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Torbay Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 10 August 2017

Torbay and South Devon NHS Foundation Trust is an integrated organisation providing acute healthcare services from Torbay Hospital, as well community health services and adult social care. The trust's acute hospital services are run from Torbay Hospital in Torquay. The trust serves a resident population of approximately 375,000, increasing by up to 100,000 at any time during the summer holiday season.

We previously inspected Torbay Hospital in February 2016 and rated the hospital as requires improvement overall.  Following that inspection we rated urgent and emergency care as inadequate, and medical care (including older people's care) as requires improvement.

This inspection was unannounced and took place in May 2017. We inspected emergency and urgent care, and medical care (including older people's care) to review progress made to improve these core services.

We found all the requirement notices issued following our previous inspection for both emergency and urgent care and medical care (including older people's care) had been met. We found significant improvements had been made in both core services.

Our key findings were as follows:

Safe:

  • We rated both core services inspected as requires improvement for safe.
  • Confidential patient records were not always stored securely, leaving them potentially subject to unauthorised access.
  • Completion of safeguarding training often fell below trust targets, which meant staff may not have had the most up-to-date knowledge in order to keep vulnerable people safe.
  • Processes for managing medicines and Patient Group Directions (PGDs) were not always effective. Some medicines were found to be out-of-date, refrigerator temperatures were not always regularly monitored and PGDs were not always signed.
  • We found two fire escape routes on two different wards were cluttered, posing a risk in the event people were required to evacuate the hospital.
  • A significant amount of equipment had no evidence of regular servicing, which meant there was a risk these items could fail or not function correctly.
  • Regular auditing of record-keeping was not always completed.
  • There was a positive incident reporting and learning culture. When things went wrong staff were encouraged and felt able to report incidents. Incident investigations were used as opportunities to learn and improve services.
  • Staffing levels had been reviewed using national tools and the numbers of staff on duty kept people safe most of the time. Consultant cover had been reviewed and changes to rotas had improved availability of consultants.

Effective:

  • We rated both core services as good for effective.
  • Protocols and pathways were evidence-based and followed national guidelines. Compliance with these was regularly audited and areas for improvement were identified and developed.
  • Multidisciplinary working had improved and was working well across the two core services.
  • Staff had a good understanding of the Mental Capacity Act 2005, including consent.
  • Regular training opportunities were made available to staff to ensure they were competent to carry out their roles.
  • Discharge summaries were not completed consistently, which meant other healthcare professionals, for example GPs, were not always aware of their patient's full medical history and ongoing plans.

Caring:

  • We rated both core services as good for caring.
  • Feedback we received from patients and relatives was consistently positive.
  • Patients and their relatives were treated with compassion, involved in discussions about their care and treated by staff with dignity and respect.
  • A small number of patients reported delays in staff responding to call bells.

Responsive:

  • We rated both core services as good for responsive.
  • Patient flow through the hospital had been improved and weekend discharges increased. Work was ongoing with partners and stakeholders to identify further strategies that could help improve patient flow.
  • The trust's escalation process for responding to severe pressures and increased demand had been overhauled and provided much improved communication and joint working across the healthcare system.
  • Complaints were responded to promptly and areas for improvement identified within investigations.
  • Performance against national standards was consistently high. For example, the trust performed better than the England average for the numbers of patients discharged, admitted or transferred from the emergency department within four hours (although this was slightly below the standard of 95%).
  • The emergency department had taken limited steps to support patients living with dementia.
  • A lack of space in the emergency department prevented patients who were waiting in the corridor from receiving adequate privacy.

Well-led:

  • We rated both core services as good for well-led.
  • The improvements that had been delivered were testament to the leadership and staff engagement.
  • Improvement plans and strategies had been developed with staff and were focused on delivering high-quality care.
  • Strong governance processes were in place and these helped drive improvement. Risks were understood, regularly discussed and actions put in place to reduce the risks where possible.
  • Staff spoke of an open, supportive culture and felt able to raise concerns with the leadership teams.
  • Mortality and morbidity reviews did not always take place regularly.
  • Some staff felt divisional leaders were not visible at service level.

