Torbay Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

For this key question we looked at the quality statements; learning culture, safe systems, pathways and transitions, safeguarding, involving patients to manage risk, safe environments and safe staffing. At the last inspection we rated this key question as good. The rating is now requires improvement. We found doctors, nurses and other healthcare professionals worked together as a team to benefit children, young people and their families. There was joined up working between the acute trust and the local mental health trust. However, there was not enough qualified paediatric nurses which meant not all shifts were filled with qualified paediatric nurses. We found some staff were overwhelmed and did not feel they had received sufficient mental health training to deal with young people with mental health conditions. The environment was not always suitable to treat children and young people with mental health conditions. Care plans to consider the management of young people with mental health conditions in an unsuitable setting were not always completed. We found 2 breaches of the regulations in relation to safe staffing and safe care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People we spoke with expressed they were generally happy with their care, however some people felt there was a lack of communication about the plan for their child and it was sometimes difficult to get an update about their care journey. Patients and carers told us they were happy to raise concerns with staff and they were confident they would be listened to.

Staff spoke about an improving positive learning culture. Staff knew how to report incidents and stated they were informed about any learning from the investigations. Incidents and themes were discussed at a monthly staff meeting. Staff knew to report when a child was restrained as an incident.

Staff said they had worked with a local dedicated eating unit to obtain information about best practice and were aware of national best practice guidance and had received training in the standard operating procedures for refeeding that included the recognition and treatment of refeeding syndrome. Clinicians spoken with had knowledge of the national guidance on the recognition and management of emergencies in eating disorders.

There were dedicated mental health champions for the ward, who alongside practice educators were responsible for providing training programmes for the staff team, focused on mental health and wellbeing.

Staff reported quality improvement work was difficult to carry out due to the lack of registered nurses that could help push this work forward.

The trust had processes and policies to foster a learning culture.

The trust was engaged in the University of London's Mental Health Admissions to Paediatric Wards Study (MAPS). The purpose of this study was to investigate the increasing number of children and young people (CYP) being admitted to general paediatric wards due to mental health issues, especially since the pandemic.

We spoke with patients and carers on Louisa Cary ward who said care and communication between the acute trust and the mental health trust was joined up. Parents were aware of the key people involved in their child’s care and said care was co-ordinated.

The children and young person service at Torbay operated a ‘consultant of the week’ model. This meant there was a different consultant each week (on a rotational basis) for Louisa Cary ward. We were told by some longer stay patients this was sometimes difficult despite this being an accepted way of working for acute trusts. It was difficult because they did not see the same doctor throughout their care journey.

Doctors, nurses and other healthcare professionals worked together as a team to benefit children, young people and their families, however lack of staffing and high numbers of agency and bank staff meant patients did not always receive continuity of care. Continuity of care for eating disorders was provided by the eating disorder specialist nurse and the consultant paediatrician, with responsibility for those children and young people presenting with an eating disorder that required medical intervention. Staff reported collaboration with Children Adolescent Mental Health Service, (CAMHS) the service best positioned to support patient transitions and provide appropriate pathways for children and young people, was effective and well-coordinated. Staff told us admissions for patients with disordered eating were carefully planned, with the eating disorder advanced nurse practitioner coordinating closely with the children and young person’s community team to ensure seamless, integrated care planning. Discharge planning follows a similar process, involving the children or young person’s and their family/carers to ensure continuity of care.

There were good working relationships with the local mental health trust. We were told the trust held regular meetings with the mental health trust.

We were told independent mental health advocates (IMHA) did not regularly receive referrals from the service, where it would have been appropriate. An independent mental health advocate supports people with issues relating to their mental health care and treatment. They also help people understand their rights under the Mental Health Act. This meant there were times when some qualifying young people were overlooked as staff did not have the knowledge to refer those young people to the support and service that the IMHA’s offered.

We found staff did not always keep detailed records of children and young people’s care and treatment. There was insufficient evidence to conclude parents/carers children and young people were fully involved in the planning of their care, and their views had been taken into consideration.

