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Provider: Torbay and South Devon NHS Foundation Trust Good

On 26 June 2018, we published a report on how well Torbay and South Devon NHS Foundation Trust uses its resources. The rating from this report is:

  • Use of resources: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 2 July 2020

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Inspection areas

Safe

Requires improvement

Updated 2 July 2020

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Effective

Good

Updated 2 July 2020

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Caring

Outstanding

Updated 2 July 2020

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Responsive

Good

Updated 2 July 2020

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Well-led

Good

Updated 2 July 2020

We have not updated trust-level ratings following these core service inspections because we were not able to complete the trust-level well-led inspection. This is due to suspension of routine inspections during the COVID-19 pandemic. Refer to the previous inspection report for the detailed findings on which the ratings are based.

Assessment of the use of resources

Use of resources summary

Requires improvement

Updated 2 July 2020

We rated it as requires improvement.

NHS England and NHS Improvement undertake the Use of Resources assessments. The report is available on our website.

Checks on specific services

Community health inpatient services

Good

Updated 2 July 2020

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

  • Wards areas were exceptionally clean and had suitable furnishings and equipment that were clean and well maintained. Staff used control measures to prevent the spread of infection such as adhering to hand washing techniques and the use of personal protective equipment.
  • Comprehensive risk assessments were carried out for people who used the services, and these were reviewed and managed appropriately. Risk management plans were developed in line with national guidance, such as the use of Malnutrition Universal Screening Tool (MUST) for patients.
  • The service had enough medical and nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The service used clear and effective systems and processes to safely prescribe, administer, record and store medicines. These were in line with the relevant legislation and current national guidance, such as having dedicated pharmacist input to support with medicines optimisation.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness. All wards used an evidence-based SAFER patient flow bundle, which is a practical tool to reduce delayed discharges for patients in adult inpatient wards. Staff monitored the effectiveness of care and treatment. They used findings to make improvements and achieved good outcomes for patients such as maintaining the average length of stay less than the national average of 28 days.
  • Staff ensured patients maintained their nutrition and hydration to meet their needs and improve their health. The service made adjustments to menus to cater for patients’ religious, cultural and dietary needs.
  • The service had a strong sense of multidisciplinary team working to benefit patients. Staff across all disciplines documented patients care and treatment to a high standard. Care was delivered and reviewed by staff in a coordinated way with different teams, services and organisations across the trust area. Specialist nurses and doctors were regularly visiting wards to provide guidance and inform care for patients they were supporting in the community.
  • Managers appraised staff’s work performance. Appraisal compliance was good at all the wards and staff felt they had opportunities for personal and professional development.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Patients told us they felt safe and were well looked after. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Staff encouraged the involvement of families and carers when making decisions about patient’s care, treatment and living arrangements following discharge.
  • The service planned and provided care in a way that met the needs of local people and the communities served. This included good working relationships with charities that provided support to patients on the wards and supported patients discharge back to their own homes.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. All premises were wheelchair friendly and special equipment could be sourced easily. People could access the service when they needed it and received the right care in a timely way. Across the service there were no waiting lists.
  • Managers at all levels had the right skills and abilities to run a service providing high-quality sustainable care. Managers had been resourceful when managing periods of staff vacancies.
  • Managers promoted a positive culture that supported and valued staff, creating a sense of common purpose based on the trust’s vision and values.
  • There were effective structures, processes and systems of accountability to support the delivery of good quality services. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. Managers had engaged staff in various initiatives to improve safety around falls and this was reflected in a reduction in the number of falls.
  • The service collected, analysed, managed and used information well to support all its activities. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff.

However:

  • Hazardous substances had not been stored away safely at Totnes Community Hospital.
  • Equipment had been stored in communal corridors on Teign ward, Newton Abbot and Brixham Community Hospital causing a potential trip hazard.
  • Supervision of staff varied across the service and the majority of staff were not receiving supervision in line with the trust policy.
  • Advocacy had not been promoted or accessed at any of the wards we visited.
  • Most staff we spoke with lacked an understanding of how cultural, social and religious needs may relate to care needs.

