Yeovil District Hospital, Yeovil

General Services Information

Hospital Questions

• How many single rooms are available to NHS patients at this hospital: 88 This number excludes the single rooms available on the Private Patients' wing

• Of these how many have an ensuite toilet: 18 This excludes the single rooms on the Private Patients' wing

• Of these how many have an ensuite toilet and shower or bath: 8 this excludes the single rooms on the Private Patients' wing

• Does this hospital operate an accident and emergency unit:

• How many specialist palliative care beds are available at this hospital: 0 The Trust employs palliative care nurses and have agreed clinical sessions from a palliative care consultant. The Trust has good working relationships with the local hospice and employs and end of life "in-reach" nurse.

• Does this hospital have a named private unit/service:

• What is the name of the private unit/service: The Kingston Wing

• How many beds are available within the private unit/service: 14

• How many single rooms are available within the private unit/service: 14

• Of these, how many have an ensuite toilet: 14

• Of these, how many have an ensuite toilet and shower or bath: 14

• Direct telephone number for the private unit: 01935 384234

Trust Questions

• Does the Trust treat private patients:

Patient Safety

Trust Questions

• Is there a system for recording operations that resulted in a foreign body being left post surgery:

• What is the reporting system for a foreign body being left post surgery: Web- based incident reporting tool (Safeguard)

• Is there a system for recording operations that were cancelled due to missing notes:

• What is the reporting system for operations that were cancelled due to missing notes: Web- based incident reporting tool (Safeguard)

• Is there a system for recording operations that resulted in wrong site surgery taking place:

• What is the reporting system for operations that resulted in wrong site surgery taking place: Web- based incident reporting tool (Safeguard)

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in a foreign body being left post surgery: 1 It was not considered beneficial to remove the retained object and the patient was fully informed of the situation.

• During the period 01 April 2010 - 31 March 2011, how many operations were cancelled due to missing notes: 1 Patient was aware of the reason for cancelled surgery and was re-scheduled 2 weeks later

• During the period 01 April 2010 - 31 March 2011, how many operations resulted in wrong site surgery taking place: 0

• How many incident investigations using a full Root Cause Analysis did were carried out in 2010/11: 54 The Trust has a very low threshold for conducting root cause analysis investigations, and an open reporting culture amongst staff. Four of these incidents were subject to a full investigation in accordance with the NPSA guidance and were reported to the commissioning Primary Care Trust as required by reporting criteria.

• What percentage of patient safety incidents resulting in severe harm or death had a full RCA initiated/completed: 100%

• What percentage of acute inpatients have a track and trigger warning system in place for the duration of the admission: 100%

• What percentage of patients are risk assessed for venous thromboembolism on admission: 31-60% This figure reflects July 2010 to March 2011 and is the data submitted to the Department of Health as a mandatory return. Data capture did not commence prior to July 1st. Work continues to improve risk assessment processes across the organisation with data fed back to individual areas regarding compliance.

• Compliant with all relevant NPSA safety alerts issues in 2010/11 (you can find a full list of alerts issued at http://www.nrls.npsa.nhs.uk/resources/?p=3). :

• Does the Trust have a policy for providing educational programmes on using and interpreting clinical indicators: The Yeovil Academy provides a wide range of educational and training programmes for all staff, which are outlined in the Education and Training Strategy which incorporates the Prospectus. Clinical staff training includes a range of courses supporting using and interpreting clinical indicators, for all professional staff: medical, nursing, allied health care professionals . For example courses such as ALERT, Immediate Life Support Training, Advanced Life Support, Paediatric Advanced Life Support. The Clinical Skills Centre provides an environment for practical learning and assessment for students and registered staff alike. The Foundation Year Teaching Programmes provide weekly sessions covering a wide range of topics supporting and developing clinical management skills.

• Does the Trust have a designated member of staff who supports teams in locating and analysing safety and quality data? (support): This is co-ordinated by the General Manager for Clinical Governance

• Is safety and quality data available on a central platform and actively disseminated to users: Monthly reports are provided to all divisions, the hospital management team and the Board of Directors. Wards have productive wards measure boards and relevant safety indictors are included on these boards

Infection Control

Trust Questions

• Does the Trust employ an antibiotic pharmacist:

• Does the Trust operate a pre-admission assessment clinic or equivalent system where patients are screened and results returned in advance of the day of admission:

• Elective patient groups screened at the pre-op assessment clinic: All elective surgical This includes general surgery, orthopaedics, gynaecology and planned caesarean sections

• Are all oncology patients screened at the pre-op assessment clinic: NO

• Are all chemotherapy patients screened at the pre-op assessment clinic: NO

• Are all elective neurosurgery patients screened at the pre-op assessment clinic: Not Applicable

• Are all patients with past history of MRSA screened at the pre-op assessment clinic:

• What method of MRSA screening is used when screening at admission: Other (please specify) The Trust uses molecular based less than 24 hours for all high risk areas, including Special Care baby unit, Intensive Care Unit and elective orthopaedic patients. For all other admissions the Trust uses culture based in 24-48hours.

