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North Devon District Hospital Requires improvement

Reports


Inspection carried out on 17 and 18 July 2018

During an inspection to make sure that the improvements required had been made

Following our last inspection of Northern Devon Healthcare NHS Trust in October 2017, we issued the trust with a warning notice under Section 29A of the Health and Social Care Act 2008.

The warning notice set out the following areas of concern, where significant improvement was required:

Regulation 12 Safe Care and Treatment

Maternity:

  • Healthcare professionals were not always following guidelines and best practice. This had led to the mismanagement of some cases, resulting in harm or death to the babies.

  • There was poor collaboration and multidisciplinary team working within the maternity unit. The negative culture did not promote safe care and treatment, or effective working within the department.

  • The consultant obstetrician workforce was unstable. A number of consultants had their practice restricted, so they no longer covered the labour ward. There was a potential risk with consultants who had their practice restricted continuing to work in antenatal clinics.

  • Medical staff were not up-to-date with training necessary to carry out their role. They consistently did not meet trust targets for maternity mandatory training.

Outpatients:

  • Patients were not being seen in a timely manner in ophthalmology due to the limited capacity within outpatient clinics.

  • In ophthalmology there were 20 patients who had gone past their follow-up dates with evidence of patient harm.

  • New systems were not always implemented successfully. Following migration to a new electronc health record, which incorporates a new booking system, missing information about outcomes and follow-ups was identified.

  • There was historical failure to act on issues identified from previous incidents of patient harm. The trust had also failed to act in a timely manner to complete actions identified in previous investigations.

  • Clinicians across outpatient specialties were not always risk-assessing patients who had been waiting a long time.

  • There were ineffective processes for monitoring patients on the cardiology waiting list.

  • There were an increased number of patients who were lost to follow up across all outpatient specialities because of lost contact or IT failure.

  • There was a lack of oversight of training completion for medical staff.

  • There were not enough staff trained to administer chemotherapy in the oncology department.

Urgent and Emergency Care:

  • Oversight of infection control within the emergency department was unclear, including actions required to improve cleanliness. The major injury department was not clean and was an infection risk.

  • Poor infection control within the department reflected poor compliance with infection control training.

Regulation 17 Good Governance

Maternity:

  • There was not a robust and regular audit programme to monitor quality and safety within the maternity unit. Audits were reactive in response to incidents and poor performance metrics.

  • The governance structure and risk management arrangements were not clear.

  • There was no multidisciplinary approach to governance.

  • Clear audit trails of actions generated and how these were monitored were not evidenced in all meeting minutes.

  • Processes to discuss and learn between the multidisciplinary team required improvement. Round table reviews for serious incidents were not well attended by consultant obstetricians.

  • The department of health’s safer maternity care recommendations had not been implemented. There was no board level maternity champion or designated obstetrician and midwife to jointly champion maternity safety in the trust.

Outpatients:

  • There was not an effective system to manage risks at a local level in outpatients. Risks were not being regularly updated or reviewed. Individual risks were not always being managed effectively.

  • Managers did not receive feedback about themes and trends from incident data which were escalated to the clinical governance lead.

  • The governance system did not support the delivery of good quality care and we could not identify who had overall responsibility for all outpatient areas at both clinic and board level.

  • There was a systematic programme of audit, however not all managers were aware of what audits were being carried out.

End of Life Care:

  • Systems did not operate effectively. There was a lack of oversight, audit and assessment of the end of life care service provided, and a poor governance structure.

  • The trust had not addressed all the shortfalls in the 2015 National Care of the Dying audit.

  • The end of life steering group had a list of actions at the end of each set of minutes but no timescales for when these would be addressed. The end of life strategy action plan included no timeframes.

  • Local audits had taken place but there was no action plan to address the areas where improvement was needed.

  • Systems for maintaining accurate and completed detailed records of patients using the end of life care service were not operating effectively. We did not see any advance care plans or an individual plan of care detailing patient choices for now and at the end of their life. Medical care plans were not complete.

We conducted an unannounced follow-up inspection on 17 and 18 July 2018. This inspection was focused solely on the improvements required as detailed within the warning notice. We did not review the ratings as part of this inspection.

The trust had made some progress in addressing our concerns and we had seen improvements. However, systems and processes were not fully embedded. The pace of change had been slow and there was further work needed to continue the improvements. The requirements of the warning notice had not been fully met.

In urgent and emergency care we found:

  • There was still ineffective oversight and inconsistent cleaning in the emergency department. We identified a significant build-up of dust in some areas. However, the trust was undertaking a major building and redesign project at the time of our visit.

However:

  • The infection prevention control training compliance concerns had been addressed. Both clinical and non-clinical staff training compliance had greatly improved.

In maternity we found:

  • Incident investigations had improved. Specialists from different professional groups contributed to reviews and identified improvements.

  • The response of medical staff to requests to review patients’ care needs had improved.

  • We observed good communication and interactions between doctors and midwives.

  • Leaders had begun to develop a vision and strategy for maternity care.

  • An improved governance framework was in development to assure and evaluate the quality of maternity care.

  • The leadership team were visible, approachable and supported staff to do their work.

  • The culture within the service was improving. The results of a recent survey would be used to influence forthcoming organisational development.