Community health services for children, young people and families

Good

Updated 17 May 2018

  • At this inspection we found that improvements had been made to improve services, including addressing shortfalls identified at our previous inspection. We had previously rated the safe, responsive and well-led domains as requiring improvement, with effective and caring rated as good. At this inspection all domains were rated as good.
  • We found the service supported and provided safe and good quality care for patients. A number of initiatives had been put into place to improve the delivery of service. This included the introduction of electronic records for some services and the introduction of new safeguarding supervision framework.
  • Business continuity and emergency plans had been given more visibility to staff.
  • There were various examples of excellent multi-disciplinary working, including joint assessments and working with colleagues from the acute service and GP practices.
  • Care and treatment was delivered by well trained, caring, professional and motivated staff.
  • Families were positive about the compassionate, supportive and informative approach of staff. Staff were friendly and helpful to parents and children.
  • Referral to treatment times had been reduced and services had improved access for parents with flexible bookings, drop-in clinics and online social media information. Nursing and therapy services proactively looked to respond to the needs of families as quickly as possible.
  • Good leadership was provided in all the services. Staff were positive about their managers and felt able to approach them with ideas or concerns. Staff were well informed about developments in the trust and were aware of the values and vision of the organisation.
  • There were clear governance structures and reporting on performance that informed managers and service development. Risks were identified and managed.

However:

  • There were potential risks as staff may not have had the information they required, due to different services using different recording systems.
  • The waiting time for an assessment for a child with an autistic spectrum disorder was 12 months.
  • Some staff were concerned about the visibility of the chief nurse and other board members to community based staff. They felt although they were part of an integrated service, the board was more focused on the acute service. Many staff had not met, or seen, board members visiting the community services and meeting them in their working locations.
  • Whilst some changes had been made there was lack of formal engagement processes and feedback arrangements to gain the views of children.

Community end of life care

Requires improvement

Updated 17 May 2018

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

  • The ratings for safe, effective and well-led remained the same as from the last inspection – requires improvement.
  • We found two breaches of regulation that were identified at the last inspection had not been addressed fully. These were regarding failure to ensure that the requirements of the Mental Capacity Act 2005 were adhered to in situations where a patient lacked capacity to make decisions about their care and treatment. We found documentation was not consistently or fully completed to ensure patients were safeguarded when lacking the capacity to make informed decisions.
  • There was insufficient evidence to demonstrate that staff were trained and competent to carry out their roles. The trust was unable to provide an overview of the training – both mandatory and role-specific – to demonstrate the workforce was up-to-date with their training. This was partly due to the trust not having a dedicated community end of life team. Training records were held by staff and at a local ward/team level. However, records provided were confirmed to be out-of-date, therefore not providing an accurate reflection of the training completed. The trust told us they were in the process of centralising records into the trust-wide electronic systems.
  • Staff safety and patient care could have been compromised by the use of mobile phones that were not fit for purpose within the community nursing teams.
  • Risks to the service were reported and recorded but action was not consistently taken in a prompt way to ensure the risk was reduced.
  • There were, at times, insufficient staff to provide care and treatment to end of life patients.
  • Staff were not provided with guidance or information on the action they were to take to meet the individualised care and treatment needs of patients. The care plans were generic and did not specify personalised care wishes and preferences.
  • The trust did not monitor outcomes for patients in a formal or systematic way. This did not ensure that the trust were able to identify areas for improvement. There were insufficient governance processes to enable full oversight of the end of life care service.