We saw some areas of outstanding practice, including:

  • The trust had fully addressed the requirement notices from our inspection in February 2016. In particular we saw significant improvements had been made in the emergency department in terms of safety, quality, performance and patient experience. The department had streamlined processes and introduced a system of triage and rapid assessment, which improved safety, efficiency and patient flow.

  • We saw exceptional multidisciplinary working between the whole healthcare system in response to the trust's escalation process

  • A newly created mental health assessment room provided a safe, welcoming and calming environment, located away from the hustle and bustle of the busy emergency department.
  • There was a separate children's area in the emergency department, which was secure and was not overlooked by adult patients and visitors. This area was staffed by a dedicated trained paediatric nurse workforce. In addition, adult trained nurses received paediatric training as part of their induction and mandatory training.
  • There were cooperative and supportive relationships amongst staff in the emergency department. We observed excellent teamwork, particularly when the department was under pressure.
  • Service improvement was everybody's responsibility in the emergency department. Staff had been engaged in the improvement journey and had been encouraged to participate in service design and to make suggestions for improvement.
  • There was a great sense of pride amongst staff in the emergency department. They contrasted their feelings of despondency at the time of our previous inspection, with feelings of pride and optimism in the present.

However, there were also areas where the trust needed to make improvements.

Importantly, the trust must:

  • Ensure the secure storage of confidential patient records in all areas.
  • Ensure all medical equipment in the emergency department is serviced in accordance with service schedules.

In addition the trust should:

  • Ensure signatures on nursing, medical and prescription records are legible.
  • Ensure risk assessments are consistently completed.
  • Ensure resuscitation trolleys and emergency equipment are checked daily across all medical areas in line with trust policies.
  • Ensure systems aimed at ensuring the safety of medicines are effective, for example the checking of refrigerator temperatures and expiry dates.
  • Consider how staff can be better included in consultation processes where service changes may affect them.
  • Ensure mandatory training targets, including adult and child safeguarding, are consistently met.
  • Ensure fire escape routes are kept free from clutter and obstructions.
  • Ensure all staff comply with minimum training attainment levels.
  • Ensure appraisals for nurses are completed.
  • Ensure that regular mortality and morbidity meetings take place and related issues are included in emergency department clinical governance meetings.
  • Ensure that appropriate and regular audit takes place.
  • Ensure staff to patient ratios in the emergency department are appropriate to keep patients safe at all times.
  • Ensure that intentional rounding frequency where critical observatuions are noted follow guidelines for all patients.
  • Ensure patient confidentiality and privacy is protected in the emergency department.
  • Ensure children waiting in the main waiting room of the emergency department are provided adequate privacy away from waiting adults.
  • Ensure resuscitation trollies and equipment in the emergency department are readily available and kept clean.
  • Ensure the emergency department sluice is secured and that flammable products are not accessible to unauthorised persons.
  • Ensure Patient Group Directions used in the emergency department are signed by staff and counter-signed by managers.
  • Provide training for emergency department receptionists to support the recognition of red flag presentations.
  • Ensure access to major incident equipment in the emergency department is not obstructed.
  • Ensure the bereavement (viewing) room in the emergency department Is an appropriate environment.
  • Review the location and visibility of surgical waste bins that are visible from the emergency department relatives' room.
  • Review the steps to support people in vulnerable circumstances, such as people living with dementia, or people with a learning disability are adequate.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 7 June 2016

Effective

Requires improvement

Updated 7 June 2016

Caring

Good

Updated 7 June 2016

Responsive

Requires improvement

Updated 7 June 2016

Well-led

Requires improvement

Updated 7 June 2016

Checks on specific services

Maternity and gynaecology

Good

Updated 7 June 2016

We rated maternity and gynaecology services good overall;

