety from an inadequate rating at our last inspection to requires improvement. There had been some significant improvements, particularly around additional staff trained to care for children, and checking of emergency equipment. However, some improvements were needed around triage times and sepsis management.
  • Surgery services improved for safety from requires improvement to good. There were sufficient staff, well-maintained patient records, and incidents were reported and used for learning. However, there were some improvements needed in infection control, the environment, and being able to demonstrate there was learning from patients’ deaths. There were medical records not held securely at all times.
  • End of life care remained good for safety. There had been new patient records introduced to promote individualised and safe care. Incidents were reported and investigated, and staff were aware of their responsibilities to keep people safe. However, the mortuary area was in poor condition (although the trust were fully aware of this) and there were some inconsistencies in the recording of decisions taken around end of life care.
  • Outpatient services was rated as good for safety. There was good reporting of incidents. Equipment and the environment was well looked after. Staffing levels were good and the staff well trained. However, there were some issues with cleaning, particularly in visitors’ toilets. Not all medicines were stored securely at all times. There were medical records not held securely in some places.
  • At our last inspection in May 2016, medical care (including older people’s care), maternity services, critical care and services for children and young people were rated as requires improvement for safe. The action plan from the trust gave us a good degree of confidence that the trust had taken the right action to improve the safety of these services. They will be inspected at a later date.

Effective

Good

Updated 5 December 2017

Our rating of effective stayed the same. We rated it as good because:

  • Urgent and emergency care remained good for effectiveness. Evidence-based guidance was used to provide care and treatment and staff were competent in their skills and knowledge. There was good multidisciplinary working. People who were in pain were helped, and consent was obtained in line with legal principles. However, the department had yet to review the 50 standards for best practice in emergency care as issued in July 2017 by the Royal College of Emergency Medicine.
  • Surgery remained good for effectiveness. Care and treatment followed evidence-based national guidance. Results from audits were used to improve practice. Staff were competent to deliver effective care and able to develop their skills. However, some staff needed to have further training in life support and staff competencies were not being consistently recorded in most wards. Annual performance reviews were below the target for some staff. Records did not always show patients had enough food and fluids.
  • End of life care services remained the same and rated as requires improvement for effectiveness. Not all patients were treated in accordance with the legislation within the Mental Capacity Act 2005, including accurate documentation. Not all staff were trained in the use of syringe drivers and the policy was not clear to some staff. The specialist palliative care team did not work on weekends, although advice was provided to staff at this time through a helpline. The referral rate from the wards to these experienced palliative care staff appeared to be low. However, there was an improvement in the documentation around the escalation of treatment to patients at the end of their life. Actions were taken around audit work. All staff working for the service we met were well trained, experienced and supported to deliver effective care.
  • Outpatient services were not rated for effectiveness. This is because we are not confident we are gathering enough information to rate this question. However, we found treatment was based on national guidance. Audits were undertaken to measure effectiveness. Staff were competent and participated in good multidisciplinary care for patients. However, performance reviews (annual appraisals) did not meet the trust’s targets.
  • At our last inspection in May 2016, medical care (including older people’s care), maternity services, critical care and services for children and young people were rated as good for effectiveness.

Caring

Outstanding

Updated 5 December 2017

Our rating of caring stayed the same. We rated it as outstanding because:

  • Urgent and emergency care remained good for caring. Patients were treated kindly and with respect for their privacy and dignity. Staff took the time to support patients and families, particularly when the patient had been seriously injured or was acutely unwell.
  • Surgery services remained good for caring. Staff could understand anxiety and the emotional distress that some patients felt, and were kind to them. Patients spoke about the helpfulness of staff and how they took time to make sure everyone close to the patient was kept informed. However, some patients told us they had not been informed about test results or diagnosis when they were waiting for this information.
  • End of life care remained good for caring. The evidence was universally positive about the way patients and relatives were treated by staff. Staff cared for patients with compassion and treated them well and with kindness. Patients were respected and valued as individuals.
  • Outpatients was rated as good for caring. Patients were treated with kindness and compassion. People with extra needs were given additional support. Patients and those close to them were involved in the decisions about their care.
  • At our last inspection in May 2016, medical care (including older people’s care) and critical care were outstanding for caring. Maternity services and services for children and young people were rated as good.

Responsive

Good

Updated 5 December 2017

Our rating of responsive stayed the same. We rated it as good because:

  • Urgent and emergency care remained good for responsiveness. The services were designed so that they served the needs of local people. Staff were able to help people who had additional needs to give them equitable care. Although the department was not meeting the target to treat people within four hours of their arrival, it was above the England average. The target had been achieved in April 2017 and the trend was upwards. Far fewer patients waited for more than 12 hours compared with the England average.
  • Surgery services remained good for responsiveness. Few operations were cancelled due to a lack of beds, which was an improved position for the trust. Length of stay for patients was lower than the England average, which improved the responsiveness to all patients. Patients with additional needs were supported. Complaints and concerns were listened to, investigated and learned from. However, not all targets for treating patients on time were achieved. This included cancer waiting times. Some patients were also moved at night, which can be distressing and recognised as potentially detrimental to their recovery.
  • End of life care services improved in responsive from requires improvement to good. Staff were positive in their approach to meeting the needs of vulnerable people. People were able to receive a rapid discharge when packages of care were arranged in the community or at home. There was a flexible and compassionate approach from the bereavement team. However, the trust was not auditing whether the wishes of people at the end of their lives were achieved or whether the fast-track discharge system was meeting patients’ needs.
  • Outpatients was rated as requires improvement for responsive. The service was not treating some patients within the targets set by NHS England. A large proportion of the referral to treatment times (incomplete pathway) were consistently below (worse than) the England average. However, patients had their individual needs assessed and met. Virtual clinics, where a doctor reviewed a patient and a nurse or the doctor talked with the patient by telephone, were working well. Some services provided next-day appointments for urgent cases. Complaints were investigated and learned from.
  • At our last inspection in May 2016, medical care (including older people’s care), maternity services, critical care and services for children and young people were rated as good for responsiveness.

Well-led

Good

Updated 5 December 2017

Our rating of well-led stayed the same. We rated it as good because:

  • Urgent and emergency care improved in well-led from a rating of requires improvement at our last inspection to good. There was effective and respected leadership among the medical and nursing teams. Engagement with patients and the public was important to the staff, who acted on complaints or incidents to improve care. However, the evidence within the governance framework needed to demonstrate clearly how this was being embedded.
  • Surgical services remained good for well-led. There was good support to staff and the culture was open, honest and patient-centred. The leadership of the directorate understood the challenges to quality and sustainable care. Governance was understood and staff recognised its importance for improving care. However, the risk registers were not being used at some of the directorates, despite this being required by policy. Despite the good work with governance at directorate level, this fundamental building-block being missed had not been picked up. Furthermore, not all staff were able to attend enough staff meetings to demonstrate they were well informed.
  • End of life care services remained good for well-led. There was good leadership and involvement in the implementation of the end of life care strategy. This extended from ward to board. The vision was well understood. A new governance structure was working well. Staff felt proud of their work and the quality of service given to their patients.
  • Outpatients was rated as good for well-led. Staff felt valued and supported. There was a good culture and staff enjoyed their work. The leadership was experienced and delivered patient-centred care. The governance of the service was good and meant staff recognised when changes were needed to improve care. Staff were rewarded for their hard work.
  • At our last inspection in May 2016, medical care (including older people’s care), maternity services, critical care and services for children and young people were rated as good for well-led.