However:

  • We rated the trust as good for the caring and responsive domains.
  • The trust had taken action to address a breach in regulation regarding medicine management. At the last inspection it was identified that untrained staff were checking the administration of controlled drugs. Since the last inspection additional training had been provided to staff who were not registered nurses to ensure they were competent to carry out these tasks.
  • Staff understood their roles and responsibilities to safeguard patients from abuse and raised concerns appropriately, taking action when necessary.
  • Staff worked well as multi-disciplinary teams. Meetings and joint visits to patients we attended demonstrated excellent team working between professionals.
  • Patients and their relatives/representatives were consistently positive about the caring, compassionate and supportive care they received from staff.
  • Staff were supported at a local level by their managers. The culture of the service was open and staff felt they were able to raise concerns or seek support whenever needed.

Substance misuse services

Updated 7 June 2016

We do not currently rate specialist substance misuse services. We found the following areas of good practice:

  • There were sufficient staff numbers to meet the needs of people who used the service.

  • Interview rooms were sound proof and staff were provided with safety alarms when using interview rooms.

  • The service provided comprehensive support for people’s healthcare needs associated with substance misuse. Staff supported people with blood-borne virus testing and vaccination programmes.

  • People had access to other medical interventions through the local hospital and GP surgeries. This included electrocardiograms (ECGs) required for all people receiving high doses of methadone, to monitor the effect on their hearts and liver function tests to ensure that people were physically fit enough to undergo the prescribing regimes.

  • People could access the service quickly. Staff were assessing people and providing substitute prescriptions within the three week guidelines set by Public Health England.

  • Risk was assessed by staff and documented on the electronic records system. Risks were an agenda item and discussed at every team meeting and recorded within the care records. Staff put measures in place to reduce and where possible prevent risks from occurring.

  • Staff regularly reviewed people’s recovery plans. People were involved with and had signed their recovery plans.

  • Staff discussed discharge plans with people from first assessment. This included asking people how long they wanted to be in treatment so they could plan appropriate treatment goals.

  • Doctors and non-medical prescribers followed guidelines for prescribing, as described in the Drug Misuse and Dependence: UK Guidelines on Clinical Management (2007).

  • The service took a clear and well laid out approach to use of illegal substances on top of prescribed medicine. This was mentioned in an introductory leaflet and through verbal discussion between clients and staff.

  • Staff kept comprehensive records following medical reviews. The records were person-centred and recovery focused, and included an assessment of the person’s prescribing treatment plan.

  • Volunteers provided a variety of support to people and were developing ways to engage people with the treatment system.

  • The service was flexible and staff saw people in places closer to their home to reduce the need for them to travel to the main office. There were options to be seen out of hours and at the weekend.

  • Staff made a concerted effort to engage with and follow up people that did not attend appointments.

  • The trust gave staff opportunities for leadership and development across different roles within the service.

  • Ninety per cent of staff had completed mandatory training and some training dates had been booked in February 2016.

  • All staff had undertaken specialist substance misuse training.

  • Staff had received regular supervision and annual appraisal.

  • Staff felt supported and spoke highly of the managers. All staff spoke highly of the service manager. The service manager felt supported by the trust.

However, we also found areas the service could improve:

  • The fire extinguishers had not been checked since 2014. We raised this with the service manager and the trust carried out immediate checks.

  • The ligature audit indicated ligature risks had been removed or replaced, however, there were visible ligature points around the building. These were low risk because the service is a community service but the service should be aware of the risks and have management plans in place. The trust took immediate action and carried out a health and safety audit at Walnut Lodge after we raised this.

  • Some staff areas were unclean and in a state of disrepair. For example, the staff toilet had very dusty surfaces and the wall paper was torn in several places.

  • The clinic room was left unlocked and staff did not see this as a risk because medicines were kept locked in cupboards and the fridge. However, other items were accessible including needles and the keys to the cupboard and fridge were kept on a shelf in the clinic room.

  • Monitoring of liver function tests (LFTs) was not always good. We were told that LFTs were carried out by GPs and they didn’t always get the results back. There was evidence that where the risk was indicated as very high, people were referred to and seen by the liver specialist nurse at Torbay. LFTs had been obtained for high risk clients.