  • There were good staffing levels within the maternity and gynaecology unit. There was sufficient consultant cover of the labour ward and consultants came into the unit out of hours when requested.
  • There was a positive culture around reporting and investigating incidents. Learning from incidents was shared and action plans were in place to ensure new learning was embedded in practice. Staff at all levels attended required training
  • Women were risk assessed throughout their pregnancy and labour. Good communication between the integrated community and hospital midwives meant that information about risks was passed on to the right people at the right time.
  • Clinical areas were clean and tidy and regular audits of infection control procedures was ongoing.
  • Adult and neonatal emergency resuscitation equipment was checked regularly and a record maintained to show it had been checked. The exception was labour ward where recording the checks done had been inconsistent. This was explained by the fact a new book had been introduced and at times had been locked in the resuscitation trolley, therefore becoming unavailable to staff.
  • Guidelines, policies and procedures were reviewed regularly to incorporate updated national guidance. They were available to staff at all times.

  • Patients had access to pain control at all times.

  • Data was collected to assess outcomes for women using the services.

  • Supervisors of midwives were at the required numbers and available to support midwives when required. There was a preceptorship programme in place to support and develop newly qualified midwives.

  • We saw multidisciplinary working well internally and externally. Midwives, nurses and medical staff spoke passionately about the women and babies being at the centre of everything they did.

  • Patients were encouraged and supported to be involved in making decisions about their care and treatment.

  • Feedback from people who were using the service was overwhelmingly positive. We saw staff treating people with respect and dignity. Where staff felt dignity was compromised, due to the layout of the environment, every care was taken to ensure their dignity and privacy was maintained. People’s choices and preferences were always a priority when planning and delivering care and support.

  • Emotional support was provided via counselling services, the on-site perinatal mental health team and midwives trained in caring for women and their families who had suffered a bereavement.

  • There was a positive culture around asking for and dealing with feedback from patients.
  • The gynaecology service had introduced enhanced recovery to improve the flow of patients through the service. The maternity unit offered a day assessment unit facility Monday to Friday until 5pm. Women then had to go to the labour ward. To reduce the amount of women being sent to labour ward the maternity service was looking into longer opening hours for the day assessment unit. Ante natal clinics were held in GP surgeries or health centres to allow women to access services closer to where they lived.

  • There was a public health midwife who worked with people who may want to stop smoking, misuse drugs and alcohol or were subject to domestic violence. There was an on-site perinatal mental health team providing support to women who had mental health conditions.

  • There were systems in place to make reasonable adjustments for patients living with learning disability or physical disabilities.

  • The maternity and gynaecology units took a positive approach to concerns or complaints raised. Any learning was shared with the relevant teams and audits in place to ensure new learning had been embedded in practice.
  • Staff felt very supported by local and trust wide management. There was an open culture with all staff engaged in ideas about how the service could be improved. Public engagement was encouraged with opportunities to feedback through the NHS Friends and Family test and via social media pages relevant to maternity and gynaecology.

  • Governance and audit were embedded in practice with staff reporting systems that provided feedback and as a result improvements to the service were made.

  • We were given examples of innovative practice that showed staff were always looking to improve the way they delivered the services offered.

However;

  • Though records seen at the time of inspection were fully completed, internal trust audits had noted that records were not always fully completed.

  • The Day Assessment Unit was run by midwives with maternity care assistants (HCA) to support them.  There were two midwives twice a week with no HCA support and the other three days there was one midwife and one HCA. It was sometimes very busy meaning women sometimes had to wait for a long period of time. After the unit closed at 5pm all women who needed to be seen were asked to attend labour ward which put added pressure on staff on duty. There was no data available to show how many women had to attend the labour ward when the maternity assessment unit was closed.
  • There were issues with newborn blood spot screening samples (heel prick test to test for a range of rare but serious health conditions) as a significant number were rejected when they reached the testing centre. Some were because the post had not reached the testing laboratory in the timescale and some were due to poor samples. This resulted in the baby having to undergo another heel prick test which could be distressing to the baby and the mother. The matron said work was underway to improve the rate of rejection. The trust were looking at potential ways to get the samples to the laboratory without using the normal postal system and ensuring that all midwives were competent in taking  that blood samples.

