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North Devon District Hospital Requires improvement

We are carrying out checks at North Devon District Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Reports


Inspection carried out on 4 October to 25 October 2017

During a routine inspection

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Urgent and emergency care services remained as requires improvement overall. Safe stayed the same since our last inspection and was rated requires improvement. Effective went down and was rated as requires improvement. Caring stayed the same since our last inspection and was rated good. Responsive and well-led both got better since our last inspection and were rated good.
  • Maternity services had got worse since our last inspection and were rated as requires improvement, having previously been rated good. Safe and effective were found to have got worse and were rated as requires improvement. Well-led stayed the same and was rated requires improvement. Caring and responsive stayed the same and were rated good.
  • End of life care stayed the same following our last inspection and was rated requires improvement. Safe and well-led stayed the same and were rated requires improvement. Effective got better and was rated requires improvement. Caring stayed the same and was rated good. Responsive got better and was rated good.
  • Outpatients got worse since our last inspection and were rated inadequate. Safe and well-led got worse and were rated inadequate. Responsive got worse and was rated requires improvement. Caring stayed the same and was rated good. Effective was not rated.

Inspection carried out on 5 – 7 August and 17 August 2015

During an inspection to make sure that the improvements required had been made

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 carried out on 2-4 and 14 July 2014

During a routine inspection

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Urgent and emergency care services remained as requires improvement overall. Safe stayed the same since our last inspection and was rated requires improvement. Effective went down and was rated as requires improvement. Caring stayed the same since our last inspection and was rated good. Responsive and well-led both got better since our last inspection and were rated good.
  • Maternity services had got worse since our last inspection and were rated as requires improvement, having previously been rated good. Safe and effective were found to have got worse and were rated as requires improvement. Well-led stayed the same and was rated requires improvement. Caring and responsive stayed the same and were rated good.
  • End of life care stayed the same following our last inspection and was rated requires improvement. Safe and well-led stayed the same and were rated requires improvement. Effective got better and was rated requires improvement. Caring stayed the same and was rated good. Responsive got better and was rated good.
  • Outpatients got worse since our last inspection and were rated inadequate. Safe and well-led got worse and were rated inadequate. Responsive got worse and was rated requires improvement. Caring stayed the same and was rated good. Effective was not rated.

Inspection carried out on 9, 10 December 2013

During a routine inspection

This inspection took place over two days with three compliance inspectors, two specialist advisors and an expert by experience. We talked with 50 patients in areas of accident and emergency department (A&E), recovery, medical and surgical wards and the acute stroke unit. We talked with visiting relatives and friends of patients who reported positively about the hospital. We also talked with a range of 60 staff from all areas. This included consultants, middle grade and junior grade doctors, ward managers, nurses, heath care assistants, hospitality staff, volunteers, workforce development managers, tissue viability specialist nurse, directors of nursing and medicine and the End of Life Care consultant.

Patients expressed a high level of satisfaction about the care support and treatment they had received in all areas of the hospital. Comments included ''You could not ask for better treatment, this is second to none.'' One person told us ''I have had a long history of health issues, but I cannot fault the doctors nurses and care staff here. Everyone goes out of their way to make sure you have what you need.'' Another patient told us, “I couldn’t have asked for better care. I feel they are the professionals and know exactly what they are doing”.

We had received some information of concern earlier in the year about how patients were managed from recovery to critical care. We had asked the trust for information and we were satisfied with their response. In this planned inspection we included a specialist in this field to look at practices within critical care. We found the way patients were being managed was in keeping with clinical guidance and best practice.

We had information of concern about consultant cover in A&E following our last inspection. Although we were satisfied with the trust’s response at the time we included a specialist in this area to ensure staffing levels were meeting people's needs. We found there were sufficient staff who worked flexibly to meet the seasonal demands to the department.

We found patients care and treatment was well planned by a staff group who were well trained and supported to do their job.

We found improvements were needed to ensure people's rights were upheld when considering emergency treatment for patients who lacked capacity.

Inspection carried out on 5, 6, 7 February 2013

During a routine inspection

This inspection was carried out on 5, 6 and 7 February 2013 with four inspectors looking at five key outcome areas. In particular; discharge planning, care of patients with dementia and how the trust engaged patients in their quality assurance processes. In total we spoke with 72 patients and 18 visitors on a variety of wards including the Accident and Emergency department (A and E), the children’s ward, surgical wards, medical wards, the medical assessment unit (MAU) and various outpatient departments. Also we met the families of six children/babies. Comments from patients we spoke with were very positive and they praised the care, support and treatment they had received.

We interviewed 70 staff including a non executive director, the complaints manager, staff from the patient and liaison service ( PALS), patient safety lead, medical director, finance director, corporate governance lead, tissue viability specialist, adult and children safeguarding leads, lead midwife, dementia pathfinder team, palliative lead nurse specialist, discharge coordinator, consultants, doctors at all levels, nurses, ward clerks, receptionists, student nurses, and members of the allied health care teams.