However:

  • Incidents and other adverse events were not used as part of service risk assessments.

  • Trust targets for mandatory and service specific training were not achieved.

  • Medical staffing remained fragile whilst a long-term strategy for consultant job plans were developed.

  • The trust was unable to demonstrate clinical practice complied with local guidelines.

  • There was no audit programme. This meant assessments of care provision and risk control measures were not co-ordinated or evaluated as part of the quality management system.

  • There was no clear ownership of the risk register.

In end of life care we found:

  • There was improved oversight, audit and assessment of the end of life service. There were improvements in the governance structure. Most systems were operating effectively.

  • Concerns and issues could be routinely identified, and improvements had been made to the service.

  • The trust was participating in the National Audit of Care at End of Life.

  • There were systems for maintaining accurate and completed detailed records of patients using the end of life care service.

  • We reviewed three patient records, which included comprehensive advance plans of care. These individual plans of care detailed patient choices for now and at the end of their life. Patient care needs and preferences were known and met by the service.

  • The end of life strategy was due to be ratified several days after our inspection on 30 July 2018. It covered the period 2018-2020.

However:

  • The trust was still addressing remaining shortfalls from the 2015 National Care of the Dying audit.

  • Actions in minutes from local working group meetings were still without timescales.

  • Several audits of treatment escalation plans did not have action plans.

  • Audits of advance plans of care were not available as completion of the audit was not due until September 2018.

In outpatients we found:

  • The trust was better sighted on waiting lists and those patients who had been waiting a long time to be seen. The referral to treatment time weekly meetings reviewed patients in detail.

  • The trust was formalising their harm review process, with retired clinicians identifiedto complete this exercise.

  • Specialities found it easier to gain approval for additional clinics, however this was dependent on capacity.

  • The ophthalmology task and finish group were reviewing how they could improve the efficiency of the ophthalmology service through different project workstreams. However, there were still actions remaining and work required to move things forward.

  • There was weekly monitoring of data quality issues. Outpatient managers were fully aware of any limitations with the electronic health record which incorporates the booking system.

  • Governance processes were being improved, however they were not yet embedded for us to see the impact across the service.

  • There was an improved system to manage and record risks at a local outpatient level.

  • The ophthalmology action plan had a person responsible for each action.

However:

  • Incident reports showed the culture for incident reporting in the Seamoor chemotherapy and day treatment unit had not improved. There was a back-log of incidents which had not been signed off by a ward manager, delaying the learning for staff.

  • Mandatory training compliance for medical staff had improved but was still below the trust target for some modules. Compliance with resuscitation training was poor and safeguarding training needed improvement.

  • There was not capacity for regular clinician reviews in some specialities. We were not provided with evidence to show the processes had improved in cardiology.

  • The in-house competency assessments on the Seamoor chemotherapy and day treatment unit were not completed in a timely way. There was still a misunderstanding between staff and the unit’s management team about what training was required to ensure competency. Some staff would soon be signed off as competent, however they were not always confident in their role.

  • The trust was still underperforming against referral to treatment times and patients were waiting for long periods of time.

  • Trauma and orthopaedics had a high number of patients waiting over 52 weeks. However, all patients waiting over 40 weeks were being formally reviewed and risk-assessed.

  • There were concerns about the culture and morale of staff on the Seamoor chemotherapy and day treatment unit. Staff told us they had not been engaged since the issue of the warning notice with regards to the concerns raised about the unit.

Following this inspection, we told the provider that it must take some actions to comply with the regulations, and that it should make other improvements, even though a regulation had not been breached, to help the service improve.

Importantly, the trust must:

  • Ensure the emergency department is cleaned to a high standard and there is not a build-up of dust.

  • Meet trust targets for mandatory and practical obstetric multi-professional training in maternity and ensure the training data produced centrally is accurate.

  • Develop and undertake audits to measure the effectiveness of the maternity service against patient outcomes, policies and risks.

  • Consider the concerns raised in the Seamoor chemotherapy and day treatment unit and ensure the skill mix is appropriate and staff are competent to deliver a safe and effective service. Competency assessment must be completed in a timely way to ensure a competent workforce.

  • Improve mandatory training compliance for medical staff across the trust, particularly for resuscitation and safeguarding training.

  • Formalise clinician review processes to risk assess patients waiting a long time to be seen or overdue follow-ups across outpatient specialities.

In addition, the trust should:

  • Consider the accuracy and validity of the cleaning audits completed in the emergency department.

  • Complete actions and shared learning from serious incidents in maternity in a timely way.

  • Consider how adverse events in maternity may impact identified risks to patient safety.

  • Make the responsibility for maintaining the maternity risk register clear and regularly identify and record risks.

  • Plan to audit advance care plans in the end of life service..

  • Review the Overarching End of Life Action Plan to Improve the Quality of End of Life Care Provision and consider the deadlines set and whether they ensure appropriate and prompt change to the service.

  • Complete timescales for meeting minutes and action plans for the end of life service.

  • Complete action plans for audits in the end of life service to identify learning and improvement, for example audits of treatment escalation plans.