Medical care (including older people’s care)

Good

Updated 10 August 2017

We found the trust had addressed the requirement notices from our inspection in February 2016 and had made improvements in the effective, responsive and well-led domains. These three domains have changed from requires improvement to good. We still had some concerns around the safety of the service and this domain continues to be rated as requires improvement.

Overall we rated medical care as good because:

  • Recent reconfiguration of consultant working rotas had resulted in improved availability of senior physicians at the weekend.
  • There was effective and consistent use of evidence based practices for patients in the medicine division.
  • Multidisciplinary working was truly embedded throughout the division, both internally and externally to the hospital. This was particularly evident in the management of an OPEL four alert.
  • Patients said staff were caring and compassionate, treated them with dignity and respect, and as an individual.
  • Staff were skilled to be able to communicate well with patients and keep them informed of what was happening and involved in their care.
  • Staff had knowledge of patients’ circumstances and the impact their health had on them and their families.
  • The division consistently met targets for senior review of acutely admitted patients both in and out of hours.
  • A twice daily multidisciplinary meeting steered patient care and ensured actions were completed to advance diagnosis and treatment.
  • The division worked closely with community based colleagues to ensure an efficient and safe step down process was in place for discharged patients.
  • Emergency admissions units were used effectively to admit, and assess patients in a timely way and worked effectively with the emergency department.
  • There was a focus on ensuring key messages from the governance team reached front line staff, and staff had a broad understanding of the direction of the medicine division.
  • Staff felt connected to their line managers, able to raise concerns and make suggestions.
  • A supportive and open culture was evident throughout the areas we visited.

However:

  • The environment on many of the medical inpatient wards was sub-optimal with cluttered conditions that could impact on the safety of vulnerable patients.
  • Confidential patient records were not kept securely; records were stored on open shelves in the ward areas.
  • Risk assessments were not always completed comprehensively, or signed legibly by nursing staff. Medical records and prescription charts were only signed legibly in two out of the 27 sets of records we looked at.
  • Completion of safeguarding adults training at level three regularly fell below trust targets.
  • Data collated showing the completion of discharge summaries demonstrated a poor performance against trust targets.
  • Day rooms on the care of the elderly wards were not being used by patients. On Simpson ward the day room was very unappealing and sparse.
  • Patients with dementia were not always cared for in line with national guidance from the Alzheimer's society. Performance against the dementia FIND targets fell substantially below expected levels.FIND targets describe the national requirement to find, assess and refer 90% of patients with dementia within 72 hours of admission.
  • Staff felt poorly informed about the plans for acute bed closures and this caused anxiety and uncertainty in many staff we spoke with.

Patient transport services (PTS)

Outstanding

Updated 7 June 2016

Urgent and emergency services (A&E)

Good

Updated 10 August 2017

We found the trust had addressed the requirement notices from our inspection in February 2016 and had made significant improvements in the effective, responsive and well-led domains. These three domains have changed from inadequate to good. Although there were also improvements in safe, we still had some concerns around the safety of the service. Safe has therefore changed from inadequate to requires improvement.

We have rated this service as good overall because:

