Archived: Northern Devon Healthcare NHS Trust

Updated 12 September 2019

Not used

Updated 12 September 2019

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

We rated trust-wide well-led as requires improvement. This was the same rating as the previous inspection.

Urgent and emergency care was rated as requires improvement overall. We rated effective and caring as good. Effective improved by one rating and caring stayed the same. Safe, responsive and well-led were rated as requires improvement. The rating for responsive went down by one rating, and safe and well-led remained the same.

Maternity was rated as requires improvement overall. We rated caring, responsive and well-led as good. We rated safe and effective as requires improvement. The rating for well-led went up. The ratings for safe, effective, caring and responsive stayed the same.

End of life care was rated as good overall. We rated safe, effective, caring, responsive and well-led as good. This was an improvement of one rating in safe, effective and well-led. The ratings for caring and responsive stayed the same.

Outpatients was rated good overall. We rated safe, effective, caring, and well-led as good. We rated responsive as requires improvement. This was an improvement of two ratings for safe, well-led and the overall core service rating. The ratings for caring and responsive stayed the same. We do not have sufficient evidence to rate effective.

Community inpatients was rated as good overall. We rated effective, caring, responsive and well-led as good. We rated safe as requires improvement. Safe went down by one rating. The ratings for effective, caring, responsive and well-led stayed the same.

Updated 12 September 2019

Updated 12 September 2019

Updated 11 September 2014

The Northern Devon Healthcare NHS Trust provides community healthcare services to a population of around 484,000 and provides services at any one time to approximately 6,000 patients who live in their own homes.  The care and treatment is provided under the regulated activities, including: diagnostics and screening, family planning, nursing care and treatment of disease, disorder and injury.  We visited community teams based in South Molton, Holsworthy, Bideford, Exmouth, Ottery St Mary, Honiton, Tiverton, Exeter, Crediton, Sidmouth and Okehampton.

We spoke with 129 members of staff, including community nurses, occupational and physiotherapists, specialist nurses, managers, healthcare assistants and administrative staff to understand their experiences of working within the trust.

We contacted and spoke with 76 patients and 12 relatives of patients, to seek their views of the service provided to them.

The inspection teams included CQC inspectors, specialist advisers in community nursing, palliative care specialist nurse, rehabilitation therapist, Allied Healthcare professionals, a sexual health nurse, community matrons and a GP.

During the inspection, we looked at patient-care documentation and associated records, observed care in patients’ homes and clinics and spoke with staff and patients individually and as part of groups.

Patients made positive comments about the service provided to them.

Community services for adults provided by Northern Devon Healthcare NHS Trust were judged as good overall.

The services provided safe and effective care and treatment to people who lived in their own homes, or attended clinics run by the trust.  Staff were able to report incidents to the trust and found action was taken to address issues, although they had not always received feedback regarding the outcome.  The community teams promoted the control of infection and followed trust policies to prevent the spread of infection.

Staff were aware of how to report any safeguarding concerns and support was available to them through dedicated members of staff and their managers.

Staffing levels were sufficient to ensure patients received care and treatment in order to meet their assessed care needs, although there were vacancies in some staff teams.  Lone working systems were in place locally to ensure the safety of staff where they worked alone in a department or clinical area.

Identified risks to patients and staff during the provision of community care services were recorded on both local and trust-level risk assessments.  Action had not always been taken promptly to address the risks.

Integrated team working was evident across the area and staff were positive about their roles, both within their local team and across the wider multidisciplinary team.

We observed some areas of outstanding care and treatment during our inspection visit. We found a day service for patients with dementia care needs provided excellent care, support and treatment.  A community nurse-led clinic provided responsive care and treatment to patients who were able to attend the clinic, thus promoting independence and providing good clinical outcomes for patients.  Multidisciplinary team meetings identified care needs for individual patients and ensured these were met by appropriate staff.

Updated 12 September 2019

Our rating of this service stayed the same. We rated it as good because:

• Staff were provided with training in safety systems, processes and practices.
• Systems were in place to ensure staff met the trust target for training compliance.
• Systems, processes and practices kept people safe and safeguarded against abuse.
• Standards of cleanliness and hygiene were maintained and there were reliable systems in place to prevent and protect people from healthcare associated infections.
• Patient’s care and treatment needs were discussed amongst the staff team so that all staff were aware of risks and the patient’s care needs.
• Staffing levels and skill mix of staff were planned and reviewed so that patients received safe care and treatment.
• Staff ensured the proper and safe use of medicines.
• Staff reported incidents and lessons were learned and improvement made when things went wrong.
• Staff worked together as a multi-disciplinary team and had the necessary skills, knowledge and experience to deliver effective care, support and treatment.
• Staff monitored and managed the pain experienced by patients.
• The nutritional and hydration needs of patients were identified, monitored and met.
• Patients were supported to live healthier lives and advice and guidance was provided to help them.
• Consent to care and treatment was sought in line with legislation and guidance.
• Patients were treated with compassion, kindness, dignity and respect.
• Patients and those close to them were provided with emotional support when needed.
• Staff took account of patient’s individual needs, including for patients who lived dementia, learning disability or physical disability.
• Patients could access the right care at the right time within the community hospital.
• Complaints were listened to and taken seriously by the trust.
• The managers had the capacity and capability to deliver high quality sustainable care.
• The vision and strategy formed a base from which to deliver high quality sustainable care to patients and a robust plan to monitor delivery of the care.
• Managers across the community hospital promoted a positive culture that valued and supported staff.
• The trust used a systematic approach to improve the quality of its services and safeguard high standards of care.
• Appropriate and accurate information was available to staff to support their work.
• The trust engaged with and involved patients, the public, staff and external partners to support high quality sustainable services.
• Staff were supported with learning and continuous improvement.