We found patients using the service were involved in all aspects of their care and were consulted about the support and treatment they needed.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 3 April 2012

During an inspection to make sure that the improvements required had been made

We carried out an unannounced inspection in November 2011 to check on compliance of standards where we had previously found improvements were needed. During this inspection we spent time observing practices with the surgical theatres and found that improvements were needed to ensure that all pre and post operative checks were being fully completed.

This inspection was carried out on 3 April 2012 to specifically check on compliance of theatres and ensuring the safety checks were being completed and that this was being reviewed and monitored by the trust on a regular basis. Prior to this inspection we had received a detailed action plan from the trust to show how they planned to achieve compliance in outcome areas we had highlighted needed improvements. These were in the regulated activity of surgical procedures and in outcomes 4, care and welfare of people and outcome 16- assessing and monitoring the quality of service provision.

Three inspectors spent time observing pre and post operative checks in theatres for planned surgery, day surgery and ophthalmic surgery. We saw the theatre teams carrying out mandatory surgical safety checks on patients undergoing surgery on that day. These checks consist of a "check in" procedure when safety checks are carried out prior to surgery, a "time out" procedure when safety checks are carried out prior to the operation starting and a "check out" procedure at the end of surgery. These are mandatory formalised checks laid down by the World Health organisation Organisation (WHO) and National Patient Safety Agency (NPSA). The checks are performed to enhance patient safety.

We also saw that since our last inspection, theatres had introduced team briefings for all theatre staff before any patients were brought in for their procedure. This included running through the patient list, what procedures were being undertaken, any anticipated equipment needs and any special requirements such as post operative pain control needs. We saw that this had a big impact on improving communication between the teams.

We found that with all 17 observations the checks were always fully completed and included the prompts listed in the WHO checklist. We saw that each theatre had laminated checklists as an aid memoire for staff. There were also laminated small check lists for staff to carry and refer to if they wished. These were used to good effect.

We saw staff perform instrument and swab checks in conjunction with the WHO checklist.

Staff that we spoke to felt that there had been improvements in the team’s commitment to ensuring that all safety checks were completed. We heard that if any staff member did not comply with the mandatory checks that they had a system to report this to senior staff. Staff felt in their view that the team brief and end of day debriefs had worked especially well. One staff member commented “There is no doubt that the team brief has empowered all staff to be able to speak out.” Another member of staff said “It has cut down on the time we spent searching for equipment at the beginning of a case.”

We asked for some additional information from the trust about how they were ensuring that they were monitoring that theatres were complying with all safety checks. We saw that regular audits had been completed and working parties set up to look at how procedures could be improved.

Inspection carried out on 1, 2, 3 November 2011

During an inspection to make sure that the improvements required had been made

CQC completed a planned inspection looking at all 16 essential standards of quality and safety in March 2011. We set two compliance actions during this inspection. The first was in outcome 14, supporting workers, as we found little evidence of staff having opportunities for formal support and supervision. We also set a compliance action in outcome 21, records, as we found that records did not always reflect the care and treatment patients received.

We completed a further unannounced inspection in July 2011 as a result of concerns received that patients with complex needs may not have been getting their needs well met. These concerns had been raised with us through safeguarding processes. During this inspection we found that there had been some improvements to some of the risk assessments and care planning around people’s treatment, but that wound care and pressure care risk assessments and care plans had not been fully documented. This meant that the trust could not guarantee consistent and appropriate care of wounds. We therefore set a further compliance action in outcome four to improve their care planning and risk assessments.

This unannounced inspection was completed over three days from 1 to 3 November 2011. The inspector teams looked at medical and surgical wards and theatres. The primary task was to check compliance with standards where we had previously set compliance or improvement actions.

The inspector team included a consultant surgeon who is a professional clinical advisor to CQC. This was because we had noted from the trust’s own quality assurance audits that pre and post operative checks to ensure safe practice had not always been followed..

We spent time on three medical wards, the stoke unit, and two surgical wards. We visited the main theatre block with four theatres, two theatres in the day case unit and the Vanguard (pre fabricated) area with day case units for ophthalmology, gynaecology, breast surgery and day case dental surgery. We did not inspect the maternity theatres as there was no planned surgery taking place on the day we visited. We talked with medical and nursing staff and care workers in these areas. We also spoke with 22 patients and eight visiting relatives/family members.

Patients who spoke with us gave very positive feedback about their experience of being in patients on ward areas. Comments included

“The staff are excellent, they cannot do enough for you, even though they are very busy all day, nothing is too much trouble for them’’

“The nurses are very good, they have really looked after me.’’