  • Engage with staff on the Seamoor chemotherapy and day treatment unit to support and improve the culture and morale. Gain assurance incidents are being reported and learning is shared with staff in a timely manner.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 4 October to 25 October 2017

During a routine inspection

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 carried out on 5 – 7 August and 17 August 2015

During an inspection to make sure that the improvements required had been made

We inspected North Devon District Hospital to check if changes had been made in specific areas where we found breaches of regulations for the core services of urgent and emergency care, end of life care, and maternity and gynaecology during our comprehensive inspection in July 2014. The inspection was carried out between 5 and 7 August and on 17 August 2015.

As this was a focused follow-up inspection, we did not inspect the following core services: medical care (including care of the elderly), critical care, surgery, services for children and young people, and outpatients and diagnostic imaging.

For the core service and quality issues inspected, we rated the North Devon District Hospital as Requires Improvement. Some areas of concern found at our previous inspection had been dealt with but others required further work, such as the need to provide effective and safe care for patients at the end of their life and to provide responsive and safe care for patients using urgent care services.

Our key findings were:

  • Work in the maternity and gynaecology service around working relationships between the medical and midwifery teams had progressed but more focused work was needed to ensure cohesive teamwork.
  • Patient flow through the hospital due to bed capacity and delays in timely discharge of patients from wards continued to impact on the emergency department but patients were seen and treated in a timely way.
  • There were delays to discharge of patients at the end of life, which led to people not being in their preferred place. While this was not always in the control of the trust, the impact on people and their families was concerning
  • In response to the findings, shortly after the inspection we asked the trust to provide us with a plan of action that set out how they will ensure they are providing an effective and well led service for people at the end of their life. The trust responded with an action plan detailing the steps they are taking to address the issues raised. We will review the implementation of the action plan in due course.
  • A number of actions had been taken in the emergency department to improve infection prevention and control measures. These were supported by regular audits, which showed good compliance with trust policies.

We saw some areas of outstanding practice, including:

  • We heard about the recent ‘open day’ held by the maternity unit. This took the form of a market place and had stalls about smoking cessation, domestic violence, infant nutrition, perinatal mental health team, National Childbirth Trust, antenatal screening and the local Maternity Service Liaison Committee. All the stalls had leaflets available for people to take away. We were told it was really well attended as it had been advertised on local radio and in the local newspapers. We were told people who attended were a mix of expectant and new mothers and some people who were interested in midwifery as a career.

However, there were also areas of poor practice where the trust needs to make improvements.

An action that a provider of a service MUST take relates to a breach of a regulation that is the subject of regulatory action by the Care Quality Commission. Actions that we say providers SHOULD take relate to improvements that should be made but where there is no breach of a regulation.

Importantly, the trust must:

  • Provide a minimum of one registered children’s nurse on duty in the emergency department every shift
  • Store medicines and medical gases securely in the emergency department.
  • Train staff adequately to ensure the safety of children attending the emergency department.
  • Implement a robust recording, reporting and monitoring process for mandatory training, including paediatric life support.
  • Ensure that all patients who meet the criteria for consideration for a Treatment Escalation Plan (TEP) are considered and afforded the opportunity to advise of their choices and preferences for care.
  • Ensure that staff throughout the trust understand how and when to make a referral to the specialist palliative care team at the appropriate time in order to meet the current and anticipated needs of patients.
  • Improve the rapid discharge process to enable patients who wish to return home quickly at the end of their lives to do so.
  • Ensure there is a programme of local audits in line with the national care of the dying audit which enables a review of services provided at the hospital to identify if patients preferred place of care had been achieved.
  • Ensure actions resulting from audits of end of life care are monitored. Some audited standards in the National Care of the Dying Audit were not met.
  • Make advance care plans available for patients in the last 12 months of life. (No advance care planning took place for patients in the last few weeks of life because there were no consistent systems in place to enable patients to make advance directives or consider the decisions needed for their future).
  • Ensure NICE guidance QS103 is followed for end of life care
  • Ensure there are arrangements for end of life services to be monitored and reviewed at all levels of the organisation.
  • Develop a strategy to achieve a consistently high standard of end of life care.
  • Continue work with the obstetrics and gynaecology and midwifery staff on team development and culture to ensure the way the teams work together does not affect patient safety.
  • Change the medical rota in obstetrics and gynaecology so that all staff are working in line with the European Working Time Directive.
  • Ensure that obstetric consultants undertake obstetric emergency workshops as part of their mandatory training.

In addition, the trust should:

  • Ensure the emergency department’s reception area provides privacy and confidentiality for patients booking in with the receptionist.
  • Make the emergency department’s reception suitable for the needs of wheelchair users.
  • Introduce a robust, regular portable appliance testing process for the emergency department.
  • Ensure appropriate and important information on patients’ allergies information and pain scores are recorded by the emergency department in all cases.
  • Ensure reception staff are able to recognise patients who attend the department with serious conditions that need urgent referral to the triage nurse.
  • Ensure that seasonal fluctuation and it impact on the emergency departments ability to respond is considered in all planning activities.
  • Ensure all agency nursing staff employed in the emergency department are appropriately prepared before working in the department and any induction processes are standardised and recorded.
  • Ensure all shift handovers in the emergency department are accurate and capture all relevant information in a consistent manner.
  • Review the security arrangements for the emergency department to ensure that staff and patients are supported and protected from harm or injury.
  • Ensure that bed meetings include all relevant staff and that all wards and departments have a clear focus on maximising patient discharge and flow in support of the emergency department.
  • Ensure that patients expected for medical and surgical care are admitted to an appropriate ward at the earliest opportunity to ensure there is no impact on the emergency department access and flow.
  • Review the incident reporting process to ensure trends are identified and actions taken to minimise risk.
  • Work with the ambulance service to understand and address how the emergency department can prevent medication errors following administration of medicines by the ambulance service.
  • Ensure the room used to assess patients with mental health related symptoms has suitable furniture.
  • Ensure all emergency department staff have completed major incident training.
  • Ensure the early warning score tool is fully implemented and used in the emergency department.
  • Consider collation of data for non-cancer patients where support of the SPCT for symptom management is required. In order to ensure all appropriate patients can access the SPCT.
  • Ensure that appropriate training for all staff, including agency staff, is made available for wards with end of life patients.
  • Consider the views of people using end of life services to shape and improve the services available.
  • Ensure maternity, obstetrics and gynaecology governance meetings are recorded.
  • Ensure that action plans made following recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG) visit and the serious incident investigation continue to be implemented.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 2-4 and 14 July 2014

During a routine inspection

The Northern Devon Healthcare NHS Trust operates across 1,300 square miles and provides both acute hospital care and community services. The North Devon District Hospital in Barnstaple provides a full range of district general hospital services.

We carried out a comprehensive inspection because Northern Devon Healthcare NHS Trust is an aspirant foundation trust. Trusts wanting to become a foundation trust have an inspection as part of that process. The inspection took place between 2 and 4 July 2014. An unannounced visit also took place on 14 July 2014.

The trust incorporates both an acute hospital setting and community locations, of which, some provided a limited level of acute service. For example, various clinics, including dermatology and gynaecology clinics. The acute report reflects the service provided at the North Devon District Hospital and does not include any of the community locations or locations providing services linked to the hospital.

Overall most areas of the inspection showed good outcomes for patients.

Improvements are needed to achieve a consistent performance in the Accident and Emergency department and to aspects of the End of Life care service provided in the acute hospital.

Our key findings were as follows:

  • Patients and relatives were all clear that the care provided by staff at the North Devon Hospital was very good. They found the staff to be kind, supportive and helpful.
  • There was a very positive atmosphere at the hospital. We found staff engaged with us and were willing to support the inspection process. Staff told us about an open and honest culture with strong teamwork.
  • We saw the hospital was clean. However, the infection control policies of the trust were not consistently followed by staff.
  • There were delays in admitting patients, a number of patients were not admitted to the most appropriate area (outliers), and the number of patients being moved at night raised questions about the overall effectiveness of night-time arrangements. The CQC team felt that this was unusual given the relatively low bed occupancy rate in the district hospital.
  • Nursing and medical staff training was encouraged and staff told us that, mostly, they were supported and encouraged to attend training to develop the care standards at the service. However, there was a lack of evidence of specialist qualifications and competency framework for nursing staff in A&E. There was also a lack of visibility of senior medical and nursing staff.
  • We saw issues around recruitment, including the challenge of attracting specialists to what is a relatively isolated part of the country. However, the trust showed creativity with solutions to recruitment issues. These also included participation in the Learning Disability Preparation for Employment Scheme.
  • Mortality rates were not raised as a concern at this trust.
  • Nutrition and hydration was managed well for patients, although improvements are needed in this area in maternity services.
  • Within the acute hospital there were aspects of safety and responsiveness that required improvement. The issues included medicines management and the environment in the surgical admissions lounge.

We saw several areas of outstanding practice, including:

  • On Alex Ward, they had recently had a ‘street party’ for the patients there. Many of these patients were living with dementia and efforts had been made to use reminiscence to help them to enjoy the afternoon. Staff had dressed up in 1940s costume and appropriate music had been played. Photographs of this event were displayed in the ward and patients had clearly enjoyed themselves. This was evidence of outstanding, appropriate emotional support for the ward population. The nursing, medical, therapy and ward clerk staff on Alex went “all out” to deliver the street party. They planned it around their normal day-to-day work. Articles in the local paper showed very happy patients and staff who had dressed up and brought in specific reminiscence music for the occasion. Someone else made cakes.
  • The acute paediatric team demonstrated excellent collaborative working providing end of life care for children in their own homes
  • Leadership and teamwork in theatre was exemplary, despite staff shortages.
  • There was thoughtful and compassionate care for those patients living with dementia, particularly on Alex Ward and Caper Wards where care was patient centred and holistic in its approach. A robust dementia policy ensured the highest standards of personalised care using all therapeutic staff was put in place. There had been an investment in staff to develop dementia care practice.
  • The nursing leadership of the acute stroke service was very highly regarded by medical, therapy and nursing staff. Staff felt valued and the service itself was very patient focused placing a high value on emotional support.
  • The Trust’s successful involvement with Project Search, an innovative scheme that supports young people with learning difficulties to find permanent work, was modelling excellent practice to local employers. The trust had provided 12-month internships to seven young people, all of whom had successfully completed the programme and had found permanent jobs, six of them with the trust in areas such as medical records and catering.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Review and improve arrangements for the assessment and management of the prevention, and control of the spread of healthcare associated infection. This includes ensuring that suitable equipment is provided and used, that all areas are kept clean and tidy and ensuring that staff are consistently following trust policies.
  • Evaluate and improve the effectiveness of the current patient flow and escalation policies. Action must be taken to improve the flow of patients from Accident and Emergency department and across the trust. The policies and procedures for patients who are not admitted to the most appropriate ward (outliers) need to be clear, focused on the best interests of patients and consistently applied. The criteria to be applied to decisions on the movement of patients and the protocols to be followed must be clear.
  • Ensure that an accurate record in respect of each service user is in place relating to their end of life care, which shall include appropriate information in relation to the care and treatment provided. The trust must make sure that staff are aware of and consistently apply these arrangements.
  • Ensure that the facilities for the antenatal sonography service are such that the safety, privacy and dignity of patients can be maintained. Rooms used by antenatal sonography staff must have a system for calling help in the event of an emergency.
  • Ensure that there is a system in place, supported by guidance, for the completion of HS A 1 (grounds for carrying out an abortion) and HS A 4 (abortion notification). These records must be completed accurately and consistently and forwarded to the Department of Health as required.