However:

• Maintenance and use of facilities, equipment and premises did not consistently keep people safe. Staff did not consistently carry out appropriate checks on all equipment. A fire exit was blocked at the start of our inspection although staff promptly addressed this when highlighted.
• Risks to patients were assessed and their safety monitored. However, action was not always taken or recorded to evidence patients were supported to stay safe.
• Not all patient records such as risk assessments were available for staff to promptly access when needed. Patient records did not consistently evidence the action staff had taken to ensure appropriate medical care and treatment was provided. Not all care plans were in sufficient detail to direct and guide staff.
• Patient care and treatment outcomes were not monitored and compared to other similar services.
• There were clear processes for managing risks, issues and performance. However, these were not always effective.

Updated 3 November 2015

Overall rating for this core serviceGood O

We previously inspected Northern Devon Healthcare NHS Trust in July 2014 when we rated end of life care overall as good but found that provision of the service in relation to being safe required improvement. At this focused inspection, we reviewed the safety in response to our previous findings. We have rated safety as good.

At our previous inspection we found that Treatment Escalation Plans (TEPs) were not being completed in line with the trust guidelines. TEPs are plans that contain details of a patient’s resuscitation status. For instance whether to be resuscitated or not following a cardiac or respiratory arrest (a heart attack or where a patient has stopped breathing). A new updated version of the treatment escalation plan had been introduced since then and we found the majority were being completed in full.

The trust had introduced new care documentation for the last few days of life, which included risk assessments and plans of care in one booklet. For patients who were near the end of life or receiving palliative care but not in the final days of their life, there was no specific advance plans of care where patient wishes were documented. This could lead to treatment or care the patient did not want or patients’ wishes not being followed.

Staff we spoke with were passionate about end of life care and wanted to provide the best care to patients. Some staff had completed additional training in end of life care and were planning to disseminate this to other staff in their area or ward.

For patients in the community setting, we saw prescribed ‘just in case’ boxes of medication that enabled trained staff to give a single dose of certain medications to treat breakthrough symptoms including pain, nausea and vomiting. This was to enable patients to be comfortable and free from pain and other symptoms until they were reviewed by a GP or their syringe driver was renewed. (A syringe driver is a piece of equipment that administers a controlled dose of drugs automatically.) Staff were trained in the use of syringe drivers and their competence to do so had been checked before they were able to set up or renew syringe drivers.

During our inspection, we spoke with one patient who was using end of life services at home and another who was admitted to a community hospitals and with four relatives. We also spoke with one GP and 24 nursing staff at the community hospitals and community nurses’ bases we visited.

Updated 11 September 2014

Overall rating for this core service

Overall, community end of life services were good. Services were found to be safe, effective, caring and responsive.

Our inspection of end of life community services included visits to community nursing services and community hospitals across a network of 17 community hospitals and nine integrated health and social care community clusters.  At the time of our visit, we saw very few patients who were considered to be at the end of life. 

We saw that patients and their needs were placed at the centre of their care.  There was a high regard for safety and we saw that lessons learned included the sharing and the cascading of information to relevant professional groups across the trust.  We viewed the use of Treatment Escalation Plans (TEP) that highlighted end of life care decisions, including do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions.  We saw that the TEPs we viewed were mostly completed correctly, although staff told us they had experienced some inconsistencies with this and this was supported by the results of an audit we saw.  Inconsistent completion of TEP forms could result in patient decisions about treatment and care being unclear to the staff caring for them.   

We viewed evidence of effective end of life care services with evidence of an end of life care plan being introduced to replace the Liverpool Care Pathway.  End of life link nurses had been introduced to community hospitals to raise the standard and profile of end of life care in community settings. 

Patients, relatives and staff were positive about the services received and we observed staff caring for patients with respect and dignity.  We observed services being delivered through multidisciplinary teams and good partnership working and we saw evidence of responsive care, particularly in relation to rapid discharge home when patients wanted to be cared for in the community at the end of their life.  Staff told us that local leadership of services was good, but that they were not always aware of whom the trust-wide leaders were. However, we viewed plans for increasing trust-wide leadership visibility in community services.