‘’ We have nothing but praise for the way my xx has been cared for…when we have needed to ask for information the doctors have given it and the nurses have been really good. You can see how busy they are, but they still make sure xx is comfortable.’’

We saw that there had been significant improvements to the way that patients care and treatment was planned and recorded. The trust had introduced new documentation to record risk assessments and care plans and we found that this was now being completed to good effect.

We saw that the trust had continued to monitor completion of records within ward areas. They had introduced more ward based learning, support and supervision to enable staff to understand the risk assessments and care plans. Staff had also been and to be given support and training in completing assessments and plans.

For those people we identified as having pressure care needs or had been at risk of developing pressure ulcers, we saw that risk assessments and wound care plans were in place. These were being reviewed and monitored well.

We observed patients being cared for in a kind and respectful way that ensured their dignity was respected. All levels of staff within the hospital showed a great deal of respect when addressing patients. We heard examples of staff making sure they explained fully what they were planning to do so that people with communication difficulties or dementia had the opportunity to understand what was being said to them.

We spoke with 30 staff across the hospital and heard that they now had a supervision contract that fully explains supervision and that most have had or had planned supervision sessions in place. Some of this was one to one sessions, group meetings and debriefing sessions where a significant event may have occurred on the ward area.

The inspectors and clinical advisor observed staff carrying out mandatory surgical safety checks on patients undergoing surgery on that day. These checks consist of a “check in” procedure when safety checks are carried out prior to surgery, a “time out” procedure when safety checks are carried out prior to the operation starting and a “check out” procedure at the end of surgery. These are mandatory formalised checks laid down by the World Health organisation Organisation (WHO) and National Patient Safety Agency (NPSA). The checks are performed to enhance patient safety.

In theatres we found that the pre and post operative checks were not properly and fully completed. This placed people at risk. We gave detailed feedback about this at the time of the inspection and we have asked the trust to make improvements to ensure that theatre staff are fully trained to understand the checks and that completion of them is properly monitored. We noted that on the third day of our inspection the Chief Executive had already taken some steps to address how surgical safety checks are monitored. We were assured that implementing more robust procedures would be given immediate priority.

We also found that improvements were needed in some theatre areas to ensure a secure and robust system is in place for the safe storage and recording of medications.

Inspection carried out on 14 July 2012

During an inspection in response to concerns

We decided to carry out this responsive review in response to an overall multi agency safeguarding strategy which is being coordinated by NHS Devon. At the same time NDHT also wrote to us asking us to carry out a review demonstrating their willingness to work in partnership with the Commission.

At the time of this review there are five safeguarding alerts currently being reviewed under DCC safeguarding process and involving NHS Devon and Southwest Strategic Health Authority.

The alerts which have been raised identify potential concerns around specific aspects of care provided to these patients which include:

• how pressure area care is managed

• how well the hospital works with patients with complex needs and/or patients with communications difficulties

• consent and assessing mental capacity for patients

• meeting nutritional and hydration needs

We carried out a responsive review with inspections to the hospital on 11, 12 and 14 July 2011 and because of the concerns we looked outcomes one, two, four and five.

We were not looking at the investigation of these alerts because these are being looked at in the separate safeguarding strategy meetings. The purpose of this review was to check compliance in these key outcome groups for current patients.

In our previous planned review of this hospital in March 2011, we set two compliance actions. One of them was in relation to records (outcome 21). The trust gave us a detailed action plan and this included some key changes to the documentation being used to ensure good care and treatment. They told us they would be fully compliant by the end of September 2011. We continue to monitor this with meetings and requests for further updates. We will also check this by a further unannounced visit to the hospital. However, record keeping was looked at as part of our reviewing compliance with the above outcomes and we have reported upon these under the relevant outcome groups.

Three inspectors spent three days at North Devon District Hospital (NDDH) completing this responsive review, two days on medical and surgical wards including those where issues via safeguarding had been identified; Staples ward, Glossop ward and the medical assessment unit (MAU). We looked at the records of 20 patients and 10 of those in more detail; where we spoke to the individual and or their carer. We also spoke to different staff including nurses, doctors, an occupational therapist, the community psychiatric liaison team and the complex care discharge team. We used an observational tool called SOFI

(Short Observational Framework Inspection) where for periods of time we sat and observed in detail interactions between staff and patients. The mapping tool helps us to understand positive and less positive interaction between the staff and patients. These were completed in two different wards. On the third day we spoke to the trust’s Tissue Viability Clinical Nurse Specialist and to 10 doctors from varying clinical areas to check their understanding and application of consent and the Mental Capacity Act.

Patients told us that they were consulted about their care and treatment. Some patients told us that staff in some wards were busy. In their opinion care and treatment was rushed. One patient said staff were ‘attentive and do their best, but they are very rushed and don’t have the same time.' Another patient described how doctors had spent time with them to explain their illness and the treatment options. They added that the nurses on the ward had also explained the treatment to them.