In addition the trust should:

  • Ensure the implementation of pain assessments. We saw poor use of pain measurement as comfort rounds did not include pain assessment.
  • Consider reviewing some areas of the environment, including in A&E, with regard to the lack of visibility of patients in the waiting area. Also, the trust should consider plans to improve the facilities and environment in the intensive care unit, in order to achieve best practice standards and consider improvements to the facilities and environment in anaesthetic rooms to address infection control risks.
  • Review medicines storage security arrangements in the intensive care unit to achieve best practice standards.
  • Consider improving the environment of children’s services, as the environment of the ward made it challenging to meet the differing needs of patients and parents, with no single-sex provision.

  • Ensure a clear protocol for doctors to follow when caring for a deteriorating patient in the intensive care unit and surgery. There was no clear protocol, pathway, or standard operating procedure for the doctor’s responsibility for managing the deteriorating patient. There were also poorly implemented early warning scores (EWS) in A&E and the trust should consider how this is managed.
  • Consider the management of clinical assessments in the A&E department. We saw there were long waits for clinical assessment of non-ambulance patients and no monitoring of waiting patients. The flow of ambulance patients was disjointed and not designed to meet national targets.
  • Ensure that staff in A&E are aware of clinical audits, and how the results compare with national standards.
  • Consider the deployment of senior staff in the A&E department; we saw a lack of visibility of senior medical and nursing staff. Nursing leadership was shared with other departments within the trust. There was limited support for junior staff needing advice in difficult clinical and organisational situations.
  • Further ensure that all medical staff have job plans that are regularly reviewed as part of their appraisal process. We had difficulty in establishing specialist qualifications or a competency framework for nursing staff in A&E.
  • Ensure that security staff have suitable training to manage violence and aggressive behaviour safely in the A&E department.
  • Demonstrate that the critical care service takes accountability for learning and improvement, with minutes and actions plans produced from clinical governance meetings.
  • Consider information provided through external reviews and work with medical teams, as suggested in the Royal College of Obstetricians and Gynaecologists (RCOG) report provided to the trust in March 2014 to ensure they engaged in processes designed to reduce the caesarean section and induction of labour rates.
  • Consider that in light of the RCOG report the need to keep staff informed of the recommendations and actions to be taken.
  • Consider the risks with the admission of young people requiring intensive mental health support. However, we are aware that this is recognised and that there are plans in place for an urgent assessment protocol.
  • Ensure there is nutritious food available to parents and breastfeeding mothers, apart from breakfast cereal.
  • Consider that patients be met and admitted into the day surgery unit when they arrive and the overall experience of the day surgery unit be improved to ensure patients’ comfort, dignity and confidentiality.
  • Ensure that Safety Thermometer data and patient assessments on wards be improved, to address the degree of patient harms from pressure ulcers and infections.
  • Demonstrate that the surgical service takes accountability for learning and improvement by actions plans produced from clinical governance meetings.
  • Should ensure management of the discharge of patients from intensive  care is in accordance with national guidelines

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 9, 10 December 2013

During a routine inspection

This inspection took place over two days with three compliance inspectors, two specialist advisors and an expert by experience. We talked with 50 patients in areas of accident and emergency department (A&E), recovery, medical and surgical wards and the acute stroke unit. We talked with visiting relatives and friends of patients who reported positively about the hospital. We also talked with a range of 60 staff from all areas. This included consultants, middle grade and junior grade doctors, ward managers, nurses, heath care assistants, hospitality staff, volunteers, workforce development managers, tissue viability specialist nurse, directors of nursing and medicine and the End of Life Care consultant.

Patients expressed a high level of satisfaction about the care support and treatment they had received in all areas of the hospital. Comments included ''You could not ask for better treatment, this is second to none.'' One person told us ''I have had a long history of health issues, but I cannot fault the doctors nurses and care staff here. Everyone goes out of their way to make sure you have what you need.'' Another patient told us, “I couldn’t have asked for better care. I feel they are the professionals and know exactly what they are doing”.

