Torbay and South Devon NHS Foundation Trust

Torbay and South Devon NHS Foundation Trust is an integrated organisation providing acute health care services from Torbay Hospital, community health services and adult social care. The Trust runs Torbay Hospital and nine community hospitals in Devon. The trust serves a residential population of approximately 375,000 people, plus about 100,000 visitors at any one time during the summer holiday season.

This was the first inspection undertaken at Torbay hospital using the comprehensive inspection methodology. We inspected Torbay hospital between 2 and 5 February and on 15 February 2016. The inspection team inspected the trust’s acute hospital services and community-based services as well as social care services provided from two locations.

Overall, we rated the trust as requiring improvement. We rated urgent and emergency care services as inadequate. We rated six other services as requiring improvement, eight as good and four as providing outstanding quality of care.

At the trust level, we rated four of the domains of quality care (safe, effective, responsive and well led) as requiring improvement. However, the caring domain was rated as outstanding, reflecting the compassion, support and patient involvement the trust provided in delivering care.

Our key findings were as follows:

Safe

• Nurse staffing was at expected levels in many areas. However, the emergency department was not always staffed by appropriately qualified, experienced and skilled nursing staff. The numbers of nurses on medical wards regularly fell below the established minimum number. The Child and Adolescent Mental Health Services (CAMHS) had difficulty recruiting staff leading to long waits for some patients.
• Medical staffing was at expected levels in most areas. However, in the emergency department there were not enough consultants or a named paediatric consultant on each shift. In outpatients, there was not enough medical staffing to allow the trust to address its significant backlog of follow up appointments.
• While most services demonstrated an understanding of patient risk, there was an inadequate response to risk in other areas. In the emergency department, patients did not always receive an initial assessment within 15 minutes. This placed patients at risk. The National Early Warning Score (NEWS) system had been implemented in the emergency department but the scores did not always indicate the action needed. Medical patients on outlying wards were not always well supervised and some CAMHS patients had long waits without updated risk assessment being carried out.
• Infection prevention and control procedures were complied with, such as in the case of regular hand hygiene audits. Clinical areas were generally clean although we saw some unclean areas in some outpatient procedure rooms. Some patients without MRSA confirmed status were being placed on surgical wards which presented an infection risk to other patients. In dermatology, minor surgical procedures were taking place in rooms that were not adequately ventilated or maintained.
• There was generally a positive culture around reporting, investigating and learning from incidents. However, in end of life care, it was not clear how lessons were learned from incidents and we were not assured about the effectiveness of incident monitoring. In outpatients, there was a mixed approach to incident reporting. In surgery, information on incidence of falls, pressure ulcers and urinary tract infections was displayed on ward boards providing transparency on incidents.
• Premises and equipment were not always fit for purpose. The facilities in the emergency department were not suitable or well maintained and compromised patient safety. In critical care, intravenous fluids were not stored securely and the safety of babies was compromised, as breast milk was not stored securely. Cautery procedures were carried out in rooms without smoke extractors and without the use of masks.
• The management of medicines was generally in line with trust policy and legislation, although in outpatients there was inconsistent recording and monitoring of fridge temperatures and there were no records of stock rotation in some areas.
• There were some areas of records management that needed improvement. We found areas for improvement in surgery, children and young people’s services and end of life care.
• Staff understood their safeguarding responsibilities and were aware of the trust’s policies and procedures.

Effective

• In most services, patient’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based practice. In the emergency department, performance was mixed against national audits to benchmark performance and in end of life care there were inconsistencies in symptom management.
• In most services, there was evidence that patient outcomes were assessed. The trust had a mortality rate in line with the national average. Surgical services benchmarked against other trusts and were performing well in terms of effectiveness and patient outcomes. In the emergency department patient outcomes varied and the results of audits were not always used to improve treatment, including management of sepsis. Unplanned re-attendances to the emergency department were not investigated to identify reasons. Lengths of stay in the trust’s community hospitals was significantly lower than average.
• Multi-disciplinary working was evident in many services inspected such as in community and hospital midwifery and in the CAMHS service. However, some areas of multidisciplinary working in the emergency department and medical care were not working effectively.
• There was variable understanding of responsibilities in relation to consent, the Mental Capacity Act 2005 and the Deprivation of Liberty Standards (DoLS), for example in critical care.
• In some areas, the equipment being used was not of an expected standard. In end of life care, temporary fridges were being used on a permanent basis, without effective temperature monitoring. In outpatients, aging equipment was preventing staff from providing effective services.
• Facilities did not always support effective services. The emergency department facilities were not suitable or well maintained. This compromised patients’ safety and experience. There was no designated space to assess patients with mental health conditions. The critical care unit did not meet currents standards although the building of a new unit had started. The design and use of some outpatient facilities did not keep patients safe at all times.
• Patients’ nutrition and hydration needs were being met.
• Staff were generally competent to deliver services to patients. However, in outpatient services a nurse practitioner was performing procedures without formal qualifications.
• Limited access for mental health services out of hours caused extended waits for patients in the emergency department.

Caring

• Patients were consistently treated with compassion, kindness, dignity and respect and feedback about the care received was very positive.
• Staff demonstrated a good level of emotional support throughout the range of acute and community services the trust provides.
• We saw examples of caring interactions between staff and patients. Staff were observed going ‘above and beyond’ in many ways to deliver outstanding support patients and relatives, often at difficult times.
• The trust had developed a ward buddy system on care of the elderly wards at Torbay Hospital where buddies were able to provide one-to-one emotional support to patients.
• Patients and their relatives were often involved in their care planning and treatment and staff supported patients to understand their care needs.
• In end of life care staff we talked to had a good understanding of the impact that a person’s care, treatment or condition might have on their wellbeing and of those close to them.
• In maternity patients’ choices were important when planning and delivering care.
• In children’s services, parents and children spoke highly of the service. Children were involved with the planning of their care wherever possible. In outpatients, we saw relatives and carers being included in decision making.