We saw that consent for care and treatment is considered and documented, but in some areas this needed improvement, particularly around the consent to use bed rails and where clinical decisions are made about emergency treatment. We did see some good examples of where patients lacked capacity to make decisions and a multidisciplinary approach had been used to look at the best interests of the individuals.The trust has training to ensure that mental capacity is assessed fully, but not all staff have completed this. Staff who were less confident in this aspect knew where they could go for support and help. We saw that the introduction of the community psychiatric liaison team has played a key part in improving consent and capacity issues.

We observed lunchtime in three wards and spoke to some people about their experiences. We also looked at records relating to nutrition and hydration, and did not find any significant issues with this. One person told us that for vegetarians on a soft diet the food choices were limited. We have passed this onto the hospital catering manager who agreed to look at this.

Patients we spoke to said that their needs were being met, but we have identified some key areas of concern where lack of assessment and care planning could place people at risk. Essentially this is around pressure damage and wound care. We did not find that outcomes for people were poor, but we did find that wound care plans were not being reviewed and monitored sufficiently to ensure appropriate treatment was consistent. We are aware that the trust are auditing and monitoring this closely. They also have a new generic wound care plan, but this was not being used during this review. We have set a compliance action in respect of this and we will be reviewing this again in the near future with further unannounced visits to the hospital.

As part of the safeguarding strategy meeting information request, the Trust sent us

their policies and guidance for the use of two mechanical devices post operatively to help prevent the risk of a deep vein thrombosis. Our specialist advisors have assured that the guidelines are appropriate but one of the references needs updating

Inspection carried out on 2 March 2011

During a routine inspection

During our visits to the hospital we spoke to both in patients and out patients about their experiences. We spoke to a total of 50 patients during our visits either as out patients or in patients on ward areas. Overall we heard very positive comments about individuals' experiences of using the hospital. One patient whom we spoke to said they had made several complaints over the years about their treatment via PALS, but at the end of the discussion said ''I still really rate the staff here, they do a great job of looking after us.''

Another patient we spoke with said they had known the hospital over several years and felt the service it provided was ‘just getting better and better’. Other patients also reflected they felt the care services provided had improved over recent years.

One relative said ''They could not have treated my wife better, I am really impressed with all the staff here, nothing is too much trouble.'' Another person told us ''On the whole staff are smashing, you may get a personality clash with one or two, but on the whole they have been great, really caring.''

We spoke with four people who were representatives for children who were staying on the children’s ward. All described their experiences as very positive, verbalising that staff always explained to them and their children what was going to happen whilst they were on the ward.

We observed care and treatment being delivered, by a cross section of trust staff, in a kind and respectful way.

Patients we spoke to gave a variable response about the food at the hospital. One patient reported it as ‘’lousy’’ and another said ‘’best not to mention what I think about the food.’’ Some patients gave more favourable responses. These tended to be in patient areas where stays were only for a short while, such as maternity. We saw that the hospital only have a one week menu at present and some people described this as ‘’very monotonous’’ and we were told that the week end pureed food was not appetising. We saw people being assisted to eat their meals when needed and that drinks and snacks were available.

Patients we spoke to had no complaints about the environment or cleanliness of the hospital. Most comments very positive and included ''It is kept very clean, I have no complaints.'' ''The cleaning staff work hard and do a good job.''

We heard that patients felt that staff explained their treatment to them, and that they were involved in decisions about their care and treatment. We were told that patients did feel comfortable in being able to make their concerns known.

One patient said ‘I don’t need to ask questions because they explain it so well’. Another said, ‘If there’s something I don’t quite understand, I just say so, and they explain everything.’ A third person, who had a hearing impairment, said the doctor realised the patient wasn’t understanding what he was saying because of his hearing difficulty, and then wrote everything down for him.

One patient in an acute medical ward said that ‘the staff are very good’. We saw staff engaging well with people, sometimes lightening their mood and sometimes acknowledging their distress with kindness. We heard staff ask how people were getting on with their treatment or a dressing and listening to them. One relative said ‘You can’t fault them (the staff). They jolly you along and they are lovely about everything’. They went on to say that the care in accident and emergency was ‘wonderful’.

We saw that the care and nursing staff had a good understanding of patients needs and care and treatment were being delivered appropriately, but that some records were not well maintained and this could lead to potential risk of care or treatment not being well monitored.

Staff working at the hospital told us that they have good training and that most have had an annual appraisal, but we found that regular planned support and supervision was not in place for all staff. This meant that there is no clear audit of how staff competencies are checked and that staff may not have had opportunities to discuss their skills and ongoing training needs on a regular basis.