Archived: Yeovil District Hospital NHS Foundation Trust

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