We had received some information of concern earlier in the year about how patients were managed from recovery to critical care. We had asked the trust for information and we were satisfied with their response. In this planned inspection we included a specialist in this field to look at practices within critical care. We found the way patients were being managed was in keeping with clinical guidance and best practice.

We had information of concern about consultant cover in A&E following our last inspection. Although we were satisfied with the trust’s response at the time we included a specialist in this area to ensure staffing levels were meeting people's needs. We found there were sufficient staff who worked flexibly to meet the seasonal demands to the department.

We found patients care and treatment was well planned by a staff group who were well trained and supported to do their job.

We found improvements were needed to ensure people's rights were upheld when considering emergency treatment for patients who lacked capacity.

Inspection carried out on 5, 6, 7 February 2013

During a routine inspection

This inspection was carried out on 5, 6 and 7 February 2013 with four inspectors looking at five key outcome areas. In particular; discharge planning, care of patients with dementia and how the trust engaged patients in their quality assurance processes. In total we spoke with 72 patients and 18 visitors on a variety of wards including the Accident and Emergency department (A and E), the children’s ward, surgical wards, medical wards, the medical assessment unit (MAU) and various outpatient departments. Also we met the families of six children/babies. Comments from patients we spoke with were very positive and they praised the care, support and treatment they had received.

We interviewed 70 staff including a non executive director, the complaints manager, staff from the patient and liaison service ( PALS), patient safety lead, medical director, finance director, corporate governance lead, tissue viability specialist, adult and children safeguarding leads, lead midwife, dementia pathfinder team, palliative lead nurse specialist, discharge coordinator, consultants, doctors at all levels, nurses, ward clerks, receptionists, student nurses, and members of the allied health care teams.

We found patients using the service were involved in all aspects of their care and were consulted about the support and treatment they needed.

Inspection carried out on 22 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 3 April 2012

During an inspection to make sure that the improvements required had been made

We carried out an unannounced inspection in November 2011 to check on compliance of standards where we had previously found improvements were needed. During this inspection we spent time observing practices with the surgical theatres and found that improvements were needed to ensure that all pre and post operative checks were being fully completed.

This inspection was carried out on 3 April 2012 to specifically check on compliance of theatres and ensuring the safety checks were being completed and that this was being reviewed and monitored by the trust on a regular basis. Prior to this inspection we had received a detailed action plan from the trust to show how they planned to achieve compliance in outcome areas we had highlighted needed improvements. These were in the regulated activity of surgical procedures and in outcomes 4, care and welfare of people and outcome 16- assessing and monitoring the quality of service provision.

Three inspectors spent time observing pre and post operative checks in theatres for planned surgery, day surgery and ophthalmic surgery. We saw the theatre teams carrying out mandatory surgical safety checks on patients undergoing surgery on that day. These checks consist of a "check in" procedure when safety checks are carried out prior to surgery, a "time out" procedure when safety checks are carried out prior to the operation starting and a "check out" procedure at the end of surgery. These are mandatory formalised checks laid down by the World Health organisation Organisation (WHO) and National Patient Safety Agency (NPSA). The checks are performed to enhance patient safety.

We also saw that since our last inspection, theatres had introduced team briefings for all theatre staff before any patients were brought in for their procedure. This included running through the patient list, what procedures were being undertaken, any anticipated equipment needs and any special requirements such as post operative pain control needs. We saw that this had a big impact on improving communication between the teams.

We found that with all 17 observations the checks were always fully completed and included the prompts listed in the WHO checklist. We saw that each theatre had laminated checklists as an aid memoire for staff. There were also laminated small check lists for staff to carry and refer to if they wished. These were used to good effect.

We saw staff perform instrument and swab checks in conjunction with the WHO checklist.

Staff that we spoke to felt that there had been improvements in the team’s commitment to ensuring that all safety checks were completed. We heard that if any staff member did not comply with the mandatory checks that they had a system to report this to senior staff. Staff felt in their view that the team brief and end of day debriefs had worked especially well. One staff member commented “There is no doubt that the team brief has empowered all staff to be able to speak out.” Another member of staff said “It has cut down on the time we spent searching for equipment at the beginning of a case.”

We asked for some additional information from the trust about how they were ensuring that they were monitoring that theatres were complying with all safety checks. We saw that regular audits had been completed and working parties set up to look at how procedures could be improved.

Inspection carried out on 1, 2, 3 November 2011

During an inspection to make sure that the improvements required had been made

CQC completed a planned inspection looking at all 16 essential standards of quality and safety in March 2011. We set two compliance actions during this inspection. The first was in outcome 14, supporting workers, as we found little evidence of staff having opportunities for formal support and supervision. We also set a compliance action in outcome 21, records, as we found that records did not always reflect the care and treatment patients received.

We completed a further unannounced inspection in July 2011 as a result of concerns received that patients with complex needs may not have been getting their needs well met. These concerns had been raised with us through safeguarding processes. During this inspection we found that there had been some improvements to some of the risk assessments and care planning around people’s treatment, but that wound care and pressure care risk assessments and care plans had not been fully documented. This meant that the trust could not guarantee consistent and appropriate care of wounds. We therefore set a further compliance action in outcome four to improve their care planning and risk assessments.

This unannounced inspection was completed over three days from 1 to 3 November 2011. The inspector teams looked at medical and surgical wards and theatres. The primary task was to check compliance with standards where we had previously set compliance or improvement actions.

