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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

Updated 18 September 2018

Some progress had been made in outpatients. However, processes were still not embedded and, in some areas, further work was required.

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.

Maternity (inpatient services)

Updated 18 September 2018

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

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 18 September 2018

Sufficient progress had not been made with regards to infection prevention and control within the emergency 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

Updated 18 September 2018

P

rogress had been made in all areas of the warning notice.

However, c

hange was ongoing and some changes were not yet embedded.