  • We saw significant sustained improvements had been made in the emergency department since our last inspection in terms of safety, quality, performance and patient experience and environment.
  • The department had streamlined processes and introduced a system of triage and rapid assessment, which improved patient safety, efficiency and patient flow. The department was working collaboratively with others to identify system-wide strategies to improve patient flow.
  • Physical improvements to the department included the creation of a triage pod in the main waiting area in minors, which enabled the triage nurse to view the waiting room. A secure children’s department had been created, which was not overlooked by adult visitors, staffed by an appropriately qualified workforce.
  • A mental health assessment room had been created, which provided a safe and calming space for patients in mental health crisis.
  • Staffing had been increased with greater consultant presence in the department. The nursing staff establishment had also been increased to improve safety in the resuscitation area and to support the new triage and rapid assessment processes. A band seven nurse coordinator had been employed to manage patient flow and escalation.
  • Escalation processes had been improved and real time information was regularly shared with the bed management team and the rest of the hospital to improve shared ownership of patient flow.
  • There was a range of recognised treatment protocols and care pathways. Performance in national audits was mostly in line with other trusts nationally. There was evidence that audit was used to improve performance, for example in the treatment of sepsis.
  • Nursing and medical staff told us they felt well supported with regular teaching.
  • Care was delivered in a coordinated way with support from specialist teams and services, such as the stroke team.
  • Feedback from patients and relatives was consistently positive. They told us staff were caring and compassionate, treated them with dignity and respect, and involved them in decisions.
  • When patients experienced pain or discomfort, staff responded in a timely and appropriate way.
  • Staff received training in the Mental Capacity Act 2005 and consent as part of their mandatory safeguarding training. Most staff demonstrated a good understanding of the legislation.
  • Staff had easy access to relevant patient information which was updated as required.
  • The trust was meeting the national standard and performed better than the England average in relation to the standard which requires that patients wait 60 minutes or less from their time of arrival to the time their treatment begins.
  • People’s complaints and concerns were listened to and responded to promptly. We saw evidence of learning and improvement following complaints.
  • There was a detailed improvement plan in place with clear milestones and accountability for actions.
  • There were effective governance arrangements in place. Risks were understood, regularly discussed and actions taken to mitigate them.
  • There were cooperative and supportive relationships among staff. We observed excellent teamwork, particularly when the department was under pressure.
  • Service improvement was everybody’s responsibility. Staff had been engaged in the improvement journey and had been encouraged to participate in service re-design and make suggestions for improvement.

However:

  • Not all staff had received recent training on the major incident plan and not all medical staff were in date with safeguarding training or mandatory training overall.
  • The emergency department was not designed to accommodate the number of patients who attended the department and sometimes there was not the physical space to accommodate all patients in a safe and appropriate environment.
  • There was no formal audit relating to records standards, although five patient records were checked daily for evidence of intentional rounding.
  • Mortality and morbidity meetings were not taking place regularly and the most recent clinical governance meetings for the emergency department held 14 March and 18 April 2017 did not include discussion regarding mortality and morbidity.
  • An inventory and service history of all medical equipment showed there was a significant amount of essential equipment which had no records of service or where a service was overdue.
  • Staffing levels in majors were planned to provide a registered nurse to patient ratio of between one to four and one to six. When all cubicles were full and patients queued in the corridor, staff were required to care for up to eight patients.
  • There was limited waiting space in the children’s department which meant some children had to wait in the main waiting room, overlooked by waiting adults.
  • Patients who queued in the corridor were afforded little privacy.
  • The unplanned emergency department re-attendance rate within seven days was generally worse than the England average and the national standard of 5%.
  • Some patients spent too long in the emergency department because they were waiting for an inpatient bed to become available. Lack of patient flow within the hospital and in the wider community created a bottleneck in the emergency department, causing crowding.

Surgery

Good

Updated 7 June 2016

Overall we rated surgical services at Torbay and South Devon NHS Foundation Trust to be good because:

  • There was a strong culture of incident reporting in the hospital which fed into the governance and management of risk. Managers had good oversight of the risks within the surgical division and risk assessments, action plans, and risk registers were detailed and used as an active tool to manage risk.
  • There was a strong culture of evidence based practice which was reflected in patient outcomes. There were good results for national audits and they performed well nationally for surgery completed in the day surgery unit.
  • Feedback about the care received was consistently positive and we saw good examples of interactions between staff and patients. Volunteers played a key role in the care of patient by completing regular questionnaires and auctioning changes to improve their experience.
  • Patients living with dementia or learning difficulties had their specific care needs met. Patients we spoke with were complimentary about the staff and felt that their needs were being met.
  • We found that local leadership was strong, even when under pressure from the demand of the service. Leaders led by example and were well respected by their peers.
  • The use of technology, such as virtual reality headsets, to learn from never events, provided staff with an engaging experience to improve their knowledge and skills.