  • Risk assessment documentation was not always up to date which meant that it was sometimes difficult to get an immediate view of current risks. However, from speaking with staff, observing team meetings, looking at team meeting minutes, and reviewing the daily electronic care records, it was evident that risk was regularly discussed and reviewed in detail.

Community health services for adults

Outstanding

Updated 7 June 2016

We rated community adults service as outstanding because:

  • The trust encouraged openness and transparency about incident reporting and incidents were viewed as an learning opporotunity. Staff felt confident in raising concerns and reporting incidents and near misses.

  • There were effective handovers during the shifts, to ensure staff managed risks to patients. Urgent visits were allocated quickly to respond to the changing needs of patients.

  • Patients were involved in managing their identified risks and risk assessments were proportionate and reviewed regularly.

  • There were defined and embedded systems, in place to keep patients safe and safeguarded from abuse.

  • Patients care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.

  • Patients care was coordinated when a number of different staff were involved in their care and treatment. All relevant staff were involved in the assessing, planning and delivery of patient care and treatment. Staff worked collaboratively to meet patients needs.

  • Staff were qualified and had the skills they needed to carry out their roles effectively and their learning were identified. Training to meet these needs was put in place and as well as other training to learn new skills pertinent to their roles.

  • Consent to care and treatment was obtained in line with legislation and guidance. Patients were supported to make decisions and, where appropriate, their mental capacity was assessed and recorded.

  • Patients were supported by all staff in the delivery of their care and treatment. They were treated with dignity and respect.

  • Staff anticipated patients’ needs and maintained their privacy and confidentiality at all times.

  • The assessed needs of all patients were taken into account when planning and delivering services.

  • Patients were able to complain or raise a concern and they were treated with openness and transparency. Their complaint or conern was listened and improvements were made to the quality of the service provided.

  • There was an effective and comprehensive governance processes in place to identify, monitor and address current and future risks.

  • Senior managers at every level prioritised safe, high quality and compassionate care . All staff felt managers at all levels were approachable and listened to their views and they felt able to report any concerns to them.

However:

  • The out of hours community nursing service had difficulty at times in accessing equipment at night as there was central storage facility where all equipment needed was stored and this had led to delays in treatment, for example syringe drivers.

  • There were concerns regarding lone working for community nurses in Newton Abbot zone. Between the hours 5pm to 7pm at a weekend as the qualified nurse was alone.

  • Appraisal rates for some zones and specialist services were as low as 50%, below trust target.

  • Evidence of consent being obtained for procedures was not always clearly documented in the patients’ notes within the outpatients department in Newton Abbot.

  • Up to March 2016, the trust was failing to meet the national standard for outpatient activity. The reasons were attributed to higher than expected new patient activity in podiatry and orthotic services, staff vacancies and inability to recruit to these posts quickly.

Specialist community mental health services for children and young people

Good

Updated 7 June 2016

We rated specialist community mental health services for children and young people (CAMHS) as good because:

  • Staff were caring and supportive. Patients, families and carers were satisfied with the service. They said their treatment helped them.
  • Patients were assessed within target times of six weeks for a routine referral and could access urgent assessment and treatment if they needed it.
  • Care was personalised, holistic and recovery orientated. Patients were given a choice of locations for their treatment appointments to help them feel comfortable.
  • Staff had good access to training including training in different kinds of therapy and mandatory training.
  • Evidence based therapies recommended by the National Institute for Health and Care Excellence (NICE) were available.
  • Patients completed outcome measures throughout their treatment. These were used to understand patients’ difficulties and to ensure patients were getting better. Patients could see graphs of their progress.
  • The service actively worked with other agencies in health, social care and education to provide joined up and preventative care and involved those agencies in the redesign of the CAMHS service.
  • The service was committed to innovation and aimed to prevent mental health problems in children and young people and reach them sooner when they were unwell.

