Source · CQC inspection
Yeovil District Hospital
Provider Yeovil District Hospital NHS Foundation Trust
Type NHS Healthcare Organisation
Region South West
Last inspected 16 Jan 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (13)
Must-do action 1 of 13
Must do
Well-led
Provide assurance of financial scrutiny and financial risk management through the trust board with a collective and consistent understanding of the major financial issues facing the trust.
Must-do action 2 of 13
Must do
Well-led
Review the corporate risk register to ensure all risks are given a priority to match their degree of seriousness. Produce a risk register which is accessible and uncomplicated. Replace the current board assurance framework with a more appropriate and accessible report actively used by the board to identify, monitor and mitigate key risks.
Must-do action 3 of 13
Must do
Well-led
Produce an effective internal communications strategy for the financial position that sets out actions the trust, and everyone in it, can take to support financial improvement. Extend this to conversations with the wider healthcare system while being able to show the trust is doing all it can to work to a resolution in the financial position.
Must-do action 4 of 13
Must do
Well-led
Seek support to ensure there is good awareness of the opportunities to access and use benchmarking data to drive improvement.
Must-do action 5 of 13
Must do
Safe
Ensure all mandatory training is meeting trust targets.
Must-do action 6 of 13
Must do
Safe
Store all confidential patient records safely and securely.
Must-do action 7 of 13
Must do
Safe
Check resuscitation equipment every day or as is required by trust policy.
Must-do action 8 of 13
Must do
Safe
Complete and escalate early warning scores appropriately.
Must-do action 9 of 13
Must do
Safe
Maintain fully accurate records of patient care and complete fluid balance charts in line with trust policy. Complete resuscitation paperwork in line with trust policy and national guidance.
Must-do action 10 of 13
Must do
Safe
Ensure the environment of ward 10 is suitable and safe for all children and young people who are admitted for care and treatment. Prevent children and young people from having access to areas of the ward which are potentially harmful to them.
Must-do action 11 of 13
Must do
Safe
Safeguard children and young people at all times by monitoring and assessment to reduce the risk from self-harm.
Must-do action 12 of 13
Must do
Safe
Improve processes for mental capacity assessment and ensure documentation is completed in line with trust policy and national guidance. Include decisions about resuscitation and treatment escalation plans to ensure these are completed in line with trust policy and national guidance.
Must-do action 13 of 13
Must do
Safe
Review processes for safe administration of medicines through a syringe driver, including infection prevention and control measures.
Should-do actions (62)
Should-do action 1 of 62
Should do
Well-led
Review the scope and membership of the financial resilience and commercial committee to consider incorporating operational performance within its remit.
Should-do action 2 of 62
Should do
Well-led
Develop a set of written and meaningful objectives for the non-executive directors.
Should-do action 3 of 62
Should do
Well-led
Set out in a single easy to interpret document the business case development and approval process and implement post implementation reviews for larger business case investments.
Should-do action 4 of 62
Should do
Well-led
Consider how the freedom to speak up guardian and guardian of safe working hours annual reports are presented to the board so it hears from and can directly question those staff who are in those roles.
Should-do action 5 of 62
Should do
Well-led
Look at the role of the trust’s governors to check it is being fulfilled in line with expectations and national guidance.
Should-do action 6 of 62
Should do
Well-led
Review the compensation arrangements for junior doctors who work extra hours so they are consistent.
Should-do action 7 of 62
Should do
Well-led
Produce an action plan for the junior doctors based on NHS Improvement’s ‘eight high impact actions’ audit tool.
Should-do action 8 of 62
Should do
Well-led
Produce action plans which are specific to the individual and specific requirements of the various equality and diversity standards.
Should-do action 9 of 62
Should do
Responsive
Audit services against the Accessible Information Standards to determine compliance or actions to be taken and publish the results.
Should-do action 10 of 62
Should do
Well-led
Present the board with assurance of training in safeguarding which has a good level of detail.
Should-do action 11 of 62
Should do
Responsive
Revise the complaints annual report to focus on learning and improvement, and not focus on numbers such as response times. Follow the requirements of trust policy in both content and how the report is approved.
Should-do action 12 of 62
Should do
Well-led
Update the trust website to be clear on the trust’s requirements and actions under the General Data Protection Regulation 2018.
Should-do action 13 of 62
Should do
Safe
Prevent unauthorised access to any confidential patient records and leave none unaccompanied in any area of the hospital or beyond.
Should-do action 14 of 62
Should do
Well-led
When publishing reports on learning from death, have improved emphasis on learning and improving outcomes.
Should-do action 15 of 62
Should do
Safe
Introduce a screening tool to assess the risk of abuse in children.
Should-do action 16 of 62
Should do
Safe
Implement specific cleaning schedules.
Should-do action 17 of 62
Should do
Safe
Improve staff compliance with cross-infection processes including being bare below the elbow and complying with hand hygiene rules.
Should-do action 18 of 62
Should do
Safe
Review doors on side rooms to check they can be fully shut to reduce cross infection risks.
Should-do action 19 of 62
Should do
Safe
Introduce a process to be able to monitor those patients waiting for computer tomography scans.
Should-do action 20 of 62
Should do
Safe
Store all equipment such as medical gases safely and securely.
Should-do action 21 of 62
Should do
Safe
Improve the department’s environment for patients arriving by ambulance.
Should-do action 22 of 62
Should do
Responsive
Look at how to increase the capacity of the department, such as the resuscitation area, to meet increasing demand and overcome current constraints.