• On admission, does topical suppression take place immediately: This is only commenced when the patient has a positive result

• Does the Trust have at least one accident and emergency unit:

• Are all patients admitted through A&E screened:

• Is screening done according to individual risk assessment:

• Does the Trust have a dedicated isolation ward:

• Protocol for isolating patients with infections: The Trust has an isolation policy, which includes an isolation risk assessment tool. This enables appropriate prioritisation of patients who need isolation.

• Does the Trust have an isolation policy: The Isolation Policy is available on the Trust's Intranet site and provides clear guidance for staff about the isolation of patients.

• Where medically appropriate, are patients with C Diff isolated in single rooms as a matter of priority:

• Does the Trust have a policy to guide the use of metronidazole and vancomycin for C.difficile infected patients: Compliance with this policy is audited through a multi-disciplinary clinical ward round that is carried out across the Trust twice weekly. In addition daily compliance is assessed by the Antibiotic Pharmacist.

• Does the Trust routinely isolate all patients with diarrhoea:

Stroke Medicine

Hospital Questions

• Does the hsopital have a specialist stroke unit:

• What type of stroke unit does the hospital have: combined acute and rehabilitation stroke unit The Trust predominantly provides acute care for stroke patients, but there are occasions when some rehabilitation services are also provided

• Number of beds in the unit: 15

Trust Questions

• Does the Trust have a specialist stroke unit or units:

• Is the Trust part of a stroke care network:

• Details: The Trust is part of the Avon, Gloucester, Wiltshire and Somerset Stroke and Cardiac network.

• How many emergency admissions with a primary diagnosis of stroke (ICD10 codes I60 - I64) did the Trust receive in the financial year (period 01 April 2010 - 31 March 2011): 298

• Of these, what was the number of patients given a Computerised Tomography (CT) scan within 24 hrs of admission: 225 Four patients either refused a CT scan or were scanned at another hospital. Taking these into account 76.5% were scanned within 24 hours of arrival.

• Is thrombolysis for stroke patients provided 24 hours per day and 7 days a week : This has been achieved by the Trust's membership of the stroke network

• Are there any formal arrangements with neighbouring hospitals for the emergency transfer of stroke patients who would benefit from thrombolytic treatment: The Trust is able to provide intravenous thrombolysis 24 hours a day seven days a week. The stroke network is currently in the process of formalising intra-arterial thrombolysis, which will be provided by North Bristol NHS Foundation Trust.

Trauma & Orthopaedics

Trust Questions

• Does the Trust offer a trauma service:

• Does the Trust have a dedicated trauma list available 24 hours a day for the duration of the week, (Sunday to Sunday): Dedicated, scheduled trauma lists are available between 8.00 am and 6.00 pm every day. Outside of these hours theatre space is available and could be utilised if required

• Does the Trust offer an orthopaedics service:

• Do all the Trust's orthopaedic ward/team have a linked geriatric team with whom they have regular meetings at least once a week:

• Does the Trust run a pre-operative patient education session/class for patients to attend prior to Total Knee Replacement (TKR) and Total Hip Replacement (THR)? : This service is facilitated by the Physiotherapy team

• What is the audited Percentage of all patients that attend the class prior to surgery: 61

• Does the Trust have a standardised anaesthetic protocol for Total Knee Replacement (TKR) and Total Hip Replacement (THR) patients:

• Not able to put a figure on the percentage compliance to this protocol:

• Estimated percentage of the Trusts total knee replacement (TKR) and total hip replacement (THR) patients walk within 24 hours of surgery: 100 The Trust follows an enhanced recovery pathway and all elective total hip and knee replacement patients are mobilised the first day after surgery

• Does the Trust have a specialist orthopaedic physiotherapy service which is available 7 days a week: Specialised orthopaedic physiotherapists are available 5 days a week, with an on-call service provided at weekends

• How many patients' discharge's delayed due to lack of physiotherapy services at weekends - estimated figure: 0 The Trust's use of the enhanced recovery programme ensures that discharge is never delayed due to a lack of therapy input.

• Are patients for total knee replacement (TKR) and total hip replacement (THR) admitted prior to the day of surgery:

• What is the principle reason for patients not being admitted on the day of surgery: Patients with significant co-morbidities who need additional pre-operative support are admitted before the day of surgery

• Are patient records routinely recorded using a specific multi-disciplinary team THR/TKR pathway document:

• Is this data used to monitor compliance with the agreed pathway: Aspects of the pathway are audited on an occasional basis, but the Trust has not audited the entire pathway for compliance

• Is criteria-based discharge used: This tends to be Physiotherapy and Nurse led discharge according to the enhanced recovery pathway.

• Are patients routinely phoned in the first 48 hours after discharge to check on their progress:

Paediatrics

Hospital Questions

• Does the hospital have a paediatrics service:

Trust Questions

• Is the Trust's elective paediatric surgery carried out only by designated surgeons with at least six months training in a specialist unit:

• Do the Trust's anaesthetists with responsibility for paediatric anaesthesia participate in at least one paediatric list per week: The Trust has a named lead Consultant Anaesthetist responsible for paediatric anaesthesia, who covers at least one list per week.