However

  • Waiting times for treatment were long at up to 36 weeks, although there was a clear strategy to bring this down to 18 weeks by the end of March 2016. Patients were not actively monitored to detect potential deterioration in their mental wellbeing or increases in risk whilst they were waiting for treatment.
  • Four out of the nine care records we looked at had risk assessments and crisis plans which were not fully completed and updated.
  • Patients’ physical health was not consistently checked. When patients were weighed and measured this was not done in a private place.
  • The provider was not ensuring staff were adhering to safe lone working practices and there was no fixed alarm system in the building for staff to seek urgent assistance.

Community dental services

Outstanding

Updated 7 June 2016

The service was outstanding in providing caring and responsive services and good for providing safe, effective and well led services.

Torbay and Southern Devon Health and Care NHS Trust provides health services from 11 community hospitals and community services. During our inspection we visited three locations which provided a dental service:

Castle Circus Health Centre – (also known as the Community Dental Service) provides NHS dental treatment for patients with complex medical histories and patients with learning disabilities. It also provides dental treatment to looked after children.

Brunel Dental Centre – Special care dental service (also known as the Community Dental Service) provides NHS dental treatment for patients with complex medical histories and patients with learning disabilities. It also provides dental treatment to looked after children

Torbay Hospital – Speciality Care Dental Service for the treatment of complex dental problems.

Overall we found dental services provided safe, effective, caring, and responsive and well led care. We observed and heard practitioners were providing an excellent service in the locations with exceptionally responsive, caring compassionate and respectful staff.

Dental services were effective and focussed on the needs of patients and their oral health care. We observed good examples of effective collaborative working practices and sufficient staff available to meet the needs of the patients who visited the clinics for care and treatment.

All the patients we spoke with, their relatives or carers, said they had positive experiences of their care. We saw good examples of care being provided with compassion; and effective interactions between staff and patients. We found staff to be hard working, caring and committed to the care and treatment they provided. Staff spoke with passion about their work and conveyed how dedicated they were in what they did.

At each of the locations we visited staff responded to patient’s needs. We found the organisation actively sought the views of patients, their families and carers. People from all communities, who fit the criteria, could access the service. Effective multidisciplinary team working ensured patients were provided with care that met their needs, at the right time and without delay.

There were elements of outstanding practice at all the locations visited.

Reference: Urgent care services not found

Good

Updated 7 June 2016

We have rated urgent care services in the minor injuries units as good overall because:

  • Openness and transparency about safety was encouraged. Lessons were learned from incidents and communicated widely to support improvement.

  • Safeguarding of vulnerable adults and children was well understood and implemented.

  • Risks to people who used the department were assessed, monitored, and managed on a day-to-day basis. Staffing levels and skill mix were planned, implemented and reviewed.

  • All minor injury units were well maintained and well equipped. However, the servicing and replacement of some equipment was not always up-to-date.

  • Care and treatment was planned and delivered in line with current evidence-based guidance and best practice.

  • Staff were well qualified, competent and demonstrated the skills required to carry out their roles effectively. They worked collaboratively with multidisciplinary teams from community services and acute services in order to ensure the best outcomes for their patients.

  • Feedback from patients and those close to them confirmed that staff were caring and kind. Communication with children and young people was age appropriate and thoughtful.

  • Each minor injury unit was easy to access and there was sufficient space for the number of people using them.

  • 99.8% of patients were treated, discharged or transferred within four hours during 2015. The average time to treatment was 23 minutes.

  • People with dementia or learning disabilities received care and treatment that was sympathetic and knowledgeable.

  • It was easy for people to complain or raise a concern and they were taken seriously when they did so.

  • The minor injury units had an effective and cohesive leadership team who identified with a strategy of delivering more care and treatment in a community setting.

  • Governance arrangements were well structured with risks and quality being regularly monitored and action taken if necessary.

However:

  • X-ray services were not always available when patients needed them. At Totnes, Brixham and Paignton the X-ray departments were only open for half days for much of the week. There were no X-ray services at weekends which meant that patients had to go to the emergency department at Torbay if a fracture was suspected.