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Inspection Summary


Overall summary & rating

Good

Updated 17 May 2018

For a summary of our findings, see the ‘What we found’ section of this report.

Inspection areas

Safe

Requires improvement

Updated 17 May 2018

Effective

Good

Updated 17 May 2018

Caring

Good

Updated 17 May 2018

Responsive

Good

Updated 17 May 2018

Well-led

Good

Updated 17 May 2018

Checks on specific services

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.

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.

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.

End of life care

Good

Updated 17 May 2018

Staff providing end of life care included ward nurses and doctors, the chaplaincy, ward housekeepers, porters, administrative staff and allied health professionals. End of life care was also provided by a hospital specialist palliative care team and cancer nurse specialists for patients needing difficult symptom management. A palliative care service was provided by the trust to support the management of pain and other symptoms and provide psychological, social and spiritual support. The objective of the palliative care service was to achieve the best quality of life for patients and their families. Support was provided to help patients live as normal routine as possible until death and to offer support to help the family cope during the patient’s illness and in their own bereavement.

Our rating of this service improved. We rated it as good because:

  • End of life care at Torbay hospital had become a more integrated service which had seen significant improvement of the care provided to its patients nearing their end of life.
  • Since our previous inspection a more comprehensive audit programme had been undertaken and from the results we could see where change had been made leading to improvements.

However:

  • There were still areas that remained an issue, such as the recording and sharing of spiritual needs and the lack of care planning. The trust had identified these as areas needing to improve, however actions taken so far had not been sufficient to address them.

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.

Patient transport services

Outstanding

Updated 7 June 2016

Urgent and emergency services

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.

Maternity

Requires improvement

Updated 17 May 2018

The Care Quality Commission last inspected the maternity service as part of a maternity and gynaecology inspection, the report being published in June 2016. The rating for maternity and gynaecology service was good overall. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated this service as requires improvement because:

  • Not all maternity staff had completed mandatory training including for safeguarding. We were concerned that the lead midwife for safeguarding and one of the midwifery matrons who was the nominated individual for safeguarding for the trust had only completed safeguarding training to level three. This did not comply with national recommendations.
  • Throughout the maternity services, improvements were required to demonstrate that infection control policy and audits of medicines and equipment was fully complied with.
  • There was inconsistency in records to demonstrate all policy and documentation had been completed regarding women’s risks of deterioration, particularly with the use of maternal early obstetric warning score (MEOWS) assessments. The use of MEOWS was also significant with regard to post-operative care and supporting women with known high (level two) medical care needs.
  • Many of the midwifery staff we spoke with about culture, leadership and support described a feeling of disconnection between senior midwives (in specialist roles and above) and others. This had led to midwives reporting they did not always feel fully valued and supported.
  • There was inconsistency in how some governance information had been reviewed, managed and disseminated. Learning from a review of still births during 2017 had been given priority and was understood by all staff. Other governance information was less well managed and shared. This included the maintenance of a quality dashboard and how information was used to inform ongoing safety and quality performance issues.
  • There was no audit evidence to confirm the World Health Organisation (WHO) surgical safety checklist had been completed with all obstetric surgeries.
  • The majority of serious incidents which had required a root cause analysis (in depth) investigation had been completed by one or two people with no external review processes built in. This meant there was less opportunity for debate and challenge and controls on any bias.

However:

  • The mandatory emergency multidisciplinary obstetric skills and drills training (PROMPT- PRactical Obstetric Multi-Professional Training) was valued by staff. Staff confirmed paramedic staff were invited to complete placements on the delivery suite and to attend the PROMPT. Paramedic staff valued the learning and experience which supported their emergency response roles.
  • There was evidence of established positive and effective multidisciplinary working within the maternity service. Midwives, midwifery healthcare assistants, doctors and sonographers all reported constructive multidisciplinary working. Staff said relationships were supportive and communication was open and honest. Midwives told us they felt valued and respected by medical staff.
  • All maternity staff had the skills and competencies to work in all areas of clinical practice in the hospital or community. The midwives worked as part of an established, integrated system which supported the maintenance and development of clinical skills. Apart from a small number of core staff, the majority of midwives were rostered to work where it was anticipated patient needs would be highest within the community or hospital.

Outpatients

Good

Updated 17 May 2018

The Care Quality Commission last inspected the outpatients service as part of an outpatients and diagnostic imaging inspection, the report being published in June 2016. The rating for outpatients and diagnostic imaging was requires improvement overall, with caring being rated as good. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated this service as good because:

  • Staff were able to speak knowledgeably about their responsibilities to safeguard children and adults.
  • All outpatients departments, apart from the fracture clinic, were visibly clean and tidy in all of the areas we visited.
  • Most risks around the design, maintenance and use of facilities and premises had been addressed and managed since the last inspection.
  • Medicines were managed safely.
  • Staff had a good understanding of incidents and felt confident to report them. When an incident was reported it was investigated well and learning shared and implemented.
  • Care, treatment and support were delivered in line with legislation, standards and evidence based guidelines throughout the outpatient service.
  • There were various wellbeing services available to patients which were provided by the trust to allow patients to manage their own health effectively.
  • Processes and practices were in line with the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • All patients and those close to them consistently described the positive caring and supportive attitudes of staff and how they went above and beyond what they expected in such a busy working environment.
  • Staff were able to adapt the care they provided based on information on patients’ personal and social needs.
  • Staff we spoke with understood the impact that a calm and supportive attitude had on patients facing a diagnosis of life altering illnesses and diseases such as cancer. There was supportive care provided to patients to help them adapt to life after diagnosis.
  • Services were delivered in a way that met the needs of the local population. They were fully integrated in multi-organisational plans for Devon to ensure patients’ needs were met.
  • Clinics were changing pathways to ensure that they were as efficient as they could be. This included using a multidisciplinary approach to patient care.
  • Most outpatient facilities were appropriate for people’s needs.
  • Patients had access to many different support services. Staff described support for patients living with depression and anxiety, eating disorders, learning disabilities, autism and attention deficit hyperactivity disorder and personality disorder.
  • The trust performed better than national targets for 31 days to initial cancer treatment and 31 days to subsequent cancer treatment.
  • There was a system-wide approach to managing capacity and demand. The strategy and plans were fully integrated with the wider health economy and demonstrated system-wide collaboration and leadership.
  • Board level reporting and other levels of governance mostly functioned effectively and interacted well with each other. There was a demonstrable improvement in care outcomes as a result of effective inter-organisational risk management.
  • There were clear processes to escalate concerns and disseminate information.
  • Staff were aware of the trusts vision and values. Senior staff we spoke with understood the strategy for outpatient services and their role in achieving them.
  • Staff meetings were held in the specialities and in the main outpatients department to ensure that points of view were gathered and acted upon.

However:

  • Not all staff were up to date with the latest practices, legislation and guidance for mandatory training or safeguarding.
  • There was limited oversight of the significant safety risks in the fracture clinic. This included risks to patient safety relating to infection control, patient confidentiality and safeguarding.
  • There were some patient paper records which were not stored securely.
  • Not all access national targets for referrals were met. This included for patients with an urgent cancer referral. There were also too many patients waiting beyond their ‘to be seen’ date.
  • There was limited engagement with patients to drive improvements in the service.
Other CQC inspections of services

Community & mental health inspection reports for Torbay Hospital can be found at Torbay and South Devon NHS Foundation Trust.