However:

  • We found that due to capacity issues within the hospital patients were waiting too long for their operations. However, there were actions to manage the risks to these patients and that work was being done with the community teams to reduce the demand of the service.
  • We also found that during times of escalation, patients without MRSA confirmed status were being put on wards with MRSA negative patients. This compromised the status of all patients on this ward.
  • Day to day risks to patients, such as regular assessments, was not always completed. These included venous thromboembolism assessments. We also found that there was some complacency around the checking of resuscitation trolleys.

Intensive/critical care

Good

Updated 7 June 2016

We have judged the overall critical care service to be good. The safety, effectiveness, responsiveness and leadership of the service were all good. Caring was outstanding.

  • Patients were kept safe from avoidable harm. Staff worked in an open and honest culture that encouraged incident reporting and learning. Generally good levels of nursing, medical and allied healthcare professional staffing ensured patients received care care. Staff adhered to infection prevention and control policies and protocols.
  • Treatment by staff was delivered in accordance with best practice and recognised national guidelines. There was a holistic and multidisciplinary approach to assessing and planning care and treatment. Patients’ needs were comprehensively assessed and outcomes were recorded and monitored. Staff were skilled, experienced and worked as part of an effective multidisciplinary team.
  • Patients were truly respected and valued as individuals. Feedback from people who had used the service, including patients and their families, had been overwhelmingly positive. Staff went above and beyond their usual duties to ensure patients experienced compassionate care and that care promoted dignity. Innovative support for patients was encouraged and valued by staff, patients and visitors.
  • The critical care service responded well to patients’ needs. Patients were treated as individuals, and there were strong link nurse roles for all aspects of patient need. There were few complaints about the department, but where a complaint was received it was dealt with in a timely and compassionate way.
  • There was a clear vision and strategy, with staff being actively involved in the development and delivery. Staff, patients and their families were actively engaged with to identify areas of good practice, as well as areas that could be improved. There was a high level of staff satisfaction in a supportive, open ‘no-blame’ culture. The leadership drove improvement and staff were accountable for delivering change. Innovation and improvement were celebrated and encouraged.

However:

  • The unit did not meet current standards for a modern critical care unit and had been recognised by the trust as not being fit for purpose. However, staff worked well within the environment to keep patients safe from avoidable harm and the building of a brand new unit had started.
  • Staff had alimited understanding of the requirements of the Mental Capacity Act 2005, and the Deprivation of Liberty Safeguards (DoLS).We could not be assured that patients who required an authorisation under DoLS were having this requested by the unit.
  • Bed pressures in the rest of the hospital affected timely discharges from the unit, but the numbers of these were below (better than) the NHS national average. Elective (planned) surgery was impacted on by bed availability in critical care. There were limited facilities for visitors and the unit did not meet the modern critical care building standards. However, a new critical care unit was being built and once opened would provide much improved facilities.
  • Governance arrangements required some improvement. In particular a holistic formal review of safety information on a more regular basis was needed, as was the regular review of mortality.

Services for children & young people

Good

Updated 7 June 2016

We rated services for children and young people as good overall.

  • There was a clear vision and overall strategy for children’s and young people’s services. The service provided effective and responsive planned and emergency care and support to children and young people and their families. People who used the service told us they felt safe.
  • We found without exception, staff at all levels were caring and supportive and keen to do the best job they could. Children and young people were placed at the heart of care and we saw many examples of where staff had gone ‘the extra mile’.
  • We found paediatric services were well-led at local and unit level. Staff reported they felt engaged with the senior team in paediatrics and across Child Health.
  • There was a clear governance and audit framework in place and staff felt able to raise issues and concerns with their local and senior managers. Staff said they were listened to and their concerns were understood.
  • There were good examples of innovative practice. For example, the short stay paediatric assessment unit and the high dependency unit, dedicated child appropriate services in outpatients, involvement of children and young people in consultant interviews and development of paediatric outpatient services who delivered children and young people’s medicines to their homes.
  • Parents and children spoke highly of the service and we saw extensive examples of positive feedback and observed many examples of compassionate child focused care during our inspection.