Responsive

• There was no flow urgency throughout the hospital, which impacted on the emergency department. A lack of available beds in the hospital resulted in poor patient flow through the emergency department. Delays were unacceptable at times placing patients at risk of avoidable harm.
• Emergency department patients were not consistently being seen within an appropriate timescale for initial assessment or by a suitable doctor for clinical review.
• There was a lack of decision makers in the emergency department which also affected the flow of patients out of the department.
• In the medical directorate, a number of patients had been transferred out of wards overnight.
• Delayed discharge rates were consistently high and large numbers of patients spend considerable time on outlier wards without senior medical input.
• Bed pressures also affected timely discharges from the critical care unit. Elective (planned) surgery was affected by the lack of bed availability in critical care.
• In surgery, the pressure on bed availability within the hospital meant patients were not always receiving timely surgery. Numbers of patients who had their surgery cancelled remained above the average for England.
• In maternity, there was a public health midwife to support people to make lifestyle changes and the service had systems to make adjustments for patients living with learning or physical disabilities.
• The gynaecology service introduced enhanced recovery procedures to improve the flow of patients through the service.
• The children and young people’s service provided responsive planned and emergency care, although there were delays accessing mental health services.
• There was a long wait (17 months at the time of our inspection) for children aged 5 to 18 to receive an autistic spectrum diagnosis.
• The end of life service collected some information about numbers of deaths of patients on end of life pathway and whether they died in their preferred place of care or not. Most end of life patients had a treatment escalation plan including a resuscitation decision.
• Plans were in place to increase clinics in outpatients. However, at the time of the inspection patients often did not have timely access for follow up appointments due to a follow up back log and the capacity of clinics.
• We saw evidence of person-centred care. In surgery patients living with dementia or learning disabilities had their needs met. The children and young people were at the centre of their care and paediatric services were highly responsive.
• There was a positive culture around dealing with feedback and complaints and learning lessons. In some areas such as the children and young peoples’ service this included identifying trends and themes to embed learning.

Well led

• There was a clear and inspiring vision for the future which had been developed in partnership and there was strong senior leadership on place.
• There was a feeling that the change had been managed. Most staff were very positive about the new organisation, with good communication in place.
• The team were not assured that the highly devolved arrangements provided the Board with sufficient oversight in key areas, for example aspects of performance in the emergency department and on mortality and morbidity.
• Dual systems, processes and policies were running in areas key to patient safety, for example, two incident reporting systems and policies.
• The effectiveness of the governance arrangements for the integrated organisation, four months old at the time of inspection, were too new to have been fully tested. There were challenges to improve governance arrangements in some services, most notably in the emergency department and in medical care.
• The sustainable delivery of quality care was put at some risk by the financial challenge.

We saw several areas of outstanding practice including:

• Staff in the Emergency Department (ED) were positive and professional under pressure, maintaining a supportive role to patients. They were always kind and thoughtful, ensuring that patient’s anxieties were relieved as much as possible.
• The trust was the highest achieving in the south west peninsula for cancer treatment targets and had the highest survival rates in the south west. The trust was also the highest achieving cancer centre in the patient survey and in the 10 nationally.
• We spoke with one patient on the surgical ward who was going through a distressing time as they found out their daughter was admitted for emergency care. The staff in the hospital had arranged and facilitated to take them down to see their daughter and had constant updates from the medical team involved in care.
• In recovery in the middle of the room there was a large clock with four faces on it pointing in different directions. This allowed patients to orientate themselves with the time as soon as they woke up after theatre reducing confusion and distress.
• We found that WHO checklists were completed using a large whiteboard in every theatre allowing all staff to observe and act upon it. These were being developed further to be interactive projection boards where each patient would have a bespoke WHO checklist depending on its requirements.
• The innovative way in which the hospital was managing capacity by making traditionally inpatient surgical stays as an outpatient procedure.
• The innovate way in which technology had influenced the educational facilities at Torbay Hospital. Particularly around the use of virtual reality headsets to train staff for specific situations such as the surgical checklist.
• The use of video calling over the internet using portable tablet devices in the critical care unit was an example of outstanding practice. This technology primarily allowed doctors to have a ‘face-to-face’ discussion with relatives who were not in the country, but also allowed those relatives to see and speak to their loved ones being treated on the unit.
• The critical care unit’s rehabilitation programme was exceptional. As well as having focus on patients while they were in the unit, there was rehabilitation support and follow-up routinely provided in the hospital for patients who had been discharged. This service was then further extended into the homes of patients who had been discharged from the hospital. Because the programme worked so well, the unit’s occupational therapist had been invited to speak nationally on the subject to encourage other hospitals to look at ways they could deliver a similar service.
• The care being provided by staff in the critical care unit went above and beyond the day-to-day expectations. We saw staff positively interacting with all patients and visitors and evidence of staff going out of their way to help patients. Patients and visitors gave overwhelmingly positive feedback.
• There was a perinatal mental health team based in the maternity unit. This had led to consistent care for women with mental health conditions and provided multidisciplinary care to women during and following their pregnancy.
• The divisional quality manager provided ‘critical incident stress debriefing’. This involved group sessions where people who had been involved in critical incidents or difficult situations were invited to talk through the process and any issues that had arisen.
• The maternity services had secured funding to have short videos produced that were available on the trust website. They were designed to build on the information given to women at the start of and during their pregnancy as it was realised that people do not take in all the information they are given by healthcare professionals. The videos could be watched at people’s leisure and aim to provide women with all the information they need to make informed choices for example around screening tests and methods of delivery.
• When women called in to say they thought they were in labour instead of being asked to come into the unit to be triaged a midwife would offer to visit the woman at home to establish if they were in labour or not. Choices about how and where they would like to have their baby could then be decided upon. This had facilitated some unplanned home births which were seen as a positive outcome. The midwives found it had meant less unnecessary attendances at the maternity unit.
• One of the general theatres operating department practitioners had noticed there were sometimes communication issues between midwifery and general theatre staff. They had carried out a project to improve multidisciplinary communication. As a result of the project a caesarean section and obstetric emergencies information chart had been produced, that was laminated and displayed in the labour ward and a theatre ‘do’s and don’ts’ also laminated and displayed for staff to follow.
• We saw a good level of involvement of children and young people in consultant interviews.
• In end of life care, bereavement officers gave out feedback cards to bereaved relatives and comments which were then discussed with the bereavement officers line manager. This had resulted in the trust introducing free parking to relatives of patients at end of life. Bereavement officers had also been able to reduce the time that death certificates took to be issued through project work. This had increased the efficiency of the process and reduced some of the emotional impact on relatives at a stressful time.
• The medical records department had consistently supplied 98-99% of records to clinics on or before the clinics, with note preparation carried out to suit consultant’s individual preferences, and had plans to track notes electronically on a live system.
• The physiotherapy direct referral service, allowed patients to access physiotherapy without the need for a GP referral. Patients using this service normally received an appointment within 72 hours of self-referral.
• In the oncology outpatient department, there was a home delivery service for some oral chemotherapy drugs. Patients received telephone consultations with their consultants for three appointments, and then came into the clinic on their fourth for a review.
• The virtual triage clinic in Fracture clinic had reduced the numbers of unnecessary fracture clinic appointments by 15%.
• The diagnostic imaging department had turned 93-99.9% of reports around within one week across all specialties and patient types. In particular, there was a dedicated inpatient-reporting radiologist for every session, which had reduced the average turnaround time for an inpatient report to six hours. The department also produced run charts to identify any outliers, and investigated the delay in their reports.
• Nursing, medical records and care plans across the eight community hospitals we visited were completed to a high standard. They were accurate, up to date with and good evidence of multidisciplinary team input. Our specialist advisors said these were some of the best care plans they had ever seen.
• Relatives spoke highly about the way in which staff involved them in the patients’ care and treatment across all of the community hospitals. They felt involved in the planning of patients’ care, in their goals towards goals towards discharge and for when the patient returned home.
• Therapy staff involved family and carers on admission to the hospital. They would go out to the patients’ home to meet with families in order to ensure the patient had access to the most appropriate services and equipment to enable their recovery. This enabled staff to understand fully the patients’ home situation and whether the family or carer was best placed to support the patient with their ongoing care and reablement. They could support families with this process and assess the level of input the patient would need from other agencies.
• The changes made to the management of diabetic patients in the community by the introduction of new care planning documentation and recording of insulin prescribed and administered. The diabetes Specialist Nurse received recognition from the Royal College of Nursing (RCN) for their work in improving the management of patients with diabetes. Their work was recognised nationally and was published by the RCN for other trusts and community nurses to follow.
• We saw a particular example of outstanding practice for end of life care in the community, in the development of a carer’s course where people caring for loved ones with life limiting illnesses could access an ongoing support group. Feedback from this was positive and described by carers as helping them to feel valued and better able to cope with their situation.
