• Organisation
  • SERVICE PROVIDER

Archived: Taunton and Somerset NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

14 January 2020 to 29 January 2020

During a routine inspection

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

At core services level, effective, responsive and well-led were rated as good overall. Caring was rated as outstanding. The rating of well-led for the trust management was good as was the trust’s use of resources. This led to a combined overall rating for the trust of good.

At core services level, safe remained as requires improvement overall following our last inspection published in late 2017, and more work was required in this area. The questions of effective, responsive and well-led remained as good. Although responsive was good overall, not enough patients were being treated in accordance with NHS constitutional referral to treatment standards. Caring retained its rating of outstanding. This outstanding rating came from caring in medical care and critical care services.

We rated well-led at the trust management level as good. The leadership had the capacity and capability and commitment to deliver high quality, sustainable care. There was a clear vision and credible strategy for the future, which involved and centred on the imminent merger with Somerset Partnership NHS Foundation Trust. There was a strong culture of high-quality, safe and sustainable care throughout the staff. However, some of the systems and processes to ensure harm to patients was avoided did not have sufficient oversight or monitoring.

There were clear responsibilities, roles and systems of accountability to support good governance and management. Information was accurate and effectively processed. There was good engagement with patients staff, and stakeholders. There were systems to support learning, and significant strength in innovation and quality improvement which were highly encouraged.

However, there was some work needed, as recognised by the trust, to tackle wellbeing and the pressure upon staff. More staff, particularly those from a black, Asian and minority ethnic background, needed to feel safe and valued and to feel confident to report abuse from members of the public, including patients and families.

The mortality investigations, encompassing the National Quality Board learning from death requirements, were not consistent, structured, or always of high quality. Learning from death and reporting did not fully meet trust policy. It was not always reported on at the trust board, and there was little evidence of learning in those reports, even though it was clearly undertaken well in the wider trust. Families or those who cared for the patient were not involved in investigations into the death where there were failings in care.

The operational performance at the trust was meeting few of the national targets or standards for treating patients. It was performing worse than the England average in some measures, particularly referral to treatment times (patients waiting to start treatment). The trust was fully aware of performance and this was responded to with recovery plans and actions which key staff were taking with sufficient seriousness.

Medical care (including older people’s care) was rated as good overall. The overall rating stayed the same, and due to improvements made, safe moved up from requires improvement to good. The trust had addressed the areas needing improvement from our last inspection, although not entirely in relation to checking emergency equipment. Responsive was rated as good, but not enough patients were being referred for treatment in a timely way and in line with NHS constitutional standards. The other key questions were rated as good and caring remained rated as outstanding.

In safe, the service had enough well-trained staff to keep patients safe and protected from abuse. There was a good safety culture. Staff had training in key skills, understood how to protect patients from abuse, and mostly managed safety well. Staff assessed risks to patients, acted on them and kept good care records most of the time.

However, the four-bed high dependency respiratory unit was not staffed in line with trust policy. Some individual risk assessments were not always completed when patients with mental health needs moved areas. Records of patients with a deteriorating condition were not always completed by medical staff after nursing staff informed them of the increasing risk. Some emergency equipment was not consistently checked on a daily basis.

Effective was good with care and treatment following evidence-based practice and outcomes for patients were good. Staff were capable and competent and their performance reviewed. Patients were able to make informed decisions. However, mental capacity documentation was inconsistent and endoscopy services had not reached accreditation.

In caring, patients were treated compassionately and to minimise any distress. The care delivered was outstanding. Patients were given time to make decisions and treated as individuals. Responsive was good and services planned to support patients and treat them in accordance with their needs. However, not all patients were treated in the time required by NHS standards. Patients and families were able to easily give feedback and this was listened to and acted on.

Well-led was good with leaders having the skills, capacity and experience to lead the service. Staff were respected and valued. Governance was effective and most risks were recognised and managed. There was a strong commitment to innovation, learning and improvement.