However, some aspects of the service did not assure us that children and young people were always 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

  • There were delays in accessing the Children’s and Adolescents Mental Health Services (CAMHS), particularly out of hours and at weekends. This meant that children, young people and staff were vulnerable whilst in the hospital setting. There had been an increase in the number of admissions to the ward by young people with mental health issues and a corresponding rise in the number of reported incidents. Steps were being taken by the trust and clinical commissioning group to address this.
  • Access to the treatment room on the paediatric ward was via the medicine storage and preparation facility. This compromised children’s safety and could cause distress to children and young people in the vicinity. Staff recognised the problem and were acting on it.
  • Staffing levels on Louisa Cary Ward were often below the recommended guidance (RCN 2013) particularly at night. The organisation had taken action to mitigate the risks through comprehensive skill mix reviews.

End of life care

Requires improvement

Updated 7 June 2016

We have rated end of life care as requires improvement overall because:

Safety and well-led required improvement, and effective, caring and responsive was good.

  • It was not clear how the trust learned all lessons from incidents and what improvements were made in end of life care.
  • We were not assured that incidents in end of life care were being monitored effectively.

  • There was inconsistent completion of patients’ records.
  • We found there were shortfalls in the frequency of recording the monitoring of the syringe drivers for some patients. This, coupled with inconsistent staff awareness of the policy, could have put patients at risk.
  • The mortuary were using temporary fridges on a permanent basis and without effective temperature monitoring.
  • There was not a coherent strategy identified and in place to deliver the vision staff had for end of life care as an integrated organisation. How the next step to an integrated end of life care service would happen was not clear.
  • We were told there were no risks recorded for end of life or palliative care. In addition, actual risk that existed in a number of action plans were not on a local or corporate risk register. For example, issues in the mortuary raised during the inspection.
  • We saw that not all of patients’ spiritual, religious, psychological and social needs were taken into account in patient records.

However:

  • Staff were aware of how to report incidents and their responsibility to be open and transparent.
  • Anticipatory medicines were always available and patients being discharged home had their medicines provided promptly.
  • There was a good level of consultant cover for the end of life service and out of hours.
  • There were processes in place to assess and respond to patient risk.
  • There was no evidence that patients had had treatment against their wishes. There was good documenting of a patients ability to eat and drink in the last 24 hours of life and medicines were reviewed in the last hours of life.
  • The majority of patients had a treatment escalation plan including a resuscitation decision, which had been discussed with the patient and/or family.
  • Compassionate care was provided to patients who were treated with respect and dignity by staff. We saw that patients and those close to them were treated with kindness, dignity, respect and compassion while they received care and treatment.
  • Patients and those close to them were involved as partners in care at end of life. Staff communicated with people so that they understood their care, treatment and condition.
  • Staff we spoke with had a good understanding of the impact that a person’s care, treatment or condition might have on their wellbeing and on those close to them.
  • The results of the national care of the dying audit published in March 2016 showed that for the quality indicators for care the trust scored significantly higher than the national average.
  • The hospital specialist palliative care team monitored the numbers of patients who were at end of life on wards through a system of gold stars on ward interactive boards. In November 2015, 62 of 77 (81%) of predictable deaths were recognised and flagged with a gold star so that relevant staff were aware of end of life care needs.
  • Bereavement officers had recently reduced the time needed to make death certificates available.
  • Leaders in end of life care we spoke with had the skills, knowledge, experience and integrity that was needed.
  • Staff we spoke with had a vision to provide quality, safe end of life care at all levels of leadership and improve upon that care.

Outpatients

Requires improvement

Updated 7 June 2016

Torbay and South Devon Foundation Trust outpatient and diagnostic services were over all rated as requires improvement, although there were many areas of good practice.