• All community minor injury units (MIUs) had reduced their un-planned reattendance rates following a review.
• There was an orientation programme for nurse practitioners at the MIUs, which lasted for a minimum of four weeks and practice during this time was always supervised.
• The trust been selected by NHS England to become one of eight urgent and emergency care vanguards, which are aimed at improving the coordination of urgent and emergency care services. Planning had started to expand the MIU services at Newton Abbot so that minor illnesses could also be treated.
• The majority of staff at the MIUs had undertaken training in the specific needs of people with dementia and learning disabilities and the involvement of families was encouraged. The computer system featured a flagging system for people with learning disabilities so that staff could be alerted to their special needs.
• A trauma triage system had been introduced which reduced the need for long journeys for people who had sustained fractures. Clinical notes and X-rays were viewed electronically by an orthopaedic consultant in the acute trust. Following this review many patients could continue their treatment at their local minor injury unit. Only people with more complicated fractures were asked to travel to Torquay for specialist treatment.
• Community dental staff in all the locations were passionate about working within the service and providing good quality care for patients.
• Patients reported an excellent dental service. We evidenced highly trained and experienced staff with excellent application of knowledge and skills in practice to meet the needs of this very vulnerable group in a high risk setting.
• The dentists and support staff were skilled at building and maintaining respectful and trusting relationships with patients and their carers. The dentists sought the views of patients and carers regarding the proposed treatment and communicated in a way which ensured people with learning disabilities were not discriminated against. 
  • The development of the Brush and Bus scheme taking oral health prevention advice to local schools. 
  • The development of a mobile dental service taking treatment to isolated areas and special schools in order to provide timely intervention in a safe manner. 
  • The development of a sedation service that is not reliant on waiting list admission therefore providing care on site in a timely manner as required by the patient.
  • The provision of a bariatric chair for the treatment of obese patients.
  • The provision of a hydraulic lift for patients who use a wheelchair to be treated in their chair.
• Specialist and secondary dental staff in all the areas of service provision were passionate about working within the service and providing good quality care for patients.
• Patient’s feedback demonstrated they experienced an excellent service within the specialist and secondary dental services. We evidenced highly trained and experienced staff with excellent application of knowledge and skills in practice to meet the needs of this very vulnerable group in a high risk setting.
• One of the patient transport service vehicles was able to take specialist transfer trolleys (one for surgical transfers and one for special care baby transfers). The patient transport service provided the ambulance and driver and the patient was escorted by clinical staff from the surgery ward or special care baby unit. The new fleet due later in 2016 has more vehicles that can be used to take specialist patient care trolleys to improve transfers from the hospital to other NHS units.
• A member of the control room staff from the patient transport service attended the daily bed meeting held in the trust. This was a meeting held at several times a day to look at the capacity and demand within the hospital. The patient transport service were an active part of this meeting and were able to share what resources they could make available and were able to ascertain the pressure points in the trust and where the priorities would be for discharging patients in a timely way.
• The provider had excellent communication systems which allowed them to track each of their vehicles and to get instant messages direct to individual crews or all the crews at once. The system also allowed crews to send messages back to the control room. Paper records and mobile phones were available as back-up systems.
• The patient transport service had good links with other agencies such as social services. These links extended to providing services they were not commissioned to do. The view of the managers was that if it was of benefit to patients and improved links with other agencies it was worth doing. As an example, the department was contacted by social services because a patient needed to be moved downstairs in their home. The patient transport service allocated a crew to assist the care staff in settling the patient into their new accommodation on the ground floor of their home.
• We observed and heard examples of where patient transport service staff went above and beyond what they were contracted to do. One outstanding example was when a patient died on the ambulance on route to their home. The crews had been instructed to return to the hospice if the patient died, however the family present with the patient wanted to return home as planned. The staff sought advice from their control room and the hospice and followed the family’s wishes and continued their journey. The crew settled the patient into their bed at home and waited with the family until the specialist palliative care nurses arrived. This was an example of where staff went above and beyond in the care they provided to their patients and their families.
• The children’s and adolescent mental health service (CAMHS) worked closely with local services in health, social care and education. In-reach roles had been developed, including a team of primary mental health workers to work in schools, practitioners to work with social services and a perinatal specialist. Clinics were held in GP practices where patients could be booked in with a CAMHS practitioner instead of a doctor. This enabled patients to get the right help more quickly.
• All clinicians involved in CAMHS received safeguarding supervision every three months even if they had not needed to make a safeguarding alert. This ensured safeguarding was always high on the agenda, staff were supported and that the need to involve the local authority safeguarding team was considered for all patients.
• The CAMHS service ran a group for parents and carers to enable them to learn about mental health and consider how best to help their children. The group was effective and received good feedback from participants.
• Children, young people, their families and carers were involved in the service and its development. Children were included in interview panels and given 50% weighting in the decision process. They were involved in creating videos that were going to be used on a new website for the service. There were forums for children and young people and for parents and carers where they could give feedback about the service. There was evidence that questionnaires completed by people who used the service were making a difference to how the service was delivered.
• Staff at Walnut Lodge were caring, compassionate and motivated to help people to the best of their abilities. This was often demonstrated with staff going above and beyond what was expected of them. For example, providing additional support to people and their families to ensure that they can access appointments, assisting people with support to access voluntary support groups in the community and often taking a professional lead in co-ordinating and organising an effective multidisciplinary approach.
• There was a specialist health visitor integrated within the substance misuse team. This role involved supporting the children of people who were using the service. The role enable staff to support the person using the service and their family. This involved visits at home, comprehensive support plans for the children and family education about the risks associated with drug and alcohol use. The role provided an additional safeguard for the family and children. We received extremely positive feedback for people who had used the service about the support provided to the family as a whole and how it had enabled them to realise that recovery was possible.
• The consent to treatment form identified, for women who used the substance misuse service, the need to monitor themselves for pregnancy whilst in treatment. This is important due to the risks associated with pregnancy and opiate withdrawals.

