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Inspection Summary


Overall summary & rating

Updated 17 April 2014

Torbay Hospital is in Torquay. The hospital has both acute and mental health services on site provided by two different NHS trusts. This inspection looked at the mental health services only, which are run by Devon Partnership NHS Trust.

The mental health services provided by Devon Partnership Trust consist of one acute admission ward for adults of working age, Haytor Ward which has 17 acute beds and 2 detox beds. Haytor Ward provides assessment, care and treatment for men and women with mental health needs. Also based on this site is Beech ward currently providing care and treatment for 14 older patients. The ward provides assessment and treatment for older people with mental health needs, such as depression, anxiety and psychosis.

We found areas of good practice and many positive findings across adult and older inpatient services in Torbay. Patients were mostly positive about staff and told us they were compassionate and caring. Patients confirmed there was a recovery approach to care and support, which they found responsive to their needs and experienced at all stages of their hospital stay. On the ward for older people, potential risks associated with ageing, such as falls, were well managed and meant that people’s health was promoted.

Patients confirmed the accommodation was comfortable. The hospital environment offered people privacy. All areas of the hospital were clean and staff followed good infection control practice.

Staff morale was generally positive and multi-disciplinary teams worked well together. There was an open culture on both wards and staff were confident about raising concerns. Governance arrangements were in place and monitored the performance of the services. Both ward managers demonstrated they had a good knowledge and understanding about their services and wanted them to succeed.

There were a number of improvements needed in the services, specifically for people using the acute services on Haytor Ward. Too many patients in crisis are being taken to police stations or the local emergency department rather than to the trust’s own 136 suites (which are the designated health-based places of safety). In the year ending November 2013 in South Devon, 47 patients used the trust’s own place of safety suite and 134 went to police custody.

For the past six months, 44% of adult patients from South and West Devon needing an acute admission had to go to Exeter and a few to North Devon. This means they are a long way from relatives, carers and their community care professionals. At the time of our inspection the acute older adult ward in Torbay was occupied by 40% of working age adults although many were over the age of fifty. The staff of the older people’s mental health community service in Torbay expressed difficulties in finding beds for older adults who required admission.

We were also concerned about the safety of patients who may need restraint or seclusion. In Torbay there is one seclusion room which is in a potentially unsuitable location on a suspended ward and different floor to Haytor Ward. We found that some recording of the use of seclusion is poor impacting on the effective monitoring of its use across the trust. In addition 21% of staff on Haytor Ward had not received up-to-date training to manage incidents where physical restraint might be required. We also found that some patients were staying in seclusion for long periods of time based on their clinical need while a bed in a Psychiatric Intensive Care Unit was found.

We found patients were lawfully detained; however there was room for improvement in the recording of procedures required under the Mental Health Act and Code of Practice. This included the recording of risk plans associated with section 17 leave.

Patients and staff told us that engagement with patients does not occur as frequently as they would like. This was attributed to periods of high activity and being busy with office duties. Some patients on the older people’s ward told us there was not enough to keep them occupied. Beech Ward had less occupational therapy input and access to activities.

In Torbay engagement with staff was variable. The trust has been running a ‘Listening into Action’ programme with mixed feedback about these events. In Torbay some staff felt the trust was not really listening or acting on what staff had said. Some staff on Haytor were negative about the trust’s performance management. They said the trust had its priorities wrong and focussed too much on “targets rather than quality of care”.

Inspection areas

Safe

Updated 17 April 2014

Systems were in place to capture and report incidents and notify external bodies. However, incident reports did not always contain detailed information explaining exactly what had occurred. For example, they did not detail what constituted as ‘threatening behaviour’ or exactly what occurred during the process of escorting a patient to seclusion. Teams were learning from incidents to improve the standards of safety for patients.

The ward environment on Haytor did present a number of ligature risks of which the staff were aware. These had been risk assessed and management plans were in place.

Staff understood and followed safeguarding procedures. 

Effective

Updated 17 April 2014

Patients experienced care and support based on the recovery model of care. This was supported by our observations of the use of appropriate clinical guidance, standards and best practice.

There were good examples of collaborative working between the ward teams, with people using the services and with external professionals.

Quality audits were used to guide and improve patient care. Care plans and risk assessments were not always person-centred or evidence based. It was not clear from some care plans if patients had been involved with writing them. Two patients on Haytor told us that they had not been involved with their care plans but would have liked to have been involved. 

Caring

Updated 17 April 2014

The majority of the patients spoke positively about the staff and many patients were full of praise and said that staff were kind, caring and mostly met their needs. Patients consistently raised concerns about not being able to access staff when they needed to. Staff confirmed they were not always able to speak with or engage with patients when they had requested as they were busy.

We observed that staff communicated with patients in a respectful way, listening and acting upon their wishes. Patients’ privacy and dignity was maintained.

People who use the service, and carers, felt able to make choices and be involved in review meetings. Staff were aware of carers needs and involved them as far as possible. We observed that staff provided support to relatives without breaching confidentiality. 