  • The systems in place for the prevention of healthcare associated infections, including hand hygiene, were not being followed throughout the whole outpatient and diagnostic imaging department.
  • Systems were in place for the safe administration and storage of medicines, but recording and monitoring of fridge temperatures used for the storage of medicines was not consistent in the outpatients department and there were no records of stock rotation in some areas.
  • Infection prevention and control protocols were not being followed in dermatology who carried out minor surgical procedures in rooms that were not adequately ventilated or maintained with visibly dirty air vents and dusty surfaces. We did not see evidence of any cleaning logs or records of emergency oxygen checks.
  • The design, maintenance and use of facilities and premises did not keep people safe at all times. Lots of small concealed waiting areas throughout outpatients and diagnostic imaging meant staff could not observe patients waiting in their departments.
  • Aging and unsafe equipment was preventing staff from providing safe and effective services in trauma and orthopaedics, ultrasound and dietetics, however, this was being addressed in the future capital funding project.
  • External training courses were available to some staff, but not all, and in some departments, staff were carrying out specialist procedures without formal qualifications, and were starting to train other staff in those procedures.
  • Staff were very competent in their roles, and we saw National Institute of Health and Care Excellence (NICE) guidelines were embedded in policies throughout many clinics. However, we saw patients called for follow-up mammograms at one, three and five years, which is not in line with best practice, and there was no metastatic breast care nurse in post, but there were triple assessment clinics in breast care for symptomatic breast referrals.
  • Staff struggled to maintain patient privacy and confidentiality in the physiotherapy and diagnostic imaging departments, mainly due to the lack of space, and design of the departments.
  • Staff told us in some outpatient clinics, chaperones were only provided in some clinics if patients asked for them.
  • We found that due to a follow up backlog, and the capacity of clinics, people were frequently not able to access services in a timely way for follow up appointments, however, the hospital was meeting 96% of its referral to treatment targets and consistently met cancer waits across all specialties.
  • The hospital identified a problem with the surgical follow up outpatients booking system, which missed patients off follow up lists. The hospital investigated, and changed procedures to prevent it happening again. This was also the case in ophthalmology.
  • The hospital appointment cancellation rate was 9%, and the DNA rate was 12%, which were both above the England average, however, no analysis of the reasons for this had been done.
  • Service plans were reliant on increasing staffing, especially at consultant level; however, plans were in place to increase clinic facilities throughout outpatients, to help meet increasing service demands.
  • There were governance processes in place, but these were inconsistent throughout outpatients and diagnostic imaging.
  • Dermatology services were split over two locations, and the services based in general outpatients were confused as to who was responsible for the day-to-day running of the service. However, oncology staff had regular multi-disciplinary team (MDT) governance meetings, and we saw evidence of shared learning available in an operational policy folder.
  • The dietetics department had raised the issue of the lack of an adult eating disorders service to the Clinical Commissioning group (CCG), and were monitoring its progress.
  • Not all staff felt supported by their immediate managers and said some managers were not visible to their teams. Some teams did not have an overall manager, and senior staff were not very supportive or visible. However, medical records staff felt much supported by senior managers, and were very proud of their clinical engagement in their projects.

However;

  • We saw detailed monitoring and analysis of patient outcomes in the Physiotherapy department.
  • Seven-day services were established as part of a normal working week in some specialities, but not in others, because capacity was meeting the current demand.
  • Diagnostic imaging reported the lowest report turnaround times in a recent benchmarking exercise of 78 departments in England.
  • Feedback from patients and their families was very positive and described staff as helpful, efficient and polite, and we saw genuine compassionate care where patients were spoken to patiently, kindly and politely. We saw carers and relatives actively involved in decision-making.
  • The Friends and Family Test produced good results, and 96% of patients who responded recommended the outpatients department at Torbay Hospital. .

  • The radiology department turned 93-99.9% of around within one week for all imaging modalities, which improved inpatient report turnaround times.
  • The physiotherapy service provided a direct referral system, with the majority of patients receiving appointments within 72 hours, with no need for GP involvement, and a virtual triage system in fracture clinic had reduced the number of patients called back to fracture clinic unnecessarily by 15%.
  • Oncology provided a delivery service for some types of oral chemotherapy, which meant some patients did not have to attend hospital appointments regularly.
  • We saw evidence that complaints were being discussed both in department and at monthly ‘learning from complaints’ meetings, and we saw evidence of shared learning.
  • The majority of staff we spoke with felt the culture was open and that staff strived to make sure the experience for the patients was outstanding in line with the trusts vision and values.