Should-do action 23 of 62
Should do
Safe
Identify and implement systems to support receptionists in the identification of patients at risk of deterioration.
Should-do action 24 of 62
Should do
Safe
Review and risk assess the lack of one registered children’s nurse present per shift.
Should-do action 25 of 62
Should do
Safe
Improve the quality and completion of the records and monitor compliance including the recording of the holistic needs of patients.
Should-do action 26 of 62
Should do
Safe
Resolve the issues with staff not recording the amount of morphine wasted.
Should-do action 27 of 62
Should do
Effective
Review the lack of a paediatric emergency medicine consultant in the department.
Should-do action 28 of 62
Should do
Well-led
Develop the structures and systems of accountability to support the service.
Should-do action 29 of 62
Should do
Effective
Support adherence to national guidance and effective practice of audits and improve patient outcomes.
Should-do action 30 of 62
Should do
Well-led
Increase the number of qualified nurses who have received an appraisal in the last 12 months in line with the trust’s target of 90%.
Should-do action 31 of 62
Should do
Effective
Improve compliance with NHS England’s seven-day services priority standards.
Should-do action 32 of 62
Should do
Safe
Determine those staff who require level three adult safeguarding training and improve training completion compliance.
Should-do action 33 of 62
Should do
Well-led
Improve the overarching governance process around risks and ensure those of the highest level are safely addressed and managed.
Should-do action 34 of 62
Should do
Well-led
Introduce specific or set methodology for mortality and morbidity reviews, as recommended by the Royal College of Physicians.
Should-do action 35 of 62
Should do
Effective
Improve audit processes so that data collected to participate in Royal College of Emergency Medicine audits is of a sufficient quality.
Should-do action 36 of 62
Should do
Effective
Have staff consistently complete malnutrition risk assessments.
Should-do action 37 of 62
Should do
Effective
Improve staff awareness of the Mental Health Act 1983 and the Mental Capacity Act 2005.
Should-do action 38 of 62
Should do
Responsive
Look to improve referral to treatment times.
Should-do action 39 of 62
Should do
Safe
Store all equipment in a safe, hygienic and organised way.
Should-do action 40 of 62
Should do
Safe
Continue to closely monitor incidents of postpartum haemorrhage and perineal trauma (third and fourth degree tears) and take preventive action to reduce the risk of harm.
Should-do action 41 of 62
Should do
Safe
Continue to closely monitor perinatal mortality and detection rates for small-for-gestational-age babies.
Should-do action 42 of 62
Should do
Safe
Take prompt action to address maintenance issues in the maternity unit, to ensure that services are not disrupted, and to ensure the safety of staff and patients.
Should-do action 43 of 62
Should do
Safe
Provide further training and guidance to staff in relation to the frequency of patient observations and the documentation of modified early obstetric warning system scores for postnatal women on Frey ward. Undertake regular audits to ensure good practice is embedded.
Should-do action 44 of 62
Should do
Safe
Continue to audit record keeping standards to ensure that good practice is embedded.
Should-do action 45 of 62
Should do
Safe
Continue to have effective on-call supervisory arrangements to prevent unnecessary temporary closure of the maternity unit.
Should-do action 46 of 62
Should do
Well-led
Continue to take steps to have an effective system of version control for policies and guidelines, to prevent duplication and the risk that staff may consult out of date guidance.
Should-do action 47 of 62
Should do
Responsive
Review the equipment and facilities on the children’s ward so that all areas are accessible for patients without full mobility.
Should-do action 48 of 62
Should do
Safe
Fully inform staff of the procedures to make equipment safe for use. For example, the monitoring of the milk fridge on ward 10.
Should-do action 49 of 62
Should do
Effective
Have care plans consistently followed to meet the assessed care needs for all patients.
Should-do action 50 of 62
Should do
Safe
Have all records containing personal and confidential information stored securely at all times.
Should-do action 51 of 62
Should do
Safe
Maintain thorough cleaning of the mortuary and ensure cleaning documentation is maintained to demonstrate compliance.
Should-do action 52 of 62
Should do
Effective
Improve assessment of patients’ hydration needs.
Should-do action 53 of 62
Should do
Responsive
Monitor when side rooms were not available for patients nearing the end of their life to enable the service to know if most patients were able to be accommodated in this way at the end of their life.
Should-do action 54 of 62
Should do
Effective
Develop processes to identify patients in their last 12 months of life in line with national guidance.
Should-do action 55 of 62
Should do
Effective
Consider auditing of bereavement services against national bereavement standards.
Should-do action 56 of 62
Should do
Safe
Review processes for refresher mortuary training for porters.
Should-do action 57 of 62
Should do
Responsive
Continue to explore plans to implement seven-day services for end of life care to meet national standards, including a review of staffing levels and recruitment to reach establishment.
Should-do action 58 of 62
Should do
Safe
Review risk assessments for all patients nearing the end of life to ensure these are completed and reviewed regularly.
Should-do action 59 of 62
Should do
Well-led
Develop processes to demonstrate how audits are being used to improve services.
Should-do action 60 of 62
Should do
Well-led
Review processes to identify, mitigate and improve oversight of risks within end of life services and develop a risk register.
Should-do action 61 of 62
Should do
Well-led
Review processes to identify incidents relating to end of life service to identify learning and service improvement opportunities.
Should-do action 62 of 62
Should do
Well-led
Develop and evolve the governance of the end of life steering group by adopting a standardised agenda to encompass all relevant topics are discussed at each meeting.