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North Devon District Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 September 2019

Northern Devon Healthcare NHS Trust primarily provides acute and community services for the populations of Torridge, North and Mid Devon. They also provide some services in East Devon and Somerset.

The main hospital site, North Devon District Hospital, is in Barnstaple and provides a full range of acute services, including an emergency department, critical care, end of life care, general medicine, maternity, cancer services, outpatients, and children and young people services.

Ear, nose and throat services are delivered in partnership with the Royal Devon and Exeter Hospital, as are cancer services as part of the cancer network. The trust also works with Musgrove Park Hospital for vascular networking, and Derriford Hospital for neonatal networking.


Inspection areas

Safe

Requires improvement

Updated 12 September 2019

Effective

Good

Updated 12 September 2019

Caring

Good

Updated 12 September 2019

Responsive

Requires improvement

Updated 12 September 2019

Well-led

Requires improvement

Updated 12 September 2019

Checks on specific services

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.

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.

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.

End of life care

Good

Updated 12 September 2019

Our rating of this service went up one rating. We rated it as good because:

The service used national standards of good practice to provide safe services for patients. This included practices around hygiene, infection prevention and control, safeguarding procedures and management of changes in patients’ conditions.

End of life care was delivered in line with national guidance. There were effective systems to monitor performance.

Care for patients approaching the end of their life was provided with compassion and respect. Staff made sure patients and those close to them understood their care and treatment. Relatives and carers were involved in discussions about the plan of care.

The end of life and specialist palliative care team met the needs of patients in a timely way .

The end of life and specialist palliative care services were now fully integrated. The leadership had continued to improve since our last inspection in 2018. It was an integrated and strong team with an emphasis on providing consistent and high quality care.

Governance processes had strengthened since our last inspection and there was an end of life strategy to support the vision for the service.

It was apparent during our inspection that all the staff had the patient and their families at the centre of everything they did. They were passionate about end of life care and were dedicated to their roles and approached their work with flexibility.

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.

Urgent and emergency services

Requires improvement

Updated 12 September 2019

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

We rated safe, responsive and well-led as requires improvement but effective and caring were rated as good.

  • There were some concerns about the completion of patient care records and medicines were not always managed safely. Reviews of safe levels of nursing staff were not carried out as often as they should be. Daily checking of emergency equipment was not always carried out. However, the cleanliness of the department had improved greatly, and patient risks were assessed and managed safely. Staff were largely compliant with mandatory training and regular updates including safeguarding training.
  • The service did not always meet national targets around waiting times. However, service leaders worked to plan and deliver the service to meet the needs of the population and staff made reasonable adjustments to meet the needs of individuals. Complaints were investigated and managed in a timely manner.
  • There were processes to improve the quality of care and patient outcomes, but these were not fully embedded. Processes and the recording of mortality and morbidity were not always sufficiently detailed to give evidence of an effective process. There was a lack of audit oversight and identified risks were not always documented, assessed and mitigated. However, the culture amongst staff was positive and most staff felt engaged with service improvements.
  • The service provided care and treatment in line with national guidance and participated in national patient outcome audits. Staff were supported to access further professional training and developed. Staff supported patients to make decisions about their care and took appropriate actions when patients lacked mental capacity.
  • Staff treated patients with kindness and compassion. Staff ensured patients were involved in decisions about their care. Patients were positive about the care they received in the department.

Maternity

Requires improvement

Updated 12 September 2019

The Care Quality Commission last inspected the maternity service in October 2017. The rating for the service was requires improvement overall, with requires improvement ratings for safe, effective and well-led care, and good ratings for caring and responsive care.

Our rating of this service was requires improvement overall. We rated it as requires improvement because:

  • Some staff were not up to date with refresher training for mandatory courses and could not evidence that all competencies were signed off.
  • Not all records were completed.
  • There were inconsistencies with theatre checklist information.
  • Room temperatures for the areas where medicines were stored were not monitored or recorded.
  • Staff members did not always annotate date open for liquid medicines, meaning it would be difficult to ascertain the shelf life of these medicines.
  • Resuscitation trolleys and resuscitation equipment was available but was not always checked daily contravening trust policies and procedures.
  • There were issues flagged regarding the high level of caesarean rates and the high level of induction of labour.
  • There was a lack of consistent benchmarking and investment in audit and analysis.
  • Not all department policies had been reviewed according to trust policy.
  • Managers had not always monitored the effectiveness of care and treatment.
  • The standardised caesarean section rates for elective sections was higher than expected.
  • As of April 2019, the trust had one active maternity outlier. The outlier relates to neonatal readmissions.
  • At the time of the inspection there was lack of a robust system of monitoring competencies and therefore confidently maintaining skills.
  • The level of inductions was high relative to the national average.
  • There was no formal system to ensure that there were risk assessments in place for all home births attended by the unit staff.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well.
  • The service controlled infection risk well.
  • Staff assessed risks to patients, acted on them and kept good care records.
  • The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it.
  • Managers monitored the effectiveness of the service and made sure staff were competent.
  • Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, and supported them to make decisions about their care.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity
  • Staff took account of patient’s individual needs and helped them understand their conditions.
  • They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs,
  • People could access the service when they needed it and did not have to wait too long for treatment.
  • It was easy for people to give feedback.
  • They supported staff to develop their skills.
  • Staff understood the service’s vision and values, and how to apply them in their work.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
  • Staff were clear about their roles and accountabilities.
  • The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Outpatients

Good

Updated 12 September 2019

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

  • The service used national standards of good practice to provide services for patients. This included practices around hygiene, infection prevention and control, safeguarding procedures and management of patient risks.
  • Staff were conversant with managing people who may be suffering with sepsis and ensuring they received appropriate treatment.
  • Most facilities were suitable for their purpose and were well maintained.
  • Staff kept records of patient consultations and shared the information with GPs.
  • We saw staff treating patients with kindness and respect and ensuring appropriate consent was gained from patients about sharing information.
  • Staff kept the patient experience at the heart of their practice. Changes made to practice and services took into account how patients would be affected. Patients were given choices and urgent needs were prioritised.
  • The service had improved some referral to treatment times.
  • Managers and leaders of the service worked together and engaged staff to make improvements to the service. They used their skills to encourage staff to contribute ideas and felt empowered to make improvements. Staff felt supported by their managers.
  • Governance structures had been improved and staff were clear about reporting procedures.
  • Development of staff was a priority for the service. Staff were competent in their roles, attended mandatory and specialist training to enhance their skills.

However:

  • Some of the premises were cramped for the number of clinics being held. This had led to a lack of privacy for some patients.
  • Some records were not stored securely.
  • Medicines management did not always follow current guidelines.
  • Referral to treatment times did not always meet national standards and ophthalmology treatment times had worsened.
  • Not all staff had received up to date appraisals, although the service was working to improve this.

Maternity (inpatient services)

Updated 18 September 2018

There were signs of improvement, but change was ongoing and new systems were not yet embedded.