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

Importantly, the trust must:

• Make the management of the emergency department environment safe. Patients waiting on corridors to be seen must be reviewed and monitored to ensure their safety.
• Address the 24 hour a day, seven day a week consultant cover for paediatrics in the emergency department and allocate a named consultant for each shift.
• Ensure that there is consultant cover provided to all medical wards and escalation wards seven days a week.
• Ensure risks to the health and safety of patients when identified are actioned. When Early Warning Scores indicate an increased level of observation that this level is consistently maintained.
• Ensure plans in place to monitor sepsis pathways are completed.
• Ensure there is timely access to psychiatric support in the emergency department. A safe room must be provided to ensure both patients and staff undertaking an assessment are safe.
• Review the process of medically expected patients having to wait in the emergency department.
• Ensure senior decision makers in the hospital are involved in the movement of patients through the emergency department.
• Ensure the escalation processes in place to support the emergency department during busy periods are effective to address the issues causing the escalation.
• Ensure the governance systems in place for the emergency department reflect the known issues and are used to address the concerns identified. The trust should ensure that when areas of anomaly such as the high readmission rates and rates of patients leaving before being seen are audited and investigated.
• Ensure there are sufficient numbers of suitably trained, competent and skilled staff deployed to meet the needs of patients. The trust must provide evidence of the sustainability of these increased levels and how monitoring of sufficient staffing is being maintained.
• Ensure ongoing monitoring of the initial time to initial assessment and clinical observation. Appropriate monitoring and actions must be undertaken to ensure the safety of patients.
• Ensure patients arriving at the emergency department are seen within an appropriate timescale by an appropriate doctor. The trust must ensure monitoring of this timescale to ensure the ongoing care and treatment of patients.
• Take action to ensure patients cared for on escalation wards, outlier wards and at weekends have access to medical input and review from appropriate clinicians.
• Take action to minimise the length of stay medical patients spent as outliers in surgical areas.
• Review staffing skill mix on Elizabeth and Warrington wards to ensure patients cared for there, particularly out of hours, are safe.
• Ensure patients cared for at weekends; in escalation wards or as medical outliers receive appropriate risk assessments.
• Review how staff are trained in fire safety on wards and ensure a named, competent fire warden is in place.
• Ensure critical care staff have a full understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards and that patients subject to these are appropriately assessed, supported and authorised.
• Review staffing levels on Louisa Cary Ward to ensure they meet the recommended guidance (RCN 2013) particularly at night.
• Ensure the safe storage of breast milk on Louisa Cary Ward and the special care baby unit was not secure which compromised the safety of babies. This was raised with staff at the time of the inspection.
• Ensure risks for end of life care are captured and reviewed effectively through the governance system.
• Ensure all staff that monitor and adjust syringe drivers are competent and have the skills to carry this out.
• Ensure minor surgical procedure rooms are clean and fit for their purpose and ensure these standards are maintained with regular monitoring.
• Ensure there is adequate ventilation and extraction in outpatient procedure rooms where cautery is carried out.
• Ensure emergency oxygen is checked and records kept.
• Ensure medicines stored in refrigerators are checked and to keep accurate temperature records.
• Take action to capture record and investigate post procedure infection rates in the dermatology general outpatients department.
• Ensure departments carry out regular hand hygiene audits in all outpatient areas and display the results for staff and patients.
• Ensure the systems and processes at community hospitals ensure information in relation to safety, particularly regarding staffing levels and skill mix, was shared and understood between ward and board level.
• Ensure where information is held on paper and electronic systems, staff are able to access information required.
• Ensure initial health assessments for ‘looked after’ children meet the statutory timescales.
• Ensure there are sufficient staff to meet people’s needs and cover caseloads of health visitors and school nurses.
• Ensure treatment escalation plans and do not attempt resuscitation decisions are appropriately completed and recorded in line with trust policy and that audits of these lead to measurable action plans used to improve performance.
• Ensure healthcare assistants checking controlled drugs and syringe drivers is risk assessed and training is provided and are competency assessed.
• Ensure patients who do not have capacity to be involved in decisions about resuscitation have a clearly recorded capacity assessment along with clearly documented best interest decisions and a detailed record of all discussions with the patient and family members.
• Ensure the clinic room at Walnut Lodge is locked and keys to obtain access to the medicine cupboard and fridge are stored securely.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service Requires Improvement l

During the inspection, we visited eight out of the nine community hospitals. At the time of our inspection, Bovey Tracey hospital inpatient beds were temporarily moved to Newton Abbott hospital. We reviewed surgical services at Teignmouth hospital day surgery unit.

Our inspection team included two Care Quality Commission inspectors and seven specialist advisors and an expert-by-experience. Our Pharmacist looked at medicines management in three community hospitals, Teignmouth, Paignton and Brixham. We spoke with approximately 60 staff, 25 patients and 7 relatives.

We rated safety in the community inpatients to require improvement. We found there were good systems in place for reporting, investigating incidents and sharing learning from them. Medicines were not consistently managed and stored in a way that would keep people safe from avoidable harm. The ward environments across all community hospitals were clean and tidy. Patient records were completed to a high standard. They were detailed, up to date and showed evidence of multidisciplinary team input. There were reliable systems in place to prevent and protect people from a healthcare associated infection and staff followed appropriate infection control procedures. Staffing levels, skill mix and caseloads were not effectively planned and reviewed to ensure people received safe care and treatment at all times. Staff of varying seniority across all community hospitals expressed concerns about staffing levels. This related to the staffing of escalation wards and to staffing at night in particular. Recruitment of staff was an on ongoing concern. Bovey Tracey hospital inpatient beds were temporarily closed and patients and staff were transferred to Newton Abbott wards due to ongoing issues with retention and recruitment there. Staff felt concerned about staffing levels and skill mix on escalation wards. There was a high use of agency staff on these wards who did not have the right skills to manage stroke patients in particular. Staff of all seniority felt lessons from the previous year’s escalation ward management had been discussed but not consistently applied.

We judged effectiveness within community hospitals as good. Staff followed national guidelines and recommendations to deliver effective care and treatment and ensured patients’ pain was well managed.

Patients’ care and rehabilitation goals were identified on admission to the hospital. Referrals to therapists and specialists were made in a timely way that would best support their reablement and recovery. A variety of quality and audit information was collected at each community hospital which was used to improve the quality of patient care. Length of stay for each community was shorter than the national average of 28 days.

Multidisciplinary team working supported effective planning and delivery of care for adults being cared for in the hospital and for their ongoing care following discharge. Staff engaged with patients’ families and carers to ensure patients were discharged into the right setting with appropriate care and treatment in place.

We judged the care of community inpatients to be good. Patients and relatives across all eight hospitals provided positive feedback about patients’ care and treatment. We saw staff treating patients with kindness, respect and dignity. Staff responded sensitively to patients’ needs when patients experienced physical pain, discomfort or emotional distress. Patients and their relatives felt involved in their care and were supported emotionally. Patients we spoke with said staff took time to explain their care and treatment in a way they could easily understand. Relatives felt involved in the planning of patients care ready for when they returned home. Patients’ call bells were answered quickly. Staff support and empowered patients to manage their own health, care and wellbeing to maximise their independence.

