Musgrove Park Hospital

Review whether the trust should produce policies for Disclosure and Barring Service checks and Fit and Proper Person Regulation assessments to ensure all areas the trust should self-determine are covered.

Consider how to better report on findings of the NHS staff survey and improve the reasons for a poor response rate (which we recognise had improved in 2019, but still had room for improvement being below 50% of staff asked to contribute).

Review the strategy for dementia and the policy for learning disabilities (a strategy not having been provided) to determine how to report better on some of the good achievements made, and whether objectives are being met.

In the well-regarded work of the freedom to speak-up guardians, examine and determine whether staff who do speak-up are treated as they should be, and executives understand their role in acting on information brought to them by the guardians.

Bring the trust’s values into annual performance reviews (appraisals) as only 34% of staff who responded to the 2018 NHS staff survey said they were discussed and this was below (worse than) the national average. Review the other appraisal and training responses from staff in the 2018 NHS staff survey as insufficient numbers of staff said the appraisal helped them improve how they did their job and set clear objectives. Fewer staff than the national average said training, learning and personal development was discussed with them as part of the review. We recognise work on this was already in progress, but improvement needed to be demonstrable.

Strengthen the action already taken to support the black, Asian and minority ethnic staff who have suffered a disproportionate level of abuse, and demonstrate this will not be tolerated within the organisation. Educate staff to further support their BAME colleagues and encourage everyone who suffers abuse or discrimination or witnesses it to report it.

Produce measurable objectives around career progression for black, Asian and minority ethnic staff as this was highlighted at the people committee but without further action considered. Actions in the Workforce Race Equality Standard plan were not owned by anyone and were not measurable to determine achievements. They were without ambition.

If key reports are not to be published through board papers, publish all those required, including those around equality and diversity and annual reports on patient safety and care on the trust website each time they are produced.

As was required of the trust since August 2016, assess, audit and then improve (if needed from assessment and audit work) provision of care for patients in the described group against the Accessible Information Standards.

When including training numbers in annual safeguarding reports for both adults and children, show these as percentages of staff and not absolute numbers or charts without targets so compliance is clear and not needing to be inferred.

Improve the performance on responding to complaints and state clearly in a policy document what the response time should be so it is clear for staff and those who make a complaint.

Continue to strengthen the critical work both internally and with healthcare system partners to reverse the growing waiting list for patients to receive treatment or diagnostic screening and procedures. Show clear and prompt progress which meets trajectories and goals for improvement in all areas of performance.

Determine how IT systems could be improved before any large-scale replacement to reduce the burden on staff, particularly in the light of consultants concerned this reduced clinic time.

Increase the level of recurrent savings it achieves and reduce its reliance on non-recurrent schemes including within the context of its planned merger with Somerset Partnership.

Provide context in board reports, annual reports and performance reports so performance data in areas such as infection control, pressure ulcers, falls, training and appraisals, can be measured against the targets, trajectories or standards set.

Produce a more recurrent evaluation of the NHS seven-day four priority clinical standards and a realistic ambition for meeting those not yet achieved.

Bring the trust website information in relation to patient confidentiality up to date with the General Data Protection Regulations and make this information more accessible for the public.

Improve the visibility of research and development work and sponsorship of this work at executive and trust board level.

Continue with making sure medical staff meet the trust target for updating mandatory training.

Complete risk assessments for patients with mental health needs in each area of the trust they visit.

Record details of mental capacity assessments fully where the assessments have been undertaken.

Improve medical staff adherence with trust policy requirements to fully document details of when they have escalated patients with a deteriorating condition and actions that were taken in response.

Review registered nurse staffing in high dependency respiratory areas so they meet national standards.

Maintain record security in all areas, including stroke unit, so they are not at risk of being moved by unauthorised people.

Improve staff compliance with mandatory training to meet the trust target of 95%.

Review infection prevention and control processes so they are in line with national guidelines and trust policy.

Consistently complete daily checks of specialist equipment, in accordance with trust policy.

Continue planned expansion of the specialist registrar rota to ensure there is always a doctor on duty with advanced airway and resuscitation skills.

Increase the number of pharmacists to the Guidelines for the Provision of Intensive Care Services recommended minimum staffing level of 0.1 whole time equivalent each week per level three bed or per two level two beds.

Review clinical guidelines so they are version controlled and dated.

Continue to support nursing staff to access post-registration training to meet Guidelines for the Provision of Intensive Care Services guidelines, which recommend 50% of registered nursing staff will be in possession of a post-registration award in critical care nursing.

Improve the completion rate of appraisals for nursing and administrative staff.

Review therapy provision/rehabilitation support for patients on the critical care unit.

Regularly review audit programmes and outcomes within the existing governance meetings.

Demonstrate the scrutiny of cases reviewed by mortality and morbidity meetings to evidence how actions were identified to improve care and treatment.

Continue to improve medical staff compliance with mandatory and safeguarding training.

Improve staff awareness of processes for cleaning birth pools and display guidance for cleaning in relevant areas.

Improve cleanliness of showers on the maternity unit.

Remind staff to follow uniform policy.

Review the risk assessment of maternity theatre one and the procedure room in line with national guidance (maternity care facilities in line with national planning and design (HBN 09-02))

Improve staff understanding of use of antidote boxes.

Make sure fire safety risk assessments are completed and reviewed every year.

Improve recording of mental health risk assessments and verbal handover of mental health risks.

Continue to improve staff reporting of all incidents.

Complete action plans to share learning from serious incident investigations.

Include shoulder dystocia and brachial plexus injuries on maternity dashboard.

Investigate and respond to complaints in a timely way.

Audit the use of the World Health Organisation checklist in maternity theatres.

Improve quality of controlled drug records in line with trust policy.

Store medical gas cylinders and anaesthetic agents in line with trust policy.

Improve accuracy of records made of the doses of medicines administered.

Review the provision of a clinical pharmacy service, including medicines reconciliation, to maternity services in order to comply with current national guidance.

Improve monitoring of medicine refrigerators in line with trust policy.

Improve, where possible, the temperatures on the ward to reduce discomfort for children and young people, their families and staff.

Improve the cleanliness of medicine cabinets to ensure any residual labels are removed from the interior shelves.

Store records securely in locked cupboards.