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North Devon District Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 February 2018

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

  • Urgent and emergency care services remained as requires improvement overall. Safe stayed the same since our last inspection and was rated requires improvement. Effective went down and was rated as requires improvement. Caring stayed the same since our last inspection and was rated good. Responsive and well-led both got better since our last inspection and were rated good.
  • Maternity services had got worse since our last inspection and were rated as requires improvement, having previously been rated good. Safe and effective were found to have got worse and were rated as requires improvement. Well-led stayed the same and was rated requires improvement. Caring and responsive stayed the same and were rated good.
  • End of life care stayed the same following our last inspection and was rated requires improvement. Safe and well-led stayed the same and were rated requires improvement. Effective got better and was rated requires improvement. Caring stayed the same and was rated good. Responsive got better and was rated good.
  • Outpatients got worse since our last inspection and were rated inadequate. Safe and well-led got worse and were rated inadequate. Responsive got worse and was rated requires improvement. Caring stayed the same and was rated good. Effective was not rated.
Inspection areas

Safe

Requires improvement

Updated 5 February 2018

Effective

Requires improvement

Updated 5 February 2018

Caring

Good

Updated 5 February 2018

Responsive

Requires improvement

Updated 5 February 2018

Well-led

Requires improvement

Updated 5 February 2018

Checks on specific services

Outpatients and diagnostic imaging

Inadequate

Updated 5 February 2018

The Care Quality Commission last inspected the outpatients service as part of an outpatients and diagnostic imaging inspection in July 2014, with a follow-up in August 2015. The rating for outpatients and diagnostic imaging was good overall. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated the service as inadequate because:

  • Incidents were not always recorded and staff were unsure of what should and should not be reported.
  • Incidents were not being reported within national time scales as set out by the serious incident reporting framework.
  • Incidents of patient harm were not being accurately captured or investigated.
  • The duty of candour was not being applied in all instances of patient harm.
  • Not all staff followed trust infection prevention and control policy to be bare below the elbows.
  • The department had not reached the trust training target for staff resuscitation training, dementia awareness or information governance, and staff were completing e-learning in their own time.
  • There was not always an appropriate skill mix of staff to support the needs of patients in some specialist clinics.
  • Missing records and clinic letters were not always recorded as incidents so the actual numbers of missing or incomplete records was not known or monitored, and records were left unattended and unsecure in open corridors.
  • We saw patients being weighed in view of one waiting area.
  • There were a significant number of patients waiting on the pending lists who had gone past their follow up dates and come to harm as a result.
  • Patients on some follow-up lists were not being monitored to ensure they did not deteriorate whilst waiting for an appointment.
  • Some outpatient appointments were cancelled when doctors were required to support the medical assessment unit. Non urgent clinics were not replaced so the service was losing outpatient appointment capacity.
  • Not all complaints were responded to within the trust target of 50 days.
  • Not all managers had the right skills and experience to lead and staff in some teams felt unsupported.
  • Some governance and risk management process were complicated and it was not clear who had overall responsibility for quality and performance for all outpatient locations.

However:

  • Nursing staff had completed safeguarding training and there was a reliable system to monitor this.
  • Policies and procedures reflected current evidence-based guidance.
  • Staff in physiotherapy worked well as a team to deliver effective care to patients and had good links with mental health teams in the pain management service.
  • Patients attending outpatients were nutritionally risk assessed in line with the NICE guidance and had specialist support in oncology.
  • Staff had good awareness of the mental health act and their responsibilities under it and made best interest decisions in line with legislation.
  • Staff took the time to interact with patients and their relatives or carers. Patients said staff were kind and helpful and often went the extra mile.
  • Staff were able to signpost patients to relevant services that may be able to offer support during and after the patient had received their diagnosis or treatment.
  • Staff communicated with patients so they understood the treatment they received and what was going to happen next.
  • The service took into account individual needs. Staff were able to support people with additional needs for example patients living with dementia, learning disabilities and visual or hearing impairments.
  • The outpatient department was performing better than the England average for all cancer referrals, including two week wait, 31 day and 62 day referrals.
  • There was a positive culture within the main outpatients department. Staff showed a willingness to change and make improvements to support a better patient experience.
  • Staff spoke highly of the senior management team telling us they were visible and approachable.