The inspector team included a consultant surgeon who is a professional clinical advisor to CQC. This was because we had noted from the trust’s own quality assurance audits that pre and post operative checks to ensure safe practice had not always been followed..

We spent time on three medical wards, the stoke unit, and two surgical wards. We visited the main theatre block with four theatres, two theatres in the day case unit and the Vanguard (pre fabricated) area with day case units for ophthalmology, gynaecology, breast surgery and day case dental surgery. We did not inspect the maternity theatres as there was no planned surgery taking place on the day we visited. We talked with medical and nursing staff and care workers in these areas. We also spoke with 22 patients and eight visiting relatives/family members.

Patients who spoke with us gave very positive feedback about their experience of being in patients on ward areas. Comments included

“The staff are excellent, they cannot do enough for you, even though they are very busy all day, nothing is too much trouble for them’’

“The nurses are very good, they have really looked after me.’’

‘’ We have nothing but praise for the way my xx has been cared for…when we have needed to ask for information the doctors have given it and the nurses have been really good. You can see how busy they are, but they still make sure xx is comfortable.’’

We saw that there had been significant improvements to the way that patients care and treatment was planned and recorded. The trust had introduced new documentation to record risk assessments and care plans and we found that this was now being completed to good effect.

We saw that the trust had continued to monitor completion of records within ward areas. They had introduced more ward based learning, support and supervision to enable staff to understand the risk assessments and care plans. Staff had also been and to be given support and training in completing assessments and plans.

For those people we identified as having pressure care needs or had been at risk of developing pressure ulcers, we saw that risk assessments and wound care plans were in place. These were being reviewed and monitored well.

We observed patients being cared for in a kind and respectful way that ensured their dignity was respected. All levels of staff within the hospital showed a great deal of respect when addressing patients. We heard examples of staff making sure they explained fully what they were planning to do so that people with communication difficulties or dementia had the opportunity to understand what was being said to them.

We spoke with 30 staff across the hospital and heard that they now had a supervision contract that fully explains supervision and that most have had or had planned supervision sessions in place. Some of this was one to one sessions, group meetings and debriefing sessions where a significant event may have occurred on the ward area.

The inspectors and clinical advisor observed staff carrying out mandatory surgical safety checks on patients undergoing surgery on that day. These checks consist of a “check in” procedure when safety checks are carried out prior to surgery, a “time out” procedure when safety checks are carried out prior to the operation starting and a “check out” procedure at the end of surgery. These are mandatory formalised checks laid down by the World Health organisation Organisation (WHO) and National Patient Safety Agency (NPSA). The checks are performed to enhance patient safety.

In theatres we found that the pre and post operative checks were not properly and fully completed. This placed people at risk. We gave detailed feedback about this at the time of the inspection and we have asked the trust to make improvements to ensure that theatre staff are fully trained to understand the checks and that completion of them is properly monitored. We noted that on the third day of our inspection the Chief Executive had already taken some steps to address how surgical safety checks are monitored. We were assured that implementing more robust procedures would be given immediate priority.

We also found that improvements were needed in some theatre areas to ensure a secure and robust system is in place for the safe storage and recording of medications.

Inspection carried out on 14 July 2012

During an inspection in response to concerns

We decided to carry out this responsive review in response to an overall multi agency safeguarding strategy which is being coordinated by NHS Devon. At the same time NDHT also wrote to us asking us to carry out a review demonstrating their willingness to work in partnership with the Commission.

At the time of this review there are five safeguarding alerts currently being reviewed under DCC safeguarding process and involving NHS Devon and Southwest Strategic Health Authority.

The alerts which have been raised identify potential concerns around specific aspects of care provided to these patients which include:

• how pressure area care is managed

• how well the hospital works with patients with complex needs and/or patients with communications difficulties

• consent and assessing mental capacity for patients

• meeting nutritional and hydration needs

We carried out a responsive review with inspections to the hospital on 11, 12 and 14 July 2011 and because of the concerns we looked outcomes one, two, four and five.

We were not looking at the investigation of these alerts because these are being looked at in the separate safeguarding strategy meetings. The purpose of this review was to check compliance in these key outcome groups for current patients.

In our previous planned review of this hospital in March 2011, we set two compliance actions. One of them was in relation to records (outcome 21). The trust gave us a detailed action plan and this included some key changes to the documentation being used to ensure good care and treatment. They told us they would be fully compliant by the end of September 2011. We continue to monitor this with meetings and requests for further updates. We will also check this by a further unannounced visit to the hospital. However, record keeping was looked at as part of our reviewing compliance with the above outcomes and we have reported upon these under the relevant outcome groups.

Three inspectors spent three days at North Devon District Hospital (NDDH) completing this responsive review, two days on medical and surgical wards including those where issues via safeguarding had been identified; Staples ward, Glossop ward and the medical assessment unit (MAU). We looked at the records of 20 patients and 10 of those in more detail; where we spoke to the individual and or their carer. We also spoke to different staff including nurses, doctors, an occupational therapist, the community psychiatric liaison team and the complex care discharge team. We used an observational tool called SOFI

(Short Observational Framework Inspection) where for periods of time we sat and observed in detail interactions between staff and patients. The mapping tool helps us to understand positive and less positive interaction between the staff and patients. These were completed in two different wards. On the third day we spoke to the trust’s Tissue Viability Clinical Nurse Specialist and to 10 doctors from varying clinical areas to check their understanding and application of consent and the Mental Capacity Act.