We judged the community inpatient services were responsive to patient’s needs. The trust and staff from community hospitals worked with local commissioners of community services and partner organisations to ensure the division provided services that met local people’s needs. Community hospital staff worked closely with community nursing and therapy teams, GP practices and social services to ensure patients access to ongoing care and treatment. Staff did their best to meet the needs of the patient and were sensitive to their personal, cultural, religious needs, or sexual preferences. Services were planned, delivered and coordinated to meet the needs of patients living in vulnerable circumstances, such as those patients living with dementia. Staff demonstrated a good level of awareness of how to best care for patients living with dementia, so that they were able to respond to their needs appropriately. People had timely access to initial assessment, diagnosis and treatment. However, some staff expressed concerns that some patients were transferred too late at night. Patients told us they felt they could ask questions or raise concerns if the felt they needed to, at any time during their stay. The complaints system was easy to use and posters and leaflets displayed around the community hospitals outlined the procedure. The trust RAG rated the number of complaints relating to community hospitals as green. The RAG rating system classified green as positive or above target and red as below target or negative, etc.

We judged the inpatients service to require improvement in its leadership. There was an organisational vision in place for the integrated care organisation overall. However, a strategy and vision for community inpatients had not been fully developed or communicated to staff. A number of staff felt the merger had gone well, whilst others felt disconnected from the rest of the organisation. This meant that staff did not always know or understand the organisational strategy and their role in achieving it. Risk registers were in place across the community hospitals, which fed into the divisional risk register. Matrons and senior ward staff were not always able to articulate what their top three risks were but were clear about issues in relation to staffing. Lines of accountability including clear responsibility for cascading information upwards to the senior management and downwards to the clinicians and other staff on the front line were not always clear. However, staff were clear about who their local leaders were and found them to be open and approachable. It was identified that there was a lack of clarity between the Trust Executive and the community senior leadership in relation to the use of a community bed status report which incorporated a staffing tool. As such, this identified a gap in assurances regarding safety going back up to the board, in particular in relation to safe staffing and skill mix at night and on escalation wards. While the board recognised that staffing in the community needed to be reviewed, they had not fully understood the shortcomings of the tool used to align staffing levels to patients’ care needs. Staff did not always feel actively engaged so that their views were reflected in the planning and delivery of services. The organisation and community hospitals engaged with the local community to seek feedback in order to shape service and kept the public informed about the changes within the organisation.

Overall services for children, young people and families was rated as requires improvement. We found that community health services for children, young people and families were ‘good’ for caring and ‘’requires improvement’ for safe, effective, responsive and well led.

Our key findings are

• A variety of patient records were kept, the majority of staff used paper records they were generally comprehensive, clear and informative. Some staff had access to electronic record systems but these systems did not link and there was a risk that important information about children could be missed.

• Health visitors and school nurses were working with high levels of need, when covering for colleagues there was no robust system to ensure the level of need matched the capacity of the staff.Staff were not aware of contingency planning to ensure there was adequate caseload cover. There was inadequate administrative support meaning that staff spent inappropriate time on clerical duties.

• Some working environments were inappropriate either as a safety risk for staff or were ill equipped with insufficient computers

• A lack of capacity in the looked after children (LAC) nurse role had been identified as had a shortage of middle grade doctors.

• The trust had identified on the risk register that a large number of guidelines were in need of updating.

• The measurement of outcomes for children was inconsistent across the services.

• Community children’s nurses were not receiving clinical supervision and did not have records of clinical competence.

• Initial health assessments for ‘looked after’ children were not meeting the statutory timescales.

• There was a long waiting list for an assessment to diagnose an autistic spectrum disorder at the Child Development Centre (CDC). At the time of our inspection for those aged 5 to 18 years documentation showed there was a 17 month wait time, this was on the trust’s risk register.

• There was a lack of oversight of the Child Development Centre (CDC) and its future was uncertain. Staff working in the CDC faced challenges in meeting patients’ needs in a timely manner and there was uncertainty over the centre’s future. There were no clear plans on how to address the challenges in the CDC.

• There was a lack of clarity about future roles and the responsibilities for health visitors possibly changing or expanding. There did not appear to have been an assessment of the staff’s competency and capacity to safely meet the needs of a wider remit of children and young people in vulnerable circumstances.

• People spoke highly of the caring and kind staff, they were involved in decisions about their care. Staff were passionate about providing good quality. Clinics were located in places where people could access them.

• Staff felt well supported in their teams but there was a lack of clarity about governance in one of the two provider unit/delivery units that covered these services.

• Business continuity plans were not robust with clear guidance to help staff know when to implement action plans.

• The trust had achieved stage 3 of the Unicef World Health Organisation (WHO) Baby Friendly Breastfeeding initiative and had doubled its uptake of breastfeeding.

Overall we rated the trust as requires improvement for community end of life care services. They required improvement in order to be safe, effective and well-led although were good in relation to being caring and responsive.

• There was poor completion of treatment escalation plans (TEPs), particularly within the community hospitals where more than half of those we reviewed had not been completed in line with trust policy in relation to recording of do not attempt pulmonary resuscitation (DNACPR) decisions.

• Where patients did not have capacity to be involved in decisions about resuscitation we saw inconsistent recording of mental capacity assessments and we did not see best interest discussions with relatives being recorded.

• At Brixham and Totnes community hospitals healthcare assistants were checking controlled drugs and syringe drivers without being trained or competency assessed.

• There was inconsistent end of life care training for registered nursing staff working in the community hospitals with some having received training in the end of life care resources while others had not

• Not every community hospital had end of life care link nurses.

• There was no trust-wide community and acute multi-disciplinary meeting

• There was no end of life care strategy in place that described the priorities for the trust as an integrated organisation, the future structure of services and how they were going to move forward in terms an integrated end of life care service.

However:

• We saw evidence of good local leadership of wards, community nursing teams and the end of life care service.

• There was good use of audit and evidence of learning from incidents being used to improve performance.

• There was a passion and commitment among the trust staff to deliver high quality end of life care. Staff were seen to be caring and compassionate and focused on patient choice and involvement in their care. Relatives and people close to those at the end of life were supported.

• We saw a particular example of outstanding practice in the development of a carers course where people caring for loved ones with life limiting illnesses could access an ongoing support group.

