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North Devon District Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 3 November 2015

We inspected North Devon District Hospital to check if changes had been made in specific areas where we found breaches of regulations for the core services of urgent and emergency care, end of life care, and maternity and gynaecology during our comprehensive inspection in July 2014. The inspection was carried out between 5 and 7 August and on 17 August 2015.

As this was a focused follow-up inspection, we did not inspect the following core services: medical care (including care of the elderly), critical care, surgery, services for children and young people, and outpatients and diagnostic imaging.

For the core service and quality issues inspected, we rated the North Devon District Hospital as Requires Improvement. Some areas of concern found at our previous inspection had been dealt with but others required further work, such as the need to provide effective and safe care for patients at the end of their life and to provide responsive and safe care for patients using urgent care services.

Our key findings were:

  • Work in the maternity and gynaecology service around working relationships between the medical and midwifery teams had progressed but more focused work was needed to ensure cohesive teamwork.
  • Patient flow through the hospital due to bed capacity and delays in timely discharge of patients from wards continued to impact on the emergency department but patients were seen and treated in a timely way.
  • There were delays to discharge of patients at the end of life, which led to people not being in their preferred place. While this was not always in the control of the trust, the impact on people and their families was concerning
  • In response to the findings, shortly after the inspection we asked the trust to provide us with a plan of action that set out how they will ensure they are providing an effective and well led service for people at the end of their life. The trust responded with an action plan detailing the steps they are taking to address the issues raised. We will review the implementation of the action plan in due course.
  • A number of actions had been taken in the emergency department to improve infection prevention and control measures. These were supported by regular audits, which showed good compliance with trust policies.

We saw some areas of outstanding practice, including:

  • We heard about the recent ‘open day’ held by the maternity unit. This took the form of a market place and had stalls about smoking cessation, domestic violence, infant nutrition, perinatal mental health team, National Childbirth Trust, antenatal screening and the local Maternity Service Liaison Committee. All the stalls had leaflets available for people to take away. We were told it was really well attended as it had been advertised on local radio and in the local newspapers. We were told people who attended were a mix of expectant and new mothers and some people who were interested in midwifery as a career.

However, there were also areas of poor practice where the trust needs to make improvements.

An action that a provider of a service MUST take relates to a breach of a regulation that is the subject of regulatory action by the Care Quality Commission. Actions that we say providers SHOULD take relate to improvements that should be made but where there is no breach of a regulation.

Importantly, the trust must:

  • Provide a minimum of one registered children’s nurse on duty in the emergency department every shift
  • Store medicines and medical gases securely in the emergency department.
  • Train staff adequately to ensure the safety of children attending the emergency department.
  • Implement a robust recording, reporting and monitoring process for mandatory training, including paediatric life support.
  • Ensure that all patients who meet the criteria for consideration for a Treatment Escalation Plan (TEP) are considered and afforded the opportunity to advise of their choices and preferences for care.
  • Ensure that staff throughout the trust understand how and when to make a referral to the specialist palliative care team at the appropriate time in order to meet the current and anticipated needs of patients.
  • Improve the rapid discharge process to enable patients who wish to return home quickly at the end of their lives to do so.
  • Ensure there is a programme of local audits in line with the national care of the dying audit which enables a review of services provided at the hospital to identify if patients preferred place of care had been achieved.
  • Ensure actions resulting from audits of end of life care are monitored. Some audited standards in the National Care of the Dying Audit were not met.
  • Make advance care plans available for patients in the last 12 months of life. (No advance care planning took place for patients in the last few weeks of life because there were no consistent systems in place to enable patients to make advance directives or consider the decisions needed for their future).
  • Ensure NICE guidance QS103 is followed for end of life care
  • Ensure there are arrangements for end of life services to be monitored and reviewed at all levels of the organisation.
  • Develop a strategy to achieve a consistently high standard of end of life care.
  • Continue work with the obstetrics and gynaecology and midwifery staff on team development and culture to ensure the way the teams work together does not affect patient safety.
  • Change the medical rota in obstetrics and gynaecology so that all staff are working in line with the European Working Time Directive.
  • Ensure that obstetric consultants undertake obstetric emergency workshops as part of their mandatory training.

In addition, the trust should:

  • Ensure the emergency department’s reception area provides privacy and confidentiality for patients booking in with the receptionist.
  • Make the emergency department’s reception suitable for the needs of wheelchair users.
  • Introduce a robust, regular portable appliance testing process for the emergency department.
  • Ensure appropriate and important information on patients’ allergies information and pain scores are recorded by the emergency department in all cases.
  • Ensure reception staff are able to recognise patients who attend the department with serious conditions that need urgent referral to the triage nurse.
  • Ensure that seasonal fluctuation and it impact on the emergency departments ability to respond is considered in all planning activities.
  • Ensure all agency nursing staff employed in the emergency department are appropriately prepared before working in the department and any induction processes are standardised and recorded.
  • Ensure all shift handovers in the emergency department are accurate and capture all relevant information in a consistent manner.
  • Review the security arrangements for the emergency department to ensure that staff and patients are supported and protected from harm or injury.
  • Ensure that bed meetings include all relevant staff and that all wards and departments have a clear focus on maximising patient discharge and flow in support of the emergency department.
  • Ensure that patients expected for medical and surgical care are admitted to an appropriate ward at the earliest opportunity to ensure there is no impact on the emergency department access and flow.
  • Review the incident reporting process to ensure trends are identified and actions taken to minimise risk.
  • Work with the ambulance service to understand and address how the emergency department can prevent medication errors following administration of medicines by the ambulance service.
  • Ensure the room used to assess patients with mental health related symptoms has suitable furniture.
  • Ensure all emergency department staff have completed major incident training.
  • Ensure the early warning score tool is fully implemented and used in the emergency department.
  • Consider collation of data for non-cancer patients where support of the SPCT for symptom management is required. In order to ensure all appropriate patients can access the SPCT.
  • Ensure that appropriate training for all staff, including agency staff, is made available for wards with end of life patients.
  • Consider the views of people using end of life services to shape and improve the services available.
  • Ensure maternity, obstetrics and gynaecology governance meetings are recorded.
  • Ensure that action plans made following recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG) visit and the serious incident investigation continue to be implemented.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 3 November 2015



Updated 3 November 2015


Not sufficient evidence to rate

Updated 3 November 2015


Requires improvement

Updated 3 November 2015


Requires improvement

Updated 3 November 2015

Checks on specific services

Maternity and gynaecology

Requires improvement

Updated 3 November 2015

Maternity and gynaecology services were rated as requires improvement for well led. .

At our previous inspection in July 2014 we found concerns relating to inaccurate and inconsistent completion of HSA1 (grounds for carrying out an abortion) and HSA4 (abortion notification) forms, which are required to be completed under the Abortion Act 1967. During this inspection, we found that a system had been put in place to check that the records had been completed accurately. The system had been audited and found to be compliant.

We also previously found that the rooms used by antenatal sonographers to carry out ultrasound scans were too small, had no curtains or screens to maintain privacy and dignity, and there was no means of calling for assistance. During this inspection, we saw two new, purpose built, rooms suitable for carrying out ultrasound scans had been developed and were in regular use.

Progress against the maternity action plan following recommendations of the Royal College of Obstetricians and Gynaecologists (RCOG) invited review visit in November 2013 was still on-going. Since our last inspection there had been some work on strategies to improve team working, especially amongst the medical staff. For example a team development programme was in its initial stages at the time of this inspection and work was ongoing around finding a medical rota that suited all medical staff.

An investigation of 13 serious incidents found a number of different root causes, with a theme of delays in appropriate escalation of clinical concerns and failure to follow trust guidelines featured in more than one investigation.

We found that individually the medical and maternity staff were working very hard but they did not always seem to function well as a team.

Feedback from the women who had used the service continued to be good. The maternity services worked hard to engage with the local population.

Medical care (including older people’s care)


Updated 9 November 2014

We found high levels of patient, relative and staff satisfaction with the care delivered across the medical wards.

Although there was evidence of much safe practice, we had concerns about the practice of moving patients overnight.

Overall, medical services were effective. There was a lack of consistency of effectiveness in overnight bed management, but there was also clear evidence of mechanisms of effectiveness in place throughout the directorate.

On each unit we inspected, the delivery of care and treatment was compassionate and caring. We saw some outstanding delivery of care where staff had planned and held a street party on the ward for those patients living with dementia. Feedback from the friends and family test was high and supported by verbal feedback from patients relatives. Patients and relatives were actively involved in decision making about treatment, care and discharge. Relatives and patients commented positively on their experiences on the wards.

Medical services were mainly responsive to local needs. There was an excellent provision of specialist care for patients with a stroke or with dementia. Service-delivery plans had raised a need for further dementia bed provision and the capital funding for this had been successful.

Overall, the medical services unit was well-led. Staff told us they felt well-supported by their managers and senior management team. They said that the quality of care and treatment delivered was of the utmost importance to the trust.

Urgent and emergency services (A&E)

Requires improvement

Updated 3 November 2015

We judged the department to require improvement for both safety and responsiveness.

Our main concerns were for children attending the department in an emergency because there were not enough registered children’s nurses to have one on duty every shift and we were not assured that enough staff were trained to deal with children in an emergency.

Rates of compliance with mandatory training varied. The trust’s recording and reporting system was not robust enough to provide accurate information on staff members who were out of date with training.

There were gaps in some care records, specifically in relation to the recording of patients’ allergies and pain scores.

There was, however, a positive reporting culture and sharing of lessons learned when things went wrong.

Despite pressures with patient flow through the hospital affecting some of the department’s performance standards, patients were triaged and had treatment started in a timely way.

The trust had taken action to address areas of concern regarding infection control found at our previous inspection in July 2014. We found improved access to handwash facilities and a programme of audit that demonstrated continued compliance with infection control policies.



Updated 9 November 2014

Care and treatment provided by surgery services was safe and effective. Almost all patients and their relatives spoke highly of the service received and the care and treatment they received. Staff were caring, kind and considerate of their patients and treated them as individuals.