Critical care was rated as good overall. Effective, responsive and well-led were rated as good. Caring was again rated as outstanding. However, as previously, safe was rated as requires improvement.

In safe, the ageing facilities were complex to manage and maintain. Not all areas were fit for purpose and some equipment stores were not secure. During our inspection we found the unit had unrestricted public access, with the main entry doors being unlocked. This was resolved by the trust shortly after our inspection. The checking of the resuscitation equipment was not carried out consistently, as was the case on our previous inspection. There were not enough specialist doctors trained in advanced airway skills on duty at all times and insufficient pharmacist cover to meet guidelines – although the pharmacist cover was addressed shortly after our inspection. There were not enough allied health professional staff to provide optimal care at all times in line with recommended practice.

However, patients were protected from abuse. Staff had good infection prevention and control processes. There were enough nursing staff to provide safe care and treatment. Patients’ records were well completed and clear, and medicines were safely managed.

In effective, which was good, care was delivered on evidence-based practice. There was good pain, nutrition and hydration management. Staff were competent for their roles and worked in a strong multidisciplinary approach to patient care. However, not all staff were having annual performance reviews on time, and there was insufficient input from therapy staff at times.

Caring was outstanding with staff treating patients with compassion and kindness. There was outstanding emotional support to patients and to their families and carers. The service received overwhelmingly positive feedback about the quality of care. Responsive was good with care planned to meet the needs of patients who were treated as individuals.

In well-led, which was good, there was strong leadership with support for staff. Staff felt respected and valued. There was good governance and engagement with patients and staff. Staff were committed to service improvement. However, there was insufficient review of audits, and there were no minutes kept for mortality and morbidity reviews.

Maternity was rated as good overall although safe required improvement. We do not compare the ratings this time with our previous ratings as in the previous report they included a review of gynaecology services. Despite a challenging environment, infection risks were well managed. Midwife staffing levels were safe and regularly reviewed. Records for patients were mostly good and complete. Incidents were investigated and families were provided with honest information when things went wrong. However, staff were not compliant with the target for updating some mandatory training modules. There were issues with the safe management of medicines. Records did not always have the right information about a patient’s mental health needs. There was a lack of clarity around the cleaning for birthing pools.

Care and treatment were effective and based on national guidance. Pain, nutrition and hydration were well-managed. Staff were competent, capable and able to develop. They cared for patients and their families with kindness and insight. The service met the needs of women and included those in need of extra support. However, due to the lack of full cover from anaesthetists at all times, there were risks to the timeliness or procedures, including administration of epidurals and delays in induction of labour. Complaints were not always responded to in good time.

There was good leadership and staff felt supported and valued. There were mostly effective governance and assurance processes including management of risk. Innovation and improvement were encouraged.

Services for children and young people was rated as good overall. Safe improved from requires improvement to good, with other key questions remaining rated as good. The areas in safe we asked the trust to address had been improved. Staff knew how to protect children and young people from abuse. Staffing levels were good, and staff had the right skills and experience to provide safe care. Records were well maintained for patients, and medicines were safely managed. However, the ageing environment was not easy to manage. The ward was located some distance from other services. The unit was often too hot in the warmer months, and due to wear and tear, not easy to maintain and keep clean. Not all patient records were stored securely.

The service provided effective care based on national guidelines. Pain, nutrition and hydration were managed well. Staff had reviews of their performance and they were all involved in decisions around care and treatment for their patients. Children, young people and their families were treated with kindness and supported to make decisions.

There was good access to all the services children and young people needed, including for their mental health. However, the need to provide care and treatment to patients with mental health illnesses had an impact at times on others on the ward especially in the context of the older building and the layout of the unit.

There was strong and committed leadership. Staff promoted a strong and cohesive culture and felt supported and valued. There was good governance and assurance and staff engaged with children and young people, their families and others to help improve the services they delivered.