Maternity and gynaecology

Requires improvement

Updated 5 February 2018

The Care Quality Commission last inspected the maternity service as part of a maternity and gynaecology inspection in July 2014, with a follow-up in August 2015. The rating for maternity and gynaecology service was good overall with well-led rated as requires improvement. 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:

  • Four serious incidents identified concerning practice within the maternity service where healthcare professionals did not assess and respond promptly to the presenting risk. There was evidence policies and procedures had not been adhered to.
  • There was poor multidisciplinary working and collaboration between the consultant obstetricians and the midwifery team. The challenging relationships did not promote safe care and effective working within the maternity unit.
  • Medical staff were consistently below trust targets for the completion of mandatory training related to care being delivered within the maternity unit. This included practical obstetric multi professional training, maternal and neonatal resuscitation, and fetal growth and monitoring.
  • Governance was not well embedded or aligned with the trust. There was not a robust programme for monitoring quality and safety on an on-going basis to identify trends, themes or gaps in the delivery of a safe and effective service.
  • The pace of change within the department was slow. Improvements had not been made in a timely manner to move the delivery of high quality care forward.
  • The risk management process and ownership of the risk register was not clear. We were not confident the senior maternity team had an oversight and were actively managing the risks on the risk register.
  • The maternity service was in disarray and the consultant workforce was unstable at the time of our inspection. A number of consultants had been restricted from their labour ward obstetric practice and in the meantime these posts were being filled by locum consultants.
  • The quality dashboard identified seven patient outcomes which were worse than the trust target and therefore were classed as red flags. This included caesarean sections, inductions of labours, blood loss 1500mls and over, retained placenta and third and fourth degree tears.

However:

  • The trust were responding to the safety concerns within the maternity unit. There was a line of sight up to the board. The executives and relevant stakeholders were having regular oversight of the department. External reviews had been requested and completed separately by a head of midwifery and the Royal College of Obstetricians and Gynaecologists. The trust were learning from incidents and making changes to improve safety and governance.
  • Care and treatment provided by all healthcare professionals was observed to be delivered with compassion and kindness. People were respected and their preferences considered. Women and their families were kept involved in their care and treatment.
  • Safeguarding processes were clearly understood by staff. Staff were aware of their responsibilities and were confident in making referrals and providing support to women and their families.
  • Mental health was well considered. A woman’s mental health was checked continually through their pregnancy. Women could be referred to the perinatal mental health team who assessed women promptly and ensured their safety was paramount.

Medical care (including older people’s care)

Good

Updated 9 November 2014

We found high levels of patient, relative and staff satisfaction with the care delivered across the medical wards.

Although there was evidence of much safe practice, we had concerns about the practice of moving patients overnight.

Overall, medical services were effective. There was a lack of consistency of effectiveness in overnight bed management, but there was also clear evidence of mechanisms of effectiveness in place throughout the directorate.

On each unit we inspected, the delivery of care and treatment was compassionate and caring. We saw some outstanding delivery of care where staff had planned and held a street party on the ward for those patients living with dementia. Feedback from the friends and family test was high and supported by verbal feedback from patients relatives. Patients and relatives were actively involved in decision making about treatment, care and discharge. Relatives and patients commented positively on their experiences on the wards.

Medical services were mainly responsive to local needs. There was an excellent provision of specialist care for patients with a stroke or with dementia. Service-delivery plans had raised a need for further dementia bed provision and the capital funding for this had been successful.

Overall, the medical services unit was well-led. Staff told us they felt well-supported by their managers and senior management team. They said that the quality of care and treatment delivered was of the utmost importance to the trust.

Urgent and emergency services (A&E)

Updated 5 February 2018

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

  • The cleanliness of the majors department was of concern. This was matched with low rates for mandatory training in non-clinical infection prevention and control.
  • While information on triage times was collected there was no evidence the emergency department used these to improve poor performance.
  • Mandatory training for emergency department support staff consisted of a package of eleven courses. Between March 2016 and March 2017, only three courses had met the trust target of 85%.
  • We could not be assured all equipment and devices had been serviced regularly.
  • The trust had not sufficiently improved the reception area for wheelchair users after this was identified as an issue in our 2015 inspection report. However, we recognised this should be resolved in a major rebuild of the department due to start imminently.
  • Some medicines had no clear expiry dates. We found two plastic cups holding strips of various tablet medicines. Some of these had been trimmed with scissors and we were unable to see on the strip when these medicines were due to expire.
  • The management of patients with sepsis was poor. The department was only managing to administer antibiotics to 23% of patients within an hour of sepsis being identified.
  • Staff training in Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training had been completed by only 65% of staff.
  • On our inspection the reception waiting area was small and overcrowded. At the end of each day of our inspection, people were standing as all chairs were being used. However, we recognised this would be addressed imminently, as the department was due to be rebuilt and more space would be available.

However:

  • Between September 2016 and August 2017, the trust was better than the England average for meeting the four-hour target to assess, admit, transfer or discharge patients. However, in that period the trust met the target in just three months of the 12.
  • A healthy culture existed where incidents were recorded, investigated and learning from them was shared with all staff in the department. Staff understood their responsibilities to raise concerns, to record safety incidents, concerns and near misses. These were reported internally and externally where appropriate.
  • There was a positive culture within the department. Staff showed an enthusiasm to change and make improvements to support patient care.
  • Safeguarding procedures and a proactive safeguarding team ensured patients were protected from harm or abuse.
  • There were good examples of multidisciplinary working between specialties to improve patient care and outcomes.
  • Patients spoke of being fully informed of treatment, expectations and potential diagnosis throughout their care.
  • We observed caring interactions at all times. We saw staff asking patients, for example, if they were comfortable or warm enough.
  • The senior leadership within the emergency department had the knowledge and experience to provide a well led service for the department.