Patient records were mostly done well, but some improvements were needed in pain and nutrition assessments. Patient assessments for safety risks needing improving in order to reduce pressure ulcer and urinary tract infection incidence. Infection control was mostly done well, but spot check audits for infection control on inpatient wards were not showing consistent improvement.

Patient outcomes were good and mortality and infection rates were low. Operating theatres met targets for referral to treatment times in all surgical specialities. Staff learned from incidents and serious events and felt confident to report incidents. The surgical teams responded proactively and positively to adverse events to bring about improvements. Patient consent was obtained in accordance with legal requirements. People in vulnerable circumstances were safeguarded and patients were treated in their best interests.

Staffing levels in theatre were not at full strength. New staff had been recruited but the current staff group were working extra hours to ensure continuity of the service as there were not enough agency staff available to provide cover. Staff were well trained and their competence was regularly assessed. There was strong and respected leadership in theatre and inpatient wards. Staff were committed to each other and their patients. Out-of-hours emergency surgery was led by consultants and there was adequate theatre time for anticipated emergency surgery or procedures.

The environment of the surgical admissions lounge was poor in terms of the patient experience. This was with respect to patient comfort, dignity and confidentiality. The anaesthetic rooms should be improved to assist in infection prevention and control. Patient outliers and handovers between wards must be improved.

Intensive/critical care


Updated 9 November 2014

Care provided by the critical care team was safe and treatment delivered was effective. Staff were caring and patients were treated as individuals. Their needs were met by considerate and compassionate staff. The service was well-led at both department, nurse and medical staff level. The team worked well together and this was commented upon by staff, patients and visitors.

Patients were happy with their care and all the discussions we had with patients were overwhelmingly positive. There was good multidisciplinary input into patient care to enhance recovery and discharge from the unit.

There were some instances of the discharge of patients not being at an optimal time. The majority of patients were not discharged at night, but some left the unit earlier than was ideal, to make room for unplanned emergency admissions. In busy times, some patients were discharged back to the wards to free bed space for more acutely-unwell patients. There was no step-down facility to a high dependency unit (HDU), as the hospital did not have a dedicated HDU.

The unit was small and there had been no renovation to bring the unit up to modern standards of facilities and equipment since it was built in the 1970s. It was, therefore, not able to respond to all treatment, or integrated care pathways.

Services for children & young people


Updated 9 November 2014

We found children’s services to be safe. Parents told us that staff were caring and we saw that children and their parents and carers were treated with dignity, respect and compassion. Ward areas and equipment were clean.

There were contingency plans in place if there were staff shortages and/or the wards were full. Patients requiring intensive mental health support were cared for by agency staff with mental health training. There was a multidisciplinary proposal for an urgent assessment protocol.

There were thorough nursing and medical handovers that took place between shifts to ensure continuity of care and knowledge of patient needs. We saw evidence of outstanding collaborative working, both within the units and with the community paediatric nurses.

We found that the environment within the ward made it challenging to accommodate the differing needs of patients, of infants, including those whose mothers were breastfeeding, and of children and young people requiring care and treatment.

We saw evidence of planning for future sustainable children’s services and learning from incidents. We also saw how the service made good use of the skills and resources it had.

End of life care

Requires improvement

Updated 3 November 2015

Areas of safety and well led were seen to require improvement, effective was rated as inadequate. In response to these findings shortly after the inspection we asked the trust to provide us with a plan of action that set out how they will ensure they are providing an effective and well led service for people at the end of their life. The trust responded with an action plan detailing the steps they are taking to address the issues raised. We will review the implementation of the action plan in due course.

The forms used to state patients choices and preferences for treatment and their decision about being resuscitated were better filled in. However, we saw patients who met the criteria for consideration for a TEP but one had not been completed. These patients had not been afforded the opportunity to advise of their choices and preferences for care.

Some aspects of the service provided were inadequate and were not consistently effective for patients at the end of life. The criteria for referral to the Specialist Palliative Care Team for assistance and advice with the management of symptoms were not consistently applied by all staff in all areas. Staff reported that the SPCT team responded promptly when requested.

The rapid discharge process to enable patients who wished to return home quickly at the end of their lives was not effective or well led at a trust level. The trust had recognised that the discharge of patients at the end of their lives was too slow, whilst work was being undertaken improvements in timescale for discharge were not evident

Leadership for end of life care in the hospital was not adequate. There was no formal strategy to ensure the service was provided to an agreed standard. The governance arrangements for end of life were unclear. When it was identified through national measurements that improvements were needed, these were not done. There was no end of life committee or governance group to review and discuss this aspect of the hospital service.



Updated 9 November 2014

The environment in the main outpatient department and associated clinic areas was clean, reasonably comfortable, well maintained and safe. Infection control procedures were not always followed by clinical staff in relation to the trust policy of ‘bare below the elbow’.

Staff were professional and promoted a caring ethos. Compassionate care was provided and staff interacted with patients in a friendly manner while treating people with dignity and respect.

Patients said that they felt involved in their care. The booking and running of clinics was efficient, with limited waiting times for patients.

Staff were provided with leadership and an ‘open’ culture was promoted in which staff felt engaged with the trust. Staff took pride in the quality of care and treatment provided by the outpatient department.