Archived: Tiverton and District Hospital

The trust told us they had introduced regular audits of the treatment escalation plans (TEP), that detailed end of life care decisions and mental capacity assessment forms to ensure consistent and sustained compliance. We saw completed TEP audit forms. The forms were completed shortly after each new admission and collated weekly to be sent to the safety team for collation.

The patients we spoke with told us they felt involved in their care and treatment. Two patients told us their wishes around resuscitation had been discussed with them and their wishes adhered to. All of the patients we spoke with knew about plans for their discharge and the current work with therapists in order to prepare them for discharge home. One said 'they talk to me about what is going on with my exercises' another said 'I see the physio every day and have seen improvements in what I can do'.

We looked at nine sets of care records, which included a TEP and associated medical records across both wards and found they were all fully completed.

We were told and saw evidence that the GPs responsible for completing the TEPs and mental capacity assessments had received training in completion of the documents and had received follow up information for reference.

Since the last inspection the Care Quality Commission (CQC) had received two anonymous concerns about low staffing levels on Blackdown and Twyford wards. The first concern, received in October 2013, was referred to the Trust to respond too. The Trust told us there had been an increase in short term sickness at this time and they provided us with assurance that staffing levels were safe. The second concern was received by CQC in January 2014. We looked at this concern as part of this inspection.

Two CQC inspectors spent 10 hours at the hospital. We spoke with 17 patients and three relatives across the two wards. We also spoke with 18 members of staff, including nurses, health care assistants; members of the therapy team (occupational therapist and physiotherapist), senior nurse managers, the Matron and the senior manager responsible for Community Hospitals.

Patients expressed a high level of satisfaction with the care and treatment they received. They were particularly positive about the staff attitude and approach. Comments included, 'They (staff) offer support in a very nice way', 'Staff don't make me feel anything is too much trouble' and 'I have been very happy with the care. I am feeling much better. The staff are a real help'.

Although the hospital had experienced staffing difficulties at times due to high levels of staff sickness, the Trust were committed to ensuring that adequate staffing levels were maintained. They had a number of mechanisms in place to deal with staff shortages, including regular use of bank and agency staff. Where staffing had not met the preferred levels, decisions were made to close admissions to vacant beds in order to mitigate risks to patients. Data showed that no significant harm had been caused to patients as a result of preferred staffing levels not being met.

We found improvements were needed to ensure the hospital always acted in accordance with legal requirements where patients lacked capacity in relation to "do not resuscitate" orders.

We saw or met all of the in-patients and spoke with 17 in some depth. Some people were unable to fully verbally communicate their views to us due to degrees of confusion, dementia and memory loss. We spent time observing the care and support provided to them. We also spoke with seven relatives and 17 members of staff, including the hospital matron, ward manager and sister, nursing staff, health care assistants, physiotherapists, occupational therapists and one GP. We also spoke with community health professionals, for example a palliative care nurse specialist who provided support to patients and staff on the wards.

Patients told us they were happy with their overall care. They told us staff were friendly and respectful. They highly rated the food and cleanliness of the hospital.

We found two outcomes where improvement was needed. The hospital did not always act in accordance with legal requirements in relation to 'do not resuscitate' orders. There were not always enough qualified, skilled and experienced staff to meet people's needs.