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Provider: Taunton and Somerset NHS Foundation Trust Good

Reports


Inspection carried out on 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


CQC inspections of services

Inspection carried out on 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.


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.