We have rated urgent care services in the minor injuries units as good overall because:

• Openness and transparency about safety was encouraged. Lessons were learned from incidents and communicated widely to support improvement.

• Safeguarding of vulnerable adults and children was well understood and implemented.

• Risks to people who used the department were assessed, monitored, and managed on a day-to-day basis. Staffing levels and skill mix were planned, implemented and reviewed.

• All minor injury units were well maintained and well equipped. However, the servicing and replacement of some equipment was not always up-to-date.

• Care and treatment was planned and delivered in line with current evidence-based guidance and best practice.

• Staff were well qualified, competent and demonstrated the skills required to carry out their roles effectively. They worked collaboratively with multidisciplinary teams from community services and acute services in order to ensure the best outcomes for their patients.

• Feedback from patients and those close to them confirmed that staff were caring and kind. Communication with children and young people was age appropriate and thoughtful.

• Each minor injury unit was easy to access and there was sufficient space for the number of people using them.

• 99.8% of patients were treated, discharged or transferred within four hours during 2015. The average time to treatment was 23 minutes.

• People with dementia or learning disabilities received care and treatment that was sympathetic and knowledgeable.

• It was easy for people to complain or raise a concern and they were taken seriously when they did so.

• The minor injury units had an effective and cohesive leadership team who identified with a strategy of delivering more care and treatment in a community setting.

• Governance arrangements were well structured with risks and quality being regularly monitored and action taken if necessary.

However:

• X-ray services were not always available when patients needed them. At Totnes, Brixham and Paignton the X-ray departments were only open for half days for much of the week. There were no X-ray services at weekends which meant that patients had to go to the emergency department at Torbay if a fracture was suspected.

We rated specialist community mental health services for children and young people (CAMHS) as good because:

• Staff were caring and supportive. Patients, families and carers were satisfied with the service. They said their treatment helped them.
• Patients were assessed within target times of six weeks for a routine referral and could access urgent assessment and treatment if they needed it.
• Care was personalised, holistic and recovery orientated. Patients were given a choice of locations for their treatment appointments to help them feel comfortable.
• Staff had good access to training including training in different kinds of therapy and mandatory training.
• Evidence based therapies recommended by the National Institute for Health and Care Excellence (NICE) were available.
• Patients completed outcome measures throughout their treatment. These were used to understand patients’ difficulties and to ensure patients were getting better. Patients could see graphs of their progress.
• The service actively worked with other agencies in health, social care and education to provide joined up and preventative care and involved those agencies in the redesign of the CAMHS service.
• The service was committed to innovation and aimed to prevent mental health problems in children and young people and reach them sooner when they were unwell.

However

• Waiting times for treatment were long at up to 36 weeks, although there was a clear strategy to bring this down to 18 weeks by the end of March 2016. Patients were not actively monitored to detect potential deterioration in their mental wellbeing or increases in risk whilst they were waiting for treatment.
• Four out of the nine care records we looked at had risk assessments and crisis plans which were not fully completed and updated.
• Patients’ physical health was not consistently checked. When patients were weighed and measured this was not done in a private place.
• The provider was not ensuring staff were adhering to safe lone working practices and there was no fixed alarm system in the building for staff to seek urgent assistance.

We do not currently rate specialist substance misuse services. We found the following areas of good practice:

• There were sufficient staff numbers to meet the needs of people who used the service.

• Interview rooms were sound proof and staff were provided with safety alarms when using interview rooms.

• The service provided comprehensive support for people’s healthcare needs associated with substance misuse. Staff supported people with blood-borne virus testing and vaccination programmes.

• People had access to other medical interventions through the local hospital and GP surgeries. This included electrocardiograms (ECGs) required for all people receiving high doses of methadone, to monitor the effect on their hearts and liver function tests to ensure that people were physically fit enough to undergo the prescribing regimes.

• People could access the service quickly. Staff were assessing people and providing substitute prescriptions within the three week guidelines set by Public Health England.

• Risk was assessed by staff and documented on the electronic records system. Risks were an agenda item and discussed at every team meeting and recorded within the care records. Staff put measures in place to reduce and where possible prevent risks from occurring.

• Staff regularly reviewed people’s recovery plans. People were involved with and had signed their recovery plans.

• Staff discussed discharge plans with people from first assessment. This included asking people how long they wanted to be in treatment so they could plan appropriate treatment goals.

• Doctors and non-medical prescribers followed guidelines for prescribing, as described in the Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007).

• The service took a clear and well laid out approach to use of illegal substances on top of prescribed medicine. This was mentioned in an introductory leaflet and through verbal discussion between clients and staff.

• Staff kept comprehensive records following medical reviews. The records were person-centred and recovery focused, and included an assessment of the person’s prescribing treatment plan.

• Volunteers provided a variety of support to people and were developing ways to engage people with the treatment system.

• The service was flexible and staff saw people in places closer to their home to reduce the need for them to travel to the main office. There were options to be seen out of hours and at the weekend.

• Staff made a concerted effort to engage with and follow up people that did not attend appointments.

• The trust gave staff opportunities for leadership and development across different roles within the service.

• Ninety per cent of staff had completed mandatory training and some training dates had been booked in February 2016.

• All staff had undertaken specialist substance misuse training.

• Staff had received regular supervision and annual appraisal.

• Staff felt supported and spoke highly of the managers. All staff spoke highly of the service manager. The service manager felt supported by the trust.

However, we also found areas the service could improve:

• The fire extinguishers had not been checked since 2014. We raised this with the service manager and the trust carried out immediate checks.

• The ligature audit indicated ligature risks had been removed or replaced, however, there were visible ligature points around the building. These were low risk because the service is a community service but the service should be aware of the risks and have management plans in place. The trust took immediate action and carried out a health and safety audit at Walnut Lodge after we raised this.