Other services and ratings

On this inspection we did not inspect urgent and emergency care (A&E), surgery, end of life care, or outpatients. The ratings we gave to these services on the previous inspection published in 2017 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

30 Aug to 28 Sept 2017

During a routine inspection

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

25 -29 January 2016 and 9 February 2016

During a routine inspection

The Care Quality Commission (CQC) carried out a comprehensive inspection between the 25 and 29 January 2016. We also carried out an unannounced inspection on 9 February 2016. We carried out this comprehensive inspection at Taunton and Somerset NHS Foundation Trust as part of our comprehensive inspection programme.

This organisation has one main location:

Musgrove Park Hospital, a large acute hospital comprising all acute services. This hospital is the largest in Somerset. However some maternity and outpatients services were delivered at different sites in the county, these were not visited as part of this inspection.

The hospital opened in late 1942, having been built as an American Army Hospital. It became part of the NHS in 1952. Work to modernise the site began in 1987 with the opening of the Queen's Building, whichincludes the Emergency Department, Orthopaedics, Ophthalmology, Ear, Nose, and Throat, Oral and Maxillofacial Surgery, Endoscopy and Therapy Services. The Duchess Building, including all Medical and Care of the Elderly Wards, Outpatients, Pharmacy and Diagnostic Imaging, was opened in 1995. The new Jubilee building opened to patients on Saturday 15th March 2014. The Jubilee building has three wards, Barrington Ward on the Ground floor with 32 beds, Hestercombe Ward on the First floor with 40 beds and Montacute Ward on the top floor with 40 beds. All 112 bedrooms have en-suite bathrooms. It replaces four open plan ‘Nightingale’ wards in the Old Building. The wards treat mainly surgical patients for the following specialities General Surgery, Colorectal, Urology, Gynaecology, Breast, Orthopaedic, Vascular and Upper GI.

The trust provides a full range of acute clinical services. The trust has 576 Inpatient and 81 day case beds.

The trust provides specialist and acute services to approximately 538,000 people in Taunton Deane, Sedgemoor, Mendip, South Somerset and West Somerset.

Previous inspection by the CQC in September and October 2013 found that there were breaches in three regulations around record keeping, equipment maintenance and specialised training. At this inspection we found that some actions had yet to addressed around specialist training and that it could not always be demonstrated that patients had been consulted regarding do not resuscitate decisions.

The trust had a relatively new executive team. The Chief Executive was appointed in February 2015, shortly after the Chair had been appointed. The Director of Patient Care was appointed in December 2015. However other members of the senior team had been in post for over two years, some considerably longer. The senior team was found to be cohesive and worked well together.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Each section of the service receives an individual rating, which, in turn, informs an overall trust rating.

The inspection found that overall; the trust had a rating of good.

Our key findings were as follows:

  • There was a strong, visible person-centred culture demonstrated by all staff. We observed staff positively interacting with patients and, patients were treated with kindness, dignity, respect and compassion while they receive care and treatment.

  • Staff were overwhelmingly caring in delivering care to patients. We witnessed some outstanding examples of care being given to patients and their relatives.

  • We considered the flexibility of the meals service to be outstanding. Patients had plenty of choice from two different menus or could choose what they wanted day or night

  • In the emergency department arrangements were not in place to ensure suitable care and treatment was provided to children and the care environment for children was not suitable.

  • There was insufficient evidence to that resuscitation trolleys were checked in line with trust policy. On some trolleys, we found out of date equipment.

  • Staff mostly followed good infection practices but not clinical area was clean and tidy. In some areas effective cleaning would not be possible due to aging and damaged estates and furniture.

  • Medicines in a number of areas were not always securely stored

  • The senior management team had engendered a culture of learning from incidents and one in which the patient was put at the centre of care provided.

  • The environment at Musgrove Park Hospital was a mix of newly built units with excellent facilities and aging departments and wards. This presented challenges in delivering care in units which met current guidelines.

  • Children’s and neonatal staffing levels did not meet the current guidelines.