Surgery

Good

Updated 9 November 2014

Care and treatment provided by surgery services was safe and effective. Almost all patients and their relatives spoke highly of the service received and the care and treatment they received. Staff were caring, kind and considerate of their patients and treated them as individuals.

Patient records were mostly done well, but some improvements were needed in pain and nutrition assessments. Patient assessments for safety risks needing improving in order to reduce pressure ulcer and urinary tract infection incidence. Infection control was mostly done well, but spot check audits for infection control on inpatient wards were not showing consistent improvement.

Patient outcomes were good and mortality and infection rates were low. Operating theatres met targets for referral to treatment times in all surgical specialities. Staff learned from incidents and serious events and felt confident to report incidents. The surgical teams responded proactively and positively to adverse events to bring about improvements. Patient consent was obtained in accordance with legal requirements. People in vulnerable circumstances were safeguarded and patients were treated in their best interests.

Staffing levels in theatre were not at full strength. New staff had been recruited but the current staff group were working extra hours to ensure continuity of the service as there were not enough agency staff available to provide cover. Staff were well trained and their competence was regularly assessed. There was strong and respected leadership in theatre and inpatient wards. Staff were committed to each other and their patients. Out-of-hours emergency surgery was led by consultants and there was adequate theatre time for anticipated emergency surgery or procedures.

The environment of the surgical admissions lounge was poor in terms of the patient experience. This was with respect to patient comfort, dignity and confidentiality. The anaesthetic rooms should be improved to assist in infection prevention and control. Patient outliers and handovers between wards must be improved.

Intensive/critical care

Good

Updated 9 November 2014

Care provided by the critical care team was safe and treatment delivered was effective. Staff were caring and patients were treated as individuals. Their needs were met by considerate and compassionate staff. The service was well-led at both department, nurse and medical staff level. The team worked well together and this was commented upon by staff, patients and visitors.

Patients were happy with their care and all the discussions we had with patients were overwhelmingly positive. There was good multidisciplinary input into patient care to enhance recovery and discharge from the unit.

There were some instances of the discharge of patients not being at an optimal time. The majority of patients were not discharged at night, but some left the unit earlier than was ideal, to make room for unplanned emergency admissions. In busy times, some patients were discharged back to the wards to free bed space for more acutely-unwell patients. There was no step-down facility to a high dependency unit (HDU), as the hospital did not have a dedicated HDU.

The unit was small and there had been no renovation to bring the unit up to modern standards of facilities and equipment since it was built in the 1970s. It was, therefore, not able to respond to all treatment, or integrated care pathways.

Services for children & young people

Good

Updated 9 November 2014

We found children’s services to be safe. Parents told us that staff were caring and we saw that children and their parents and carers were treated with dignity, respect and compassion. Ward areas and equipment were clean.

There were contingency plans in place if there were staff shortages and/or the wards were full. Patients requiring intensive mental health support were cared for by agency staff with mental health training. There was a multidisciplinary proposal for an urgent assessment protocol.

There were thorough nursing and medical handovers that took place between shifts to ensure continuity of care and knowledge of patient needs. We saw evidence of outstanding collaborative working, both within the units and with the community paediatric nurses.

We found that the environment within the ward made it challenging to accommodate the differing needs of patients, of infants, including those whose mothers were breastfeeding, and of children and young people requiring care and treatment.

We saw evidence of planning for future sustainable children’s services and learning from incidents. We also saw how the service made good use of the skills and resources it had.

End of life care

Requires improvement

Updated 5 February 2018

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

  • The end of life care and the specialist palliative care services had different leadership. This meant there was limited joined up working as they were leading on separate services and projects associated with these.
  • The end of life care lead role was as an educator and they did not hold a caseload of patients. They also only worked part-time.
  • The governance arrangements in place were not effective in monitoring the service provision for all patients. There was lack of action plans to address the shortfalls.
  • We found records relating to patients care especially those in the last few days of their life were not always completed or sections were omitted.
  • There was a lack of clinical consultant support in place to provide clinical expertise for end of life care and palliative care. This was despite the interim arrangements made as not all staff were aware of this. However, at the time of our inspection a palliative care consultant was in post but there was confusion over their role and whether it involved practising clinically at the hospital.
  • The trust had not participated in some of the latest national audits and there was limited evidence that the trust was meeting national guidance in relation to end of life care.
  • Not all qualified staff were aware of the trust’s policy on the safe use of syringe drivers in relation to training and competencies.

However:

  • All disciplines of staff worked together to benefit patient care. Since our last inspection the specialist palliative care service had made vast improvements in liaising with all staff involved in patient care to include external stakeholders.
  • Patients at the end of their life who wished to be cared for at home were being discharged much quicker than at our last inspection.
  • Staff cared for patients with compassion and kindness and their dignity was respected and maintained.
  • The end of life care and specialist palliative care services were passionate about their visions and the improvements they wanted to make to benefit patients and improve their care and support.