Through the records we reviewed, we found care plans did not contain sufficient information and accompanying assessments to meet the nursing care needs for the management of the young person’s mental health needs. Three of the children and young persons whose records we reviewed had been admitted for the management of their eating disorder or disordered eating. Care plans we reviewed which focused on their refeeding were not signed or dated. We could not identify who had actioned the care plans, a start or finish date and there was no evidence the care plan had been under regular review.

Patients we spoke with told us they felt safe, supported and able to approach staff if they had any concerns or felt unsafe. Staff supported them to manage risks and acted where needed to keep them safe and offer support.

Staff demonstrated a strong understanding of safeguarding procedures, including what to report, how to report it, and the subsequent processes involved. They confirmed safeguarding training is included in their mandatory training package and is supplemented by refresher sessions. As of July 2024, all staff had completed safeguarding adults training and 88.3% of ward staff had completed safeguarding children training. Improvement was required for other medical professionals as only 66.7% had completed the safeguarding children mandatory training. We were told there was a named nurse who took the safeguarding lead. There were 2 named doctors for Child Protection and Safeguarding who led alongside the named nurse. Staff had access to safeguarding policies, which referenced appropriate legislation and best practice guidance.

Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They always shared concerns quickly and appropriately.

We observed staff ensuring the main door to the ward was locked for the safety of all the children and young people. Visitors requested entry to the ward via an intercom and buzzer. Staff on the ward had to open the locked door for visitors and the young people to leave the ward. Young people and their carers were aware they were able to access outside space.

During our tour of the ward, we reviewed the shower facilities available to patients and were informed patients with disordered eating and mental health conditions would be supervised during this activity due to ligature risks. This raised safeguarding concerns, particularly regarding the legal and procedural framework governing 1:1 observation, as well as concerns about the sexual safety of patients and the potential for abuse. We were told the trust were looking to approve a business case which would ensure there was one facility on the ward which was ligature free. This would enable patients to use the facilities without a member of staff observing.

Patients we spoke with told us in the main they felt safe and supported whilst they were on Louisa Cary ward. All the young people and their families were invited into meetings about their care and treatment.

We were told some parents / carers did not always feel listened to and had to ask staff for any care plan updates on their young person as information was not always forthcoming.

Staff we spoke with described processes to assess and identify patients at risk using a nationally recognised tool. Staff demonstrated how they would assess and document mental capacity assessments and arrange mental health act assessments if required.

Restrictive practices, including the use of emergency sedation, for example rapid tranquilisation were carried out according to national best practice, and the hospital had a policy for managing disturbed behaviour in children aged 12 to 18 years. Physical intervention was undertaken by the hospitals healthcare security team who were trained in techniques which were suitable to be used on children and young people. Staff involved in the physical intervention were clear regarding their role within the team, including the techniques to be used. We saw staff used the minimum amount of restraint for the shortest period necessary and had considered least restrictive options as alternatives prior to hands on restraint. We saw good evidence the young person’s physical condition was monitored closely throughout the period of restraint and body maps were completed. We were told the healthcare security staff recorded all use of restraint on the trust’s incident reporting system. Debriefs took place for staff involved in any restraint and also for the young people and conversations with both supported this.

There were processes for managing risk and emergencies. Staff understood and were trained regarding restrictive practice.

Children and young people we spoke with told us they felt safe in the care environment, however there was no separate room for patients who required nasogastric feeding under restraint. This procedure was carried out by staff in the high dependency unit when there were no patients using this facility. We were told by staff and the young people that when the high dependency unit was in use, the procedure had been carried out whilst they were on their bed on the ward. The bed space areas did have blinds or pull round screens, however patients experiencing distress during nasogastric feeding under physical restraint, would be overheard by other patients and visitors on the ward. We were concerned not only for the privacy and dignity of patients subject to nasogastric feeding, but also for the wellbeing of other children, young people, and visitors on the ward.

Staff told us that the layout of the environment meant it was difficult for staff to monitor patients. We were told there were plans for a new childrens unit to be built however they were limited by the built environment.

Staff said they were able to obtain the relevant equipment to support the care of children and young people.

