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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 17 May 2018

Our rating of the trust improved. We rated it as good because:

  • Effective, responsive and well-led were rated as good. Caring was rated as outstanding. Safe was rated as requires improvement.
  • Acute maternity services were rated as requires improvement overall. Safe and well-led were both rated as requires improvement. Effective, caring and responsive were rated as good. We cannot compare maternity service ratings with previous inspections because our previous inspections also included gynaecology.
  • Acute end of life care got better since our last inspection and was rated as good overall. Safe stayed the same and was rated as requires improvement. Effective, caring and responsive stayed the same and were rated as good. Well-led improved and was rated as good.
  • Acute outpatients were rated as good overall. Effective was not rated. Caring, responsive and well-led were all rated as good. Safe was rated as requires improvement. We cannot compare acute outpatients ratings with previous inspections because our previous inspections also included diagnostic imaging.
  • Community health services for children and young people got better since our last inspection and were rated as good overall. Safe, responsive and well-led all improved and were rated as good. Effective and caring stayed the same and were rated as good.
  • Community end of life care stayed the same since our last inspection and was rated as requires improvement. Safe, effective and well-led stayed the same and were rates as requires improvement. Caring and responsive stayed the same and were rated as good.
Inspection areas

Safe

Requires improvement

Updated 17 May 2018

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

  • In maternity, not all staff had completed mandatory training, including safeguarding. Infection control policies and audits of medicines and equipment were not fully complied with. World Health Organisation (WHO) checklists were not audited and patient records for monitoring and recording deteriorating health were not consistent. However, staffing levels kept patients safe and there was a positive incident reporting culture.
  • In acute end of life, comprehensive records of patients’ care and treatment plans were not being kept and advanced care planning documentation was not being used. Not all medical staff had completed mandatory training, including safeguarding. Bottles used for holding cleaning chemicals were not always clearly marked with their contents and actions to take in case of accidental exposure. However, learning from incidents was implemented and do not attempt cardio-pulmonary resuscitation records were clear. Improvements had been made to the mortuary refrigerators following our previous inspection and medicines were managed well.
  • In outpatients, the fracture clinic environment did not allow good infection prevention and control, or protect patient confidentiality. Not all staff were up-to-date with mandatory training, including safeguarding, and patient records were not always stored securely. However, there were comprehensive patient risk assessments and there was a positive incident reporting and learning culture.
  • In community children and young people, most staff were up-to-date with mandatory training, and all staff were up-to-date with the appropriate level of safeguarding training. There was a positive incident reporting culture, and learning from incidents was evident. Records were clear and up-to-date, treatment areas were visibly clean and well-maintained, and there were sufficient staff to keep patients safe. However, the upkeep of premises varied and remote access to records was unreliable.
  • In community end of life, not all staff were up-to-date with mandatory training and there were not always sufficient staff on duty to keep patients safe. Staff did not always have sufficient information available to them to treat patients according to their needs. However, staff were aware of their safeguarding responsibilities and took action where necessary. The prevention and control of cross-infection was managed well and medicines were managed safely.

Effective

Good

Updated 17 May 2018

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

  • In maternity, policies were aligned with national guidance and best practice, and a programme of audit was used to make improvements to services. Patients’ pain levels were regularly reviewed and medicines were available to control pain. There was effective multidisciplinary working between professionals. However, the clinical dashboard did not match regional benchmarking standards and not all staff had an appraisal.
  • In acute end of life, patients’ needs were assessed, and care and treatment was delivered, in accordance with legislation, national standards and guidance. The service had access to mental health assessments 24 hours a day, seven days a week. Pain was well-controlled and healthy lifestyles were encouraged. However, pain records were limited, not all staff had an appraisal, and provision of seven-days did not meet national recommendations.
  • In outpatients, care, treatment and support were delivered in line with legislation, standards and evidence-based guidelines. All relevant staff were involved in the planning and delivery of care and treatment, some clinics were run at weekends, and staff understood their responsibilities under the Mental Health and Mental Capacity Acts.
  • In community children and young people, care and treatment was based on national guidance, including specialist advice where appropriate. The effectiveness of care and treatment was monitored and audit findings were used to improve services. Staff received regular supervision and appraisals, and there was effective multidisciplinary working. However, although portable devices had been introduced, connectivity was unreliable so staff could not always readily access information they needed.
  • In community end of life, mental capacity assessments and records were inconsistent and additional role-specific training was not always up-to-date. Clinical supervision was not consistent and participation in audits and benchmarking was limited. However, there was effective multidisciplinary working, pain was monitored and managed as needed, and nutrition and hydration of patients was well-managed.

Caring

Outstanding

Updated 17 May 2018

Our rating of caring stayed the same. We rated it as outstanding because:

  • In maternity, compassionate support was consistently provided to women, and those close to them. Results in CQC’s maternity survey were better than most other trusts, and women felt fully involved in all aspects of their care.
  • In acute end of life, patients were treated with kindness, respect, dignity and compassion. Patients were empowered and supported to manage their own health, care and wellbeing, and were partners in their care. Patients and those close to them received the emotional support they needed.
  • In outpatients, staff took time to interact with patients in a personable, respectful and considerate way. Specialist nurses were available to support patients following bad news. Staff communicated with patients in a way that ensured they understood their care, treatment, condition and advice given. However, privacy and dignity in the fracture clinic was not maintained.
  • In community children and young people, staff cared for patients with compassion. Emotional support was provided to patients to minimise distress, and aftercare support was provided for as long as was required. Patients and those close to them were involved with decisions affecting care and treatment.
  • In community end of life, staff demonstrated compassion, understanding and empathy towards patients at the end of their life. Patients and their relatives or representatives were involved in care planning and clear information was provided to support decision-making.

