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Musgrove Park Hospital

Provider Somerset NHS Foundation Trust Type NHS Healthcare Organisation Region South West Last inspected 27 Jun 2025

Overall rating: Good  View full CQC report

Domain ratings

Five CQC key questions
Safe
Requires Improvement
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Good Assessed 27 June 2025
The service is performing well and meeting our expectations.
Date of assessment: 14 January to 11 February 2025. Musgrove Park Hospital provides a range of NHS hospital services. This assessment looked at the Children and Young People Service, due to new and emerging risk. We rated this service as Good. The rating from the Children and Young People Service has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at Musgrove Park Hospital. The overall rating of Musgrove Park Hospital remains Good. In our …

Ratings by service

Services for children & young people
Good
Oct 2024

Earlier inspection findings

pre-2024 framework · 9 must-do 3 should-do

Must-do actions (9)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 9
Must do
Well-led
The service must ensure they apply and demonstrate compliance with Duty of Candour requirements.
Regulation: Regulation 20
⚠ Staff did not always effectively carry out duty of candour. There was no evidence that duty of candour was met in several cases we reviewed as part of the inspection. Within investigation reports the service had explicitly documented that duty of candour had not been completed.
Must-do action 2 of 9
Must do
Safe
The service must ensure staff are up to date with maternity mandatory training modules.
Regulation: Regulation 12(1)(2)(c)
⚠ The service did not make sure everyone completed and kept up to date with mandatory training. Staff were not always up to date with their mandatory training. Records showed low compliance rates for training modules.
Must-do action 3 of 9
Must do
Safe
The service must ensure the security of the unit is reviewed in line with national guidance.
Regulation: Regulation 12(1)(2)(a)(d)
⚠ We found that the unit was not secure, some of the issues we found had been highlighted during a baby abduction drill 2 months prior to the inspection. Insufficient action had been taken at the time of inspection to ensure ward areas, windows and doors were secured and monitored. The …
Must-do action 4 of 9
Must do
Safe
The service must ensure staff are up to date with the appropriate level of safeguarding training in line with national guidance.
Regulation: Regulation 12(1)(2)(c)
⚠ Not all staff understood how to protect women and birthing people from abuse. Staff had not received training at a level appropriate to their role to ensure they knew how to recognise and report abuse.
Must-do action 5 of 9
Must do
Well-led
The service must ensure that policies are available, up to date and reviewed in accordance with the review date.
Regulation: Regulation 17(1)(2)
⚠ Staff didn’t have access to up-to-date policies and procedures to support them in their role. The service did not ensure staff had access to up-to-date policies, procedures, and guidance. From the 12 policies and procedures requested for trust, 5 were out of date.
Must-do action 6 of 9
Must do
Well-led
The service must ensure all staff must receive annual appraisals.
Regulation: Regulation 18(2)(a)
⚠ Not all staff had received an appraisal of their performance or support with their development. Midwifery staff compliance with mandatory appraisals did not meet the trust target of 92% for any staff groups. As of 1 November 2023, compliance across departments ranged between 33% and 80% with an average of …
Must-do action 7 of 9
Must do
Safe
The service must ensure that staff adhere to infection, prevention and control policies and procedures.
Regulation: Regulation 12(2)(h)
⚠ The service did not control infection risk well as the environment was unsuitable. Staff did not always follow infection control principles including following the correct uniform policy and storage of towels and linen. We observed staff wearing jumpers in clinical areas and not all staff were bare below the elbows. …
Must-do action 8 of 9
Must do
Safe
The service must ensure medicines and breast milk is stored safely and securely.
Regulation: Regulation 12(2)(f)
⚠ Not all medicines were stored safely. We found anaesthetic agents that could be misused by the public in the room which were not secured. The service did not ensure the safe, secure, and effective storage and management of expressed breast milk (EBM). We found that fridges and freezers used to …
Must-do action 9 of 9
Must do
Safe
The service must ensure there are risk assessments for women and birthing people presenting to the triage service and best practice is considered to mitigate any identified risk.
Regulation: Regulation 12(2)(a)(b)
⚠ Women and birthing people presenting to triage were not appropriately risk assessed and prioritised based on the presenting risk. Staff didn’t have a standardised, evidence-based risk assessment guidance to follow in the triage area. The service did not use an evidence-based, standardised risk assessment tool for maternity triage. There was …

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3
Should do
Well-led
The service should ensure the monitoring of incidents by ethnicity to evaluate incidents and clinical outcomes to ensure equality in maternity care.
Should-do action 2 of 3
Should do
Well-led
The service should consider providing additional support to staff around the use of electronic patient records.
Should-do action 3 of 3
Should do
Safe
They should consider how ‘medicines as required’ (PRN) medicines and patient weight is recorded on the electronic medicines record.

Location details

CQC ID: RH5A8
Local authority: Somerset
Region: South West

Inspection report

Type: Location
Date: 10 May 2024
Rating: Requires Improvement
Actions: 9 must-do 3 should-do
AI-extracted 2 Jun 2026

Related PFD reports

2022-0165 — Andrew Nixon ()
2025-0200 — Jacqueline Potter (Apr 2025)
2024-0349 — Michelle Moore (Jun 2024)
2018-0126 — Robin Richards (May 2018)