During our ward tour, we observed there were no rooms or facilities that were entirely ligature point-free. In one instance, the staff had attempted to 'strip' a room bare to reduce risks for a patient at elevated risk of suicide and self-harm. Whilst the acute hospital is not a mental health facility, they are a designated place of safety and have a duty of care towards the children and young people it is treating. The service, due to there not being any suitable placements elsewhere, has been treating children with mental health conditions for a considerable length of time and there appears to be a gap in service provision that is not being addressed by the trust, the Integrated Care Board, nor the mental health trust. The environment was mostly clean however we observed ‘The Cove’, a recreational area for patients, was dirty and had items that could be used to self-harm. We informed a member of staff who ensured this area was cleaned and the items were removed immediately.

We were not assured young people with a mental health condition were cared for in a safe environment that was appropriately risk assessed. There was no dedicated, separate room for patients who required nasogastric feeding under restraint. There were ligature points on the ward and there was no toilet or shower which was ligature free. The trust was putting together a business plan to have a ligature free toilet which at the time of the inspection had not yet been approved. This meant a member of staff had to accompany the patients with mental health difficulties whilst they attended to their personal care. Staff told us in the past, some young people had been self-harming or ligaturing and the ward was not suitable for young people experiencing mental and emotional distress. Despite these concerns, care plans to consider the management of these young people in an unsuitable environment, managing their self-harm or managing their levels of distress were not always fully completed.

We observed staff ensuring the main door to the ward was locked for the safety of all the children and young people. Visitors requested entry to the ward via an intercom and buzzer. Staff on the ward had to open the locked door for visitors and the young people to leave the ward. Young people and their carers were aware they were able to access outside space.

Young people and carers were positive about the care they received from staff. However the lack of suitably qualified nurses available would have impacted upon their care.

The service had enough medical staff to keep patients safe and was close to establishment. However, staff told us balancing skill mix and competency on shifts had been challenging due to existing gaps in the nursing staffing establishment. At the time of the inspection the service was short of 9 Registered Nurses (approximately 22%) with paediatric experience. Staff we spoke with said the service often operated with unfilled shifts and when agency and bank staff were used, these nurses often did not have paediatric qualifications. We were told when agency and bank staff were used who did not have paediatric qualifications, they were given the older young people to look after. This may have placed those children at risk of avoidable harm. We were told nursing staff were finding it difficult to manage workloads and provide the level of care to the young people they would like to deliver. This was exacerbated when staff had to look after high acuity patients, such as those with eating disorders, who required additional supervision and care. To manage the risk when there were high numbers of eating disorder patients, staff told us the ward manager in conjunction with the consultant and other staff could take the decision to lower the number of admissions so there were less patients to care for.

The service had bank and agency staff usage of 15%. We were told by staff some of the agency staff were not suited to deal with young people experiencing mental health difficulties. The trust had tried to mitigate the risks associated with usage of bank and agency by block booking agency nurses 3 months in advance and trying to use agency staff that knew the service, to provide consistency of care.

Staff said they continued to raise incidents and report when they used agency staff that were only adult trained.

Agency usage was being reduced and was 4% in November 2024. In December 2024 the service had improved its fill rate so it was only 3 whole time equivalents short.

On the day of inspection we observed that the nursing shifts were filled and that agency staff were used to achieve this. We observed staff who were committed to providing the best possible care and treatment for the young people and children.

Staff were up to date with their mandatory training. In June 2024 staff were above 83% for all subjects. All staff had completed the E-learning for Oliver McGowan training, training for health and social care staff who work with autistic and people with a learning difficulty, however only 32% of staff as of January 2025 had attended the face to face learning session. We were told by the trust this was due to operational challenges and the availability of these face to face sessions.

Staff told us they received regular supervision and annual appraisals. In June 2024, 90% of staff had completed an annual appraisal.

There were processes to offer an induction to new starter staff and agency and bank staff. The service used practice educators to offer additional support to newly qualified staff.

We were told staff often felt overwhelmed and did not feel confident when dealing with young people experiencing distress. This was because as an acute trust, staff did not receive the training that a mental health registered nurse would receive. Staff informed us the trust was having to treat children with mental health issues due to a lack of availability of community and inpatient CAMHS in the county.

There was a twice daily meeting to discuss and address any staffing shortages and issues.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.