• Some staff areas were unclean and in a state of disrepair. For example, the staff toilet had very dusty surfaces and the wall paper was torn in several places.

• The clinic room was left unlocked and staff did not see this as a risk because medicines were kept locked in cupboards and the fridge. However, other items were accessible including needles and the keys to the cupboard and fridge were kept on a shelf in the clinic room.

• Monitoring of liver function tests (LFTs) was not always good. We were told that LFTs were carried out by GPs and they didn’t always get the results back. There was evidence that where the risk was indicated as very high, people were referred to and seen by the liver specialist nurse at Torbay. LFTs had been obtained for high risk clients.

• Risk assessment documentation was not always up to date which meant that it was sometimes difficult to get an immediate view of current risks. However, from speaking with staff, observing team meetings, looking at team meeting minutes, and reviewing the daily electronic care records, it was evident that risk was regularly discussed and reviewed in detail.

The service was outstanding in providing caring and responsive services and good for providing safe, effective and well led services.

Torbay and Southern Devon Health and Care NHS Trust provides health services from 11 community hospitals and community services. During our inspection we visited three locations which provided a dental service:

Castle Circus Health Centre – (also known as the Community Dental Service) provides NHS dental treatment for patients with complex medical histories and patients with learning disabilities. It also provides dental treatment to looked after children.

Brunel Dental Centre – Special care dental service (also known as the Community Dental Service) provides NHS dental treatment for patients with complex medical histories and patients with learning disabilities. It also provides dental treatment to looked after children

Torbay Hospital – Speciality Care Dental Service for the treatment of complex dental problems.

Overall we found dental services provided safe, effective, caring, and responsive and well led care. We observed and heard practitioners were providing an excellent service in the locations with exceptionally responsive, caring compassionate and respectful staff.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practices and sufficient staff available to meet the needs of the patients who visited the clinics for care and treatment.

All the patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion; and effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the locations we visited staff responded to patient’s needs. We found the organisation actively sought the views of patients, their families and carers. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs, at the right time and without delay.

There were elements of outstanding practice at all the locations visited.

We rated community adults service as outstanding because:

• The trust encouraged openness and transparency about incident reporting and incidents were viewed as an learning opporotunity. Staff felt confident in raising concerns and reporting incidents and near misses.

• There were effective handovers during the shifts, to ensure staff managed risks to patients. Urgent visits were allocated quickly to respond to the changing needs of patients.

• Patients were involved in managing their identified risks and risk assessments were proportionate and reviewed regularly.

• There were defined and embedded systems, in place to keep patients safe and safeguarded from abuse.

• Patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

• Patients care was coordinated when a number of different staff were involved in their care and treatment. All relevant staff were involved in the assessing, planning and delivery of patient care and treatment. Staff worked collaboratively to meet patients needs.

• Staff were qualified and had the skills they needed to carry out their roles effectively and their learning were identified. Training to meet these needs was put in place and as well as other training to learn new skills pertinent to their roles.

• Consent to care and treatment was obtained in line with legislation and guidance. Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.

• Patients were supported by all staff in the delivery of their care and treatment. They were treated with dignity and respect.

• Staff anticipated patients’ needs and maintained their privacy and confidentiality at all times.

• The assessed needs of all patients were taken into account when planning and delivering services.

• Patients were able to complain or raise a concern and they were treated with openness and transparency. Their complaint or conern was listened and improvements were made to the quality of the service provided.

• There was an effective and comprehensive governance processes in place to identify, monitor and address current and future risks.

• Senior managers at every level prioritised safe, high quality and compassionate care . All staff felt managers at all levels were approachable and listened to their views and they felt able to report any concerns to them.

However:

• The out of hours community nursing service had difficulty at times in accessing equipment at night as there was central storage facility where all equipment needed was stored and this had led to delays in treatment, for example syringe drivers.

• There were concerns regarding lone working for community nurses in Newton Abbot zone. Between the hours 5pm to 7pm at a weekend as the qualified nurse was alone.

• Appraisal rates for some zones and specialist services were as low as 50%, below trust target.

• Evidence of consent being obtained for procedures was not always clearly documented in the patients’ notes within the outpatients department in Newton Abbot.

• Up to March 2016, the trust was failing to meet the national standard for outpatient activity. The reasons were attributed to higher than expected new patient activity in podiatry and orthotic services, staff vacancies and inability to recruit to these posts quickly.

The service was outstanding in providing caring and responsive services and good for providing safe, effective and well led services.

Torbay and Southern Devon Health and Care NHS Trust provides health services from 11 community hospitals and community services. During our inspection we visited The Speciality Dental Service provision which is as a secondary care dental service located in Torbay Hospital.

Torbay Hospital – Secondary Care Dental Service is for the treatment of complex dental problems which are considered too specialised for the patient’s general dental practitioner.

Overall we found dental services provided safe, effective, caring, responsive and well led care. We observed and heard practitioners were providing an excellent service in the locations with exceptionally caring compassionate and respectful staff.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practices and sufficient staff available to meet the needs of the patients who visited the clinics for care and treatment.

All the feedback we saw demonstrated patients had positive experiences of their care. We saw good examples of care being provided with compassion; and effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At the location we visited staff responded to patient’s needs. We found the organisation actively sought the views of patients, their families and carers. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs, at the right time and without delay.

There were elements of outstanding practice at this location e.g.

• Staff were passionate about working within the service and providing good quality care for patients.

• Patients feedback demonstrated they felt it was an excellent service. We evidenced highly trained and experienced staff with excellent application of knowledge and skills in practice to meet the complex needs of patients treated by the service.