Patients told us that they were consulted about their care and treatment. Some patients told us that staff in some wards were busy. In their opinion care and treatment was rushed. One patient said staff were ‘attentive and do their best, but they are very rushed and don’t have the same time.' Another patient described how doctors had spent time with them to explain their illness and the treatment options. They added that the nurses on the ward had also explained the treatment to them.

We saw that consent for care and treatment is considered and documented, but in some areas this needed improvement, particularly around the consent to use bed rails and where clinical decisions are made about emergency treatment. We did see some good examples of where patients lacked capacity to make decisions and a multidisciplinary approach had been used to look at the best interests of the individuals.The trust has training to ensure that mental capacity is assessed fully, but not all staff have completed this. Staff who were less confident in this aspect knew where they could go for support and help. We saw that the introduction of the community psychiatric liaison team has played a key part in improving consent and capacity issues.

We observed lunchtime in three wards and spoke to some people about their experiences. We also looked at records relating to nutrition and hydration, and did not find any significant issues with this. One person told us that for vegetarians on a soft diet the food choices were limited. We have passed this onto the hospital catering manager who agreed to look at this.

Patients we spoke to said that their needs were being met, but we have identified some key areas of concern where lack of assessment and care planning could place people at risk. Essentially this is around pressure damage and wound care. We did not find that outcomes for people were poor, but we did find that wound care plans were not being reviewed and monitored sufficiently to ensure appropriate treatment was consistent. We are aware that the trust are auditing and monitoring this closely. They also have a new generic wound care plan, but this was not being used during this review. We have set a compliance action in respect of this and we will be reviewing this again in the near future with further unannounced visits to the hospital.

As part of the safeguarding strategy meeting information request, the Trust sent us

their policies and guidance for the use of two mechanical devices post operatively to help prevent the risk of a deep vein thrombosis. Our specialist advisors have assured that the guidelines are appropriate but one of the references needs updating

Inspection carried out on 2 March 2011

During a routine inspection

During our visits to the hospital we spoke to both in patients and out patients about their experiences. We spoke to a total of 50 patients during our visits either as out patients or in patients on ward areas. Overall we heard very positive comments about individuals' experiences of using the hospital. One patient whom we spoke to said they had made several complaints over the years about their treatment via PALS, but at the end of the discussion said ''I still really rate the staff here, they do a great job of looking after us.''

Another patient we spoke with said they had known the hospital over several years and felt the service it provided was ‘just getting better and better’. Other patients also reflected they felt the care services provided had improved over recent years.

One relative said ''They could not have treated my wife better, I am really impressed with all the staff here, nothing is too much trouble.'' Another person told us ''On the whole staff are smashing, you may get a personality clash with one or two, but on the whole they have been great, really caring.''

We spoke with four people who were representatives for children who were staying on the children’s ward. All described their experiences as very positive, verbalising that staff always explained to them and their children what was going to happen whilst they were on the ward.

We observed care and treatment being delivered, by a cross section of trust staff, in a kind and respectful way.

Patients we spoke to gave a variable response about the food at the hospital. One patient reported it as ‘’lousy’’ and another said ‘’best not to mention what I think about the food.’’ Some patients gave more favourable responses. These tended to be in patient areas where stays were only for a short while, such as maternity. We saw that the hospital only have a one week menu at present and some people described this as ‘’very monotonous’’ and we were told that the week end pureed food was not appetising. We saw people being assisted to eat their meals when needed and that drinks and snacks were available.

Patients we spoke to had no complaints about the environment or cleanliness of the hospital. Most comments very positive and included ''It is kept very clean, I have no complaints.'' ''The cleaning staff work hard and do a good job.''

We heard that patients felt that staff explained their treatment to them, and that they were involved in decisions about their care and treatment. We were told that patients did feel comfortable in being able to make their concerns known.

One patient said ‘I don’t need to ask questions because they explain it so well’. Another said, ‘If there’s something I don’t quite understand, I just say so, and they explain everything.’ A third person, who had a hearing impairment, said the doctor realised the patient wasn’t understanding what he was saying because of his hearing difficulty, and then wrote everything down for him.

One patient in an acute medical ward said that ‘the staff are very good’. We saw staff engaging well with people, sometimes lightening their mood and sometimes acknowledging their distress with kindness. We heard staff ask how people were getting on with their treatment or a dressing and listening to them. One relative said ‘You can’t fault them (the staff). They jolly you along and they are lovely about everything’. They went on to say that the care in accident and emergency was ‘wonderful’.

We saw that the care and nursing staff had a good understanding of patients needs and care and treatment were being delivered appropriately, but that some records were not well maintained and this could lead to potential risk of care or treatment not being well monitored.

Staff working at the hospital told us that they have good training and that most have had an annual appraisal, but we found that regular planned support and supervision was not in place for all staff. This meant that there is no clear audit of how staff competencies are checked and that staff may not have had opportunities to discuss their skills and ongoing training needs on a regular basis.