All inspections: Musgrove Park Hospital

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

Patients were protected from abuse and avoidable harm. Most infection prevention and control practices were carried out effectively. There were good staffing levels and most patient records well managed with medicines looked after safely. There was a strong culture around reporting incidents. Most risks to patients were assessed well and acted upon.
Care was effective and patients had good outcomes. Staff promoted a good quality of life with patients. There was a strong culture of multidisciplinary input into care and treatment. Care was delivered in line with evidence-based practice and legal frameworks. Pain relief, nutrition and hydration were managed well.
Patients and those who cared for them spoke highly of the care and treatment given to them. They were treated with compassion and kindness and as individuals. People were able to make their own decisions and supported to do so. The right people were involved when patients were not able to decide for themselves.
Services were designed to meet the needs of local people. Patients were treated as individuals and adjustments were made to give everyone the best outcome. Care was mostly available to people when it was needed. There was learning from complaints and concerns raised by patients and those who spoke for them.
The staff leadership teams had the skills, knowledge, and experience to manage services. High-quality and patient-centred care was promoted. There was a vision for the future of services, and a clear set of values for staff based on the experience for the patient. Staff were well supported and there was good morale and a strong culture. Staff were willing to challenge poor practice and support each other. There was a strong culture around innovation, research, development and improvement. There were mostly good governance systems to give assurance of good, safe and quality services.

However:

We had concerns about the safety of the anaesthetic cover out of hours, particularly in maternity and critical care services. We had this concern on our previous inspection in 2017, and although this had progressed, it was not fully resolved. Staff were not compliant with the target for updating some mandatory training modules. As with our previous report in 2017, not all emergency equipment was being checked as it should be, although this had improved. There were security problems in critical care (although the unit was locked to open access shortly after our inspection). There were insufficient numbers of allied health professional staff in critical care.
Clinical deterioration of patients was not always well documented once the patient was highlighted to the medical staff for review.
Most patient records were held securely, although as with our previous inspection, there were some lapses in this area at times. The care for children admitted with underlying mental health illnesses had sometimes impacted on others on the ward.
Not all mental capacity assessments were documented consistently. Less than the recommended number of nursing staff in critical care had post-registration training. Not all staff were receiving annual performance reviews.
The trust had not met the NHS constitutional standards for treating patients on time for a number of years, and this was not improving.
Governance meetings did not always include key elements and not all were well recorded.

Our inspection of the trust covered only this hospital. What we found is summarised in the Overall summary under the sub-heading Overall trust.

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 specialties 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.

A 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.

During our unannounced inspection we had serious concerns regarding the level of paediatric cover in the emergency department, care for the deteriorating patient and those with sepsis, medicines management and the completion of the surgery checklist. We wrote to the trust explaining the reasons for our serious concerns. The trust took immediate action following this letter implementing a series of reviews and external support. The trust have told us they have since implemented paediatric nurses on every shift within the emergency department and reviewed the training of nurses within the department. They also told us they have implemented a safer storage system for medicines management. They have reviewed the practice for alerting the deteriorating patient and those with sepsis. The trust has implemented a sepsis nurse of the day in the department to ensure that patients with sepsis are care for in a timely manner. The trust has also reviewed completion of the checklist for surgery. The trust now has an action plan, agreed with CQC, for further actions to ensure the health and safety of patients using the emergency and surgical services. The CQC were reassured that the trust had taken on board the serious concerns and decided to take no further enforcement action in this respect. We will continue to monitor improvements at the trust. This report reflects the issues we found at the trust on our inspection.

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

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.
General Practitioners (GPS) worked in the emergency department. GPs supported management of patients in the ambulatory stream with primary care problems.
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 the whole Haematology, Oncology and Palliative Care Directorate (which included the Beacon Centre), 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.
Two paediatric consultants developed an App, whose aims was to develop a single care pathway from home through to community healthcare and into hospital. The app ‘HANDI Taunton’ was launched in March 2015 and provided parents with ‘clear and concise advice’ about the six common childhood illnesses. The conditions covered included, diarrhoea, chesty baby, chesty child, high temperature, abdominal pain and common new-born problems.
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 on-going 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.

In addition the trust should:

The trust should 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 should ensure maternity staff report all incidents and near misses through the trust incident reporting system.
The trust should ensure regular mortality and morbidity meetings take place in the emergency department.