  • Patients using the service were receiving effective care and treatment, which met their needs. Outcomes for patients were routinely collected and monitored, and were mostly positive.

We saw several areas of outstanding practice including:

  • The trust had a Joint Emergency Therapies Team (JETT) and Older Persons Assessment and Liaison service (OPAL) which assessed all patients over the age of 75 with the view to prevent avoidable admissions.

  • The hospital was named as one of the top hospitals in the 2015 CHKS awards, (CHKS is a provider of healthcare intelligence and quality improvement services), and was highly commended for patient experience. The CHKS awards commended the cancer care team, in the International Quality Improvement category, for their work.

  • Investors in People awarded the gold standard to the Beacon Centre for oncology, one of only 7% of accredited organisations to win this.

  • Colorectal Specialist Nurses had been trained to use clinically developed criteria and pathways to direct patients to the relevant test or clinic thus avoiding unnecessary steps or diagnostic procedures in the patient’s pathway. This improved the speed of diagnosis for patients with suspected colorectal cancer.

  • We saw the use of a number of initiatives to mitigate the risks identified as a direct result of previous low staffing levels and skill mix. These included; banked hours; clinical supervision; an on call system; the appointment of a Practice Educator and; the band five and six development programmes.

  • Critical care participated in the Potential Donor Audit (PDA). PDA audit results for the reporting period April 2015 to September 2015 showed the trust as the best trust in the South West region for; approaching patients and, securing a good number of donors.

  • A tracheostomy ward round, led by a consultant intensivist in collaboration with a nurse specialist for ‘head and neck’, took place daily to assess tracheostomy care and improve standards both in critical care and throughout the hospital.

  • As part of the ABCDE assessment of new admissions to critical care, the team had added F (for family) to remind staff to communicate with the family about any concerns or worries they may have.

  • Local safety projects were in place to highlight current incidents and areas of concern and included the ‘take note project’ and, ‘raising standards project’.

  • One of the midwives at the service had also recently won a MAFTA award for her innovative ideas. She had designed a fabric placenta as a teaching aid and designed the “smoke free buttons” located throughout the hospital, which when pressed plays a voice recording outside to remind patients and visitors of the smoke free message.
  • The Marie Curie companion service is the only one currently in the country. It uses the innovative approach of using trained volunteers to help provide emotional comfort to patients. There was overwhelming praise from staff about this service and the report of the six-month review of the service showed positive feedback from family members. The service was shortlisted for the National End of Life Safer Patient Award in June 2015.
  • In partnership with the complex care GPs and a neighbouring community NHS trust palliative care consultant team, the trust had made a successful bid to the Health Education South West to develop a health improvement programme between hospital and community. The aim of the programme was to increase effective communication with regard to those who are dying. This project was ongoing at the time of inspection.

  • The trust had an end of life poetry project. This was led by a staff member, whose aim was to help make colleagues comfortable with having difficult conversations with patients and their families.

  • The orthotic department could facilitate the provision of prosthetic boots within 15 days following an appointment. This was considered an exceptional service as this could take several months in some areas.

  • The trust e-referral advice and guidance system. This enabled GPs to discuss symptoms with a specialist consultant who would advise on the preferred treatment pathway, reducing the need for hospital attendance.

  • The clinical support directorate clinical lead had undergone specialist training in change management to the implementation of seven day working.

  • There was priority access to imaging services for trauma and patients suspected of having suffered a stroke.

  • The outpatients department worked closely with the health community setting up testing hubs in general practitioner (GP) practices. Patients could have cardiac assessments and be fitted with a 24-hour tape. Results were transferred to MPH cardiology department. This meant that only those patients who needed to attend hospital would receive appointments.

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

Importantly, the trust must:

  • Ensure all emergency lifesaving equipment, is sufficient and safe for use in all clinical areas and that there is evidence it has been checked in line with the trust policy.

  • Medications were not always suitably stored so were at risk of theft, being tampered with, and accidental or unintentional ingestion by unauthorised persons. The trust must ensure medicines are always safely managed in line with trust policies, current legislation and best practice guidance.