• Is a paediatrician on site (SpR or higher) 24 hours per day, 7 days per week:

• Are at least two registered children's nurses on duty 24hours per day in each children's ward:

• Is there a designated facility on site for parents or guardians to stay overnight: Facilities exist for parents to remain resident with their child.

Palliative Care

Trust Questions

• Does the Trust provide a palliative care service:

• How is specialist palliative care delivered at the hospital: Other (please specify) The Trust provides a palliative care service that is a combination of acute Trust employed specialist nurses and visiting Consultants in palliative care.

• Does the hospital's specialist palliative team includes: A palliative care nurse,Other (please specify) The Trust works with a Marie Curie funded "in-reach" nurse specialist

• Is the Trust's specialist palliative care team available 24 hrs a day seven days a week: Out of hours service is supported by the local hospice team who are available 24 hours a day

• Are facilities provided to support relatives and carers who wish to stay with a patient in hospital: The Trust has 4 dedicated rooms within a flat for use by relatives and carers. Facilities are also available on each clinical floor within the hospital.

• Does the Trust routinely survey and evaluate the views of patients and bereaved relatives and carers regarding the delivery of care on the end of life programme: The Trust does not have a regular programme of surveys for the end of life care, but does participate in any national audit as required.

Maternity Care

Maternity Sites

• Yeovil District Hospital - Consultant Led

• How many women gave birth in the unit during the year? (not including home births): 1567

• How many babies were born in the unit during the year? (not including home births): 1590

• How many women were booked for a home birth: 54

• How many women had a home birth? (not including births at home by accident): 41

• Number of antenatal rooms: 9 This includes 4 single rooms, 1 double room and 4 bays

• Total antenatal beds: 22 This is a combined antenatal and post natal ward, with beds being used for either group of women

• Number of assessment area rooms (for monitoring and / or induction): 2

• Total assessment area beds: 2

• Number of delivery rooms: 5

• Total delivery beds: 5

• Number of postnatal rooms: 9 This includes 4 single rooms, 1 double room and 4 bays

• Total postnatal beds: 22 This is a combined antenatal and post natal ward, with beds being used for either group of women

• Number of rooms in obstetric high dependency unit: 0 Women needing high dependency care would be transferred to the main HDU beds which are on site

• Total obstetric high dependency beds: 0 Women needing high dependency care would be transferred to the main HDU beds which are on site

• Number of single rooms used for both delivery and postnatal care (labour, delivery, recovery and postnatal, or LDRP, rooms): 0

• Amenity rooms; Are women able to book a single room in advance of their birth:

• If women can pay for a single room what is the average cost per night (GBP): 0

• Does the maternity unit have a neonatal intensive care unit: The Trust is part of the Southwest Neonatal Network

• Does the maternity unit have a neonatal high dependency unit: The Trust is part of the Southwest Neonatal Network

• Does the maternity unit have a special care baby unit:

• Security measures - ankle bands for the baby:

• Security measures - cot alarms:

• Security measures - CCTV:

• Security measures - restricted access:

• Pain relief available - bath or shower: Provided by unit

• Pain relief available - birthing pool: Not available

• Pain relief available - birth ball: Provided by unit

• Pain relief available - Massage: Provided by unit

• Pain relief available - Aromatherapy: Provided by unit

• Pain relief available - TENS: Provided by women

• Pain relief available - Epidural: Provided by unit

• Pain relief available - Mobile epidural: Not available

• Pain relief available - Entonox (gas and air): Provided by unit

• Pain relief available - Intramuscular injection: Provided by unit

• Total number of WTE midwives at the unit in your funded establishment, including vacant posts: 59

• Total number of WTE midwives at the unit as staff in post, including agency and bank staff: 60

• Does the unit have midwives available to provide one-to-one care available 24 hours a day, 7 days a week: On site

• Does the unit have midwives available for home births available 24 hours a day, 7 days a week: On call

• Does the unit have midwives trained and experienced in water birth available 24 hours a day, 7 days a week: On call

• Does the unit have a paediatrician available 24 hours a day, 7 days a week: On call

• Does the unit have an obstetrician available 24 hours a day, 7 days a week: On call

• Does the unit have an anaesthetist available 24 hours a day, 7 days a week: On call

• Does the unit have a dedicated obstetric anaesthetist available 24 hours a day, 7 days a week: The Trust has a lead Consultant Anaesthetist for obstetric work, and a restricted number of anaesthetists work with the Obstetricians

Trust Questions

• Do all women have a choice about where they receive their antenatal appointments (i.e. at hospital or local health centre):

• Are NHS antenatal classes available (e.g. Parentcraft):

• Available during the daytime (until 5pm):

• Available in the evenings (after 5pm):

• Available at weekends (Saturday and/or Sunday):

• Available for women only groups:

• Available for other groups:

• Also available for: Groups for partners available

• Are all women routinely offered ultrasound scans:

• Scan 1 available between: 10-12 weeks

• Scan 2 available between: 18-20

Trust Statistics

Trust Questions

• You can view various measures relating to the Trust's performance by clicking the following link: Yeovil District Hospital NHS Foundation Trust