The trust should consider reorganising or amalgamating morbidity and mortality meetings to ensure learning is captured and shared across all specialities.
The trust should ensure there are a suitable number of staff with the appropriate skill mix available in the emergency department and Jowett Ward at all times.
The trust should ensure patients hydration levels are monitored whilst in the emergency department and this is documented in their care records.
The trust should ensure there is a screening tool in place to assess risk of physical abuse in children.
The trust should review children’s provision in the emergency department to meet the 2012 Intercollegiate Committee Standards for Children and Young People in Emergency Care Settings.
The trust should ensure staff consistently adhere to local guidelines available in the emergency department.
The trust should review the way in which the treatment areas for children in the emergency department are used, to ensure they are always available to deliver care to children.
The trust should ensure there is a robust system in place for delivering and recording the induction of locum and agency staff working in the emergency department.
The trust should ensure the safeguarding checklist is completed on all children’s records when they attend the emergency department.
The trust should consider confidentially displaying the most recent early warning score for patients in the department on the electronic computer system.
The trust should ensure it reviews critical care services in line with the Core Standards for Intensive Care Units 2013 to address areas where they are not meeting these standards.
The hospital must improve the accuracy and timeliness of patient risk assessments.
Should take measures to ensure procedures are followed regarding the safe management of sharps boxes.
The hospital should ensure patient records are securely stored.
The hospital should ensure, where appropriate capacity assessments are clear and visible in patient medical records.
The trust should ensure local clinical guidelines in critical care have been monitored and reviewed to ensure consistency of practice.
The trust should ensure there is a program of work/time-line identified to establish when national standards (HBN 04-02) will be met in critical care.
The trust should consider reviewing the discharge process for critical care.
The trust should meet the OAA/AAGBI Guidelines for Obstetric Anaesthetic Services 2013 which state that that there should be a minimum of 12 consultant anaesthetist sessions per week.
The trust should ensure staff that are recovering post-operative patients, regardless of the method of anaesthesia, should have appropriate training to comply with the recommendations of the British Anaesthetic and Recovery Nurses Association (2012).
The trust should benchmark critical aspects of performance on the maternity dashboard to ensure staff are able to check that performance falls within acceptable levels.
The trust should implement a system of “red flags” for midwifery staffing incidents in line with NICE NG4 guidance “Safe midwifery staffing”.
The trust should ensure that staff that have appropriate additional training in the care of the critically ill women in line with guidance from the Royal College of Anaesthetists 2011.
The trust should ensure the provision of dedicated elective section list that is not interrupted by emergency cases or the lack of theatre staff.
The trust should ensure that all staff have access to the trust’s report and gap analysis of the Kirkup report and are aware of the recommendations and the implications for their practice.
The service should look to provide a more cohesive service for all gynaecology patients receiving care at Musgrove Park Hospital.
The trust should ensure that all staff have completed mandatory and role specific training and should ensure that the training record held by the service is accurate.
The trust should consider a regular audit programme to ensure that water temperatures in birthing pools are within safe limits.
The trust should consider the implementation of a system in maternity services that allows staff to know a piece of equipment is clean.
The trust should ensure that they have written formal arrangements in place with the children and adolescent mental health team so that the needs of children and young people with mental health problems are met.
The trust should review its paediatric high dependency service to ensure that it has sufficient funding and staffing in place to operate the service safely.
The trust should ensure that staff have an understanding of the Frazer guidelines and Gillick competence in relation to consent processes for children and young people.
The trust must ensure that an experienced, senior nurse as identified within Royal College of Nursing guidance (August 2013) works during the 24-hour period to provide the necessary support to the HDU children’s nursing team.
The trust should continue the strategy to improve 18 week target referral to treatment times in those areas currently non-compliant.
The trust’s end of life strategy should be implemented as a matter of urgency.
The trust should implement version two of the individualised end of life care plan with full educational support, so that comprehensive plans are care are consistently recorded in patients records.
The trust should ensure all patients in the last days/hours of life are prescribed anticipatory medicines.
The trust should consider increasing the number of nurses within SPCT and consultant palliative care cover to meet the recommendation of the Commissioning Guidance for Specialist Palliative Care.
The trust should develop a coordinated systematic approach for the provision of all EOLC training and education, including considering make end of life training part of the mandatory training programme.
The trust should ensure DNACPR decisions are recorded in line with trust policy.
The trust develop a comprehensive framework for governance, risk management and quality measurement for end of life care.
The trust should take steps to ensure staff receive annual appraisals.
The trust should provide training on the Mental Capacity Act and ensure that all staff are suitably skilled and knowledgeable.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Musgrove Park Hospital is the largest general hospital in Somerset and is part of Taunton and Somerset NHS Foundation Trust. It has 700 beds, 30 wards, 15 operating theatres, an intensive care and high dependency unit, a medical admissions unit, a fully equipped diagnostic imaging department and a purpose-built cancer treatment centre. There is also a specialised children’s department, including a paediatric high-dependency bay and a neonatal intensive care unit for all of Somerset. The trust has an annual budget of nearly £240 million and employs more than 4,000 staff.