  • Fridge temperatures were monitored and recorded, but these were not completed consistently which could impact on the optimum storage conditions of medicines.

  • Ensure staff have the appropriate qualifications, competence, skills and experience, in excess of paediatric life support, to care for and treat children safely in the emergency department, critical care and children’s ward.

  • Ensure trained health care professionals triage all patients attending the emergency department within 15 minutes of arrival, and have systems in place to escalate and mitigate risks where this is not achieved.

  • Ensure there are robust systems in place to assess, monitor, and mitigate risks to deteriorating patients in the emergency department.

  • Emergency department leaders were not aware of all of the current risks affecting the department and the delivery of safe care. Risks identified during the inspection such as no paediatric nurses working in the department and the environment had not been assessed or placed on the department risk register.

  • The hospital must improve the accuracy and timeliness of patient risk assessments. Delays present serious risks to patients who are deteriorating or seriously ill and could result in a delayed treatment.

  • The trust must take action to ensure that the WHO five steps to safer surgery checklist are completed and documented for every patient undergoing a surgical procedure.

  • The medical staffing levels for the provision of advanced airway management, in the absence of the consultant, did not meet the Core Standards for Intensive Care 2013.

  • The registered provider must ensure 50% of nursing staff within critical care have completed the post registration critical care module. This is a minimum requirement as stated within the Core Standards for Intensive Care Units

  • The obstetric anaesthetic staffing levels for the provision of emergency work on the delivery suite, did not meet the guidelines for Obstetric Anaesthetic Services 2013.

  • Trained nurse staffing did not fully meet ‘British Association of Perinatal Medicine Guidelines (2011).’(BAPM). This was because the ratio of 1:1 and 1:2 nurse to baby care in the neonatal high dependency unit was not achieved.

  • Staffing within the children’s service, although currently considered as being safe by the senior management, and reflecting both occupancy rates and the fluctuating number of children as inpatients, were recognised as not achieving Royal College of Nursing (RCN) (2013) guidance because they had two less staff per shift than recommended by national guidance. (Full funding for the paediatric high dependency unit (HDU) was not available which had affected the numbers of staff employed to provide this part of the service.

  • The children’s service were not compliant against the ‘Facing the Future’ standards because of a lack of permanent consultant cover between 5pm – 10pm. The trust identified that in accordance with ‘Facing the Future 2015’ funding had been secured to provide additional senior paediatric consultant cover until later evenings (5pm until 10pm) to match periods of highest activity.

  • The registered provider must ensure that at least one nurse per shift in each clinical area (ward / department) within the children’s and young people’s service is trained in advanced paediatric life support or European paediatric life support.

  • Ensure an accurate record is kept for each baby, child and young person which includes appropriate information and documents the care and treatment provided.

  • Ensure that appropriate systems are in place to ensure that DNACPR decisions for patients who lacked capacity were made in line with the Mental Capacity Act 2005.

  • Develop a comprehensive framework for governance, risk management and quality measurement for end of life care.

  • The registered provider must ensure that clinical staff who have direct contact with children and young people have completed level three safeguarding training as identified through the Safeguarding Children and Young people: roles and competences for health care staff intercollegiate document (March 2014, v3).
  • The registered provider must ensure that staff in the emergency department and children, and young peoples services staff are suitably trained to have the skills and knowledge to identify and report suspected abuse.
  • The trust must take action to ensure that the WHO five steps to safer surgery checklist are completed and documented for every patient undergoing a surgical procedure.

  • When a person lacks mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.

  • Ensure that appropriate systems are in place to ensure that DNACPR decisions for patients who lacked capacity were made in line with the Mental Capacity Act 2005.

  • The Registered Provider did not have proper processes in place to enable it to make the robust assessments required by the Fit and Proper Persons Requirement.

Professor Sir Mike Richards

Chief Inspector of Hospitals

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.