Responsive

Updated 17 April 2014

Major improvements are needed to the responsiveness of services so they meet the needs of people who use them, especially for adults accessing acute services. One of the wards at Torbay is currently suspended.

Patients knew how to make complaints if they wanted to. Staff told us how they would support patients to make complaints and how the ward would learn from any complaints made.

Well-led

Updated 17 April 2014

There was an open culture within both ward teams. Staff told us that they felt supported by their clinical team leader and the wider multi-disciplinary team.

Both clinical team leaders were knowledgeable about the wards and the needs of the patients and how to deliver good practice in their area.

Staff told us they felt able to report incidents and raise concerns and that they would be listened to. The Senior Nurse Manager told us that they felt senior managers in the Trust listened to concerns that they raised and acted on them. However some staff told us that they felt the trust was not really listening or acting on what staff had said and that it was focussed too much on “targets rather than quality of care”.

Checks on specific services

Acute admission wards

Updated 17 April 2014

We found areas of good practice in the acute adult inpatient ward in Torbay. Patients were mostly positive about staff and told us that they were compassionate and caring. Patients confirmed there was a recovery approach to care and support, which they found responsive to their needs and experienced at all stages of their hospital stay. This was supported by good occupational therapy services.

Patients said the accommodation was comfortable. The ward offered people privacy. All areas of the ward were clean.

Staff morale was generally positive and they worked together well in multi-disciplinary teams. There was an open culture and staff were confident in raising concerns. Governance arrangements were in place and monitored the performance of the services. The ward manager demonstrated a good knowledge and understanding about their service and wanted it to succeed.

There were a number of improvements needed in the services. Too many patients in crisis are being taken to police stations or to the local emergency department rather than to the trust’s own 136 suites (which are the designated health-based places of safety). In the year ending November 2013 in South Devon 47 patients used the trust’s own place of safety suite and 134 went to police custody.

For the past six months, 44% of adult patients from South and West Devon needing an acute admission have had to go to Exeter and a few to North Devon. This has meant they are a long way from relatives, carers and their community care professionals.

We were also concerned about the safety of patients who may need restraint or seclusion. In Torbay there is one seclusion room which is in a potentially unsuitable location on a suspended ward on a different floor to Haytor ward. We found that some recording of the use of seclusion is poor and this affects the effectiveness of monitoring of use across the trust. In addition 21% of staff on Haytor ward had not received up-to-date training to manage incidents where physical interventions might be required.

Patients and staff told us that engagement with patients does not occur as frequently as they would like. This was attributed to periods of high activity and being busy with office duties.

Engagement with staff was variable. Some staff on Haytor were negative about the trust’s performance management. They said that the trust had its priorities wrong and focused too much on “targets rather than quality of care”.

Services for older people

Updated 17 April 2014

Beech ward provided a high standard of care to people using the service. It was a safe and secure place for patients to stay, where staff cared for them in the least restrictive way.

Patients told us that they felt safe and well cared for. However, two patients told us that there was not always a lot to do and they sometimes got bored.

Carers were full of praise about the service provided to their relatives. Where patients did not have mental capacity, appropriate steps were taken to promote their rights through best interest and involvement of carers. However, one capacity assessment we saw, which deemed the patient not to have capacity, was only partially completed. It was not evident from this assessment that the principles of the Mental Capacity Act had been followed.

Patients had thorough assessments, which considered appropriate risks and health issues related to the ageing process. Patients were involved in discussions about treatment options available and alternatives to inpatient care, such as adult social care providers in the community.

Management of risks and care planning was done on an individual basis. Good quality information was given to carers and individuals throughout their stay at the ward.

Collaborative working across all sectors and services was evident to ensure patients had the right support and experienced seamless care.

The manager on Beech was passionate and promoted best practice. Staff worked well together as a multi-disciplinary team. There was an open culture on the ward and staff were confident in raising concerns. Morale was positive on Beech ward.

The governance of the hospital was monitored at both local and Trustwide levels by senior managers. 

Mental Health Act responsibilities

Updated 17 April 2014

We found that patients were lawfully detained; however there was room for improvement in the recording of procedures required under the Mental Health Act and Code of Practice. This included the recording of risk plans associated with section 17 leave.

Care planning and risk assessments were not always fully completed or inclusive of the patient’s views.

We found for two patients that they had been receiving medication without the appropriate authority to treat in place.

We heard about difficulties in accessing psychiatric intensive care facilities which are not commissioned from the trust and that this could mean patients being secluded for periods based on clinical need to manage this risk.

The use of seclusion is not being recorded appropriately and this affects the quality of the monitoring. We found that there were difficulties in accessing the seclusion facility due to this being sited on a different floor within a separate unit.

We found that there was a programme of audit in place to consider how well the Mental Health Act is being implemented at the hospital. Audits undertaken included recording of consent to treatment, information on rights, section 17 leave arrangements, discharge arrangements and use of the place of safety.

Other CQC inspections of services

Community & mental health inspection reports for Torbay Hospital can be found at Devon Partnership NHS Trust.