We chose to inspect Musgrove Park as one of the Chief Inspector of Hospital’s first new inspections because we were keen to visit a range of different types of hospital, from those considered to be high risk to those where the risk of poor care is likely to be lower. From the information in our ‘Intelligent Monitoring’ system, Taunton and Somerset NHS Foundation Trust was considered to be a low risk provider.

Our inspection team included CQC inspectors and analysts, doctors, nurses, patient ‘experts by experience’ and senior NHS managers. The team spent two days visiting the hospital. They also visited out of hours and at the weekend over three nights and undertook a pharmacy inspection visit on one day. We held a public listening event in Taunton and heard directly from people about their experiences of care. We spoke with patients and staff at the hospital. We received valuable information from local bodies such as the clinical commissioning groups and Healthwatch.

Most patients received safe and effective care. Surgical procedures were safe and most patients were being treated according to best practice guidelines. Most staff had received the specialist training they needed, but improvements were required in some areas. We found that most areas of the hospital were clean and infection rates were low compared to other hospitals.

Patients were treated with dignity and respect and involved in their treatment and care. The patients we spoke to were very satisfied with the service they received and all patients praised the caring, helpful and compassionate attitude of staff.

Among staff there was a sense of collective responsibility for ensuring that good quality care was delivered at every level. Staff morale was generally good and many staff told us they were proud to work in the trust.

In A&E most people were seen within the four-hour national waiting time limit. Care was taken to manage safety concerns for medical patients, particularly those who were frail and elderly. Surgical procedures were safe and the Critical Care service performs better than most other similar units across the country. Women reported good experiences of child birth. Children’s care was coordinated and services were being designed to make children comfortable in hospital. End of Life care was managed by a passionate and specialist team. Most outpatient clinics were managed efficiently and patients felt that communication was good. Many of the services we inspected were well-led and used performance information, comments and complaints to improve.

The trust was well-led, and the leadership team was focused on making sure it provides good quality, safe services. Clinical staff were involved in developing and improving services.

However, there were a number of areas for improvement in all of the services we inspected: A&E, medical care, surgery, intensive/critical care, maternity, children’s care, end of life care and outpatients.

The trust had increased the number of senior doctors on duty at weekends over the last two to three years to improve the decisions made about treatment. However, staff told us there were still not enough senior doctors present at night and weekends in the A&E, medical care and surgical departments. This was affecting the quality of medical decisions and patient handovers. In addition, due to an increasing number of medical emergencies, people were not always transferred to the appropriate specialist ward and may not have been seen by a specialist. Some patients in surgery did wait for a senior surgical opinion.

Most patients were discharged appropriately. A few patients at our listening event expressed concerns about being discharged too early, including at night. We also found that discharge arrangements needed to improve over weekends, in maternity, and for people with complex needs. The number of emergency medical admissions was comparatively higher at night and weekends, yet there were fewer discharges at the weekend and this put the hospital under pressure.

Patients’ care needs were being met. However, staff told us that sometimes, when it was busy, older people and people with dementia, may not receive the care and emotional support they need. Children in A&E were seen by specialist staff from the paediatric department but not enough staff in A&E were qualified in emergency care of children.

The theatre and wards in the older part of the hospital needed to be better maintained, for example, where water leaked through ceilings. Some of the wards, including ITU, were cramped, with equipment stored in corridors. Some parts of the maternity department were in need of refurbishment. Important equipment in maternity was not fit for purpose, and equipment in intensive care was not appropriately maintained.

Some patient records were not well-maintained. The hospital was not meeting the national waiting time of 18 weeks from referral to treatment for patients undergoing planned spinal, colorectal, bariatric, ophthalmic and ear, nose and throat surgery. Some patients waited a long time for an outpatient appointment and some orthopaedic patients had long waits in clinics.

In some departments ‘do not attempt resuscitation’ (DNAR) forms were not always fully completed. This meant there was a risk of inappropriate decisions being taken about their treatment. Many of the forms did not show that decisions had been discussed with patients or their families which could mean that patients’ rights and wishes were not respected. End of life care needed to improve on medical and surgical wards.

While there was good signage and other patient information available for people who speak English, there was none available for people whose first language is not English and for people with learning disabilities. The translation service was not always used when it was required.