Responsive

Good

Updated 17 May 2018

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

  • In maternity, services were planned and provided to meet the needs of local people. A bereavement suite was available for families, and staff felt competent and confident to support bereaved families. There were good access arrangements.
  • In acute end of life, the palliative care team worked closely with the local hospice to ensure patients received a joined-up service. A chaplaincy team provided multi-faith spiritual support and the hospital chapel welcome people of all faiths, or of no faith. Patients living with dementia, mental health conditions or a learning disability had services available to support them, and the end of life care team was responsive to referrals from the wards. However, individualised care plans were not in use, not all patients received full assessments of their cultural, psychological and spiritual/religious needs, and not all patients were discharged promptly to their preferred place of death.
  • In outpatients, services were provided to meet the needs of the population and were integrated with the trust’s plans for integrated care. Work had been undertaken with other hospitals and commissioners across the wider healthcare system to better manage risks. Efficiencies had been made to improve the two-week wait process for patients with cancer, and there was good access to support for patients with dementia, learning disabilities or mental health conditions. Most cancer targets were performing better than the national average, and complaints were handled well. However, the environment in physiotherapy was not responsive to patients’ needs, and not all patients with suspected cancer were seen within two weeks from referral.
  • In community children and young people, services reflected the needs of the local population and were flexible, enabled choice and promoted continuity of care. A restructure of the speech and language therapy service had delivered significant improvements, and changes had been made to improve access to services. However, waiting times for autistic spectrum disorder assessments was 12 months.
  • In community end of life, services were planned to meet the needs of local people. The wishes of patients were considered and respected wherever possible, and specialist advice and guidance was available for patients with a learning disability or mental health condition.

Well-led

Good

Updated 17 May 2018

Our rating of well-led improved. We rated it as good because:

  • The trust’s board was a team of exceptionally strong and capable directors who were well-respected by staff and stakeholders. Despite significant financial pressures, the board retained a strong focus on quality. Most staff told us the executive team were visible, accessible and approachable. There was a clear vision, which staff felt connected to. This was supported by a clear strategy. The trust had delivered an extremely challenging financial savings plan through strong leadership, strategy, and engagement. There was an open and honest culture. Staff were encouraged to raise concerns and they felt safe doing so. The trust had a number of innovative programmes designed to improve services. Quality improvement methodologies were being used to support a number of improvement projects, including the NHS Quicker smartphone application. However, the trust’s process for meeting the Fit and Proper Persons regulation needed strengthening and the dispersed leadership model was not yet embedded and a number of areas were still quite hierarchical in processes and structures. Although leadership development programmes were available, these were not always clearly signposted to staff. There had been a lack of investment in the Freedom to Speak-up Guardians. Black and minority ethnic (BME) staff reported experiencing more incidents of harassment, bullying or abuse compared with their white colleagues. Governance structures were complicated and staff were not able to describe reporting and assurance processes easily. There was not a clear method of measuring and evidencing the successes of the care model. IT systems were nearing the end of their serviceable life, but there was no money available to upgrade them. Further work was required to strengthen learning from deaths processes.
  • In maternity, midwifery staff felt disconnected from senior midwives and this was affecting the culture. There were no clear succession plans and governance systems were inconsistent. However, staff had been consulted with about future plans for services and continuous learning was promoted.
  • In acute end of life, leaders were visible and approachable and staff felt well-supported. A clear statement of vision was supported by a strong strategy, which had delivered improvements since our previous inspection. There were clear governance processes, and the board had an up-to-date awareness of end of life care across the hospital. However, only a small amount of feedback had been collected from patients’ families, or those close to them.
  • In outpatients, managers were visible, approachable and compassionate towards staff. There were clear plans to develop and ensure sustainable management of services and a clear strategy underpinned this. There were clear processes to escalate concerns and disseminate information and strong partnership working had been developed with other organisations in Devon. However, governance processes did not sufficiently address the risks to patients in the fracture clinic, and records were not always stored securely.
  • In community children and young people, effective and professional leadership encouraged and supported the delivery of person-centred care. Staff were kept well-informed of issues that may affect the service, and they felt well-supported by managers. There was a positive culture and staff were supported to discuss new ideas and make suggestions for improvements. However, some staff felt the board members were not particularly visible in the community and there were a lack of formal engagement and feedback processes to gain the views of children.
  • In community end of life, there was no systematic approach to monitoring and improving the quality of the services. The governance processes in place were managed by the trust-wide end of life care service. Staff in the community were not fully aware of these organisational processes. Actions were not always taken promptly to address risks to the service, for example equipment not functioning as intended.

  • However, there was an end of life strategy and integrated services were working well in collaboration. Staff were encouraged to report incidents and action was taken to investigate and learn from these.
Checks on specific services

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.

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.

Community health inpatient services

Requires improvement

Updated 7 June 2016

Overall rating for this core service Requires Improvement l

During the inspection, we visited eight out of the nine community hospitals. At the time of our inspection, Bovey Tracey hospital inpatient beds were temporarily moved to Newton Abbott hospital. We reviewed surgical services at Teignmouth hospital day surgery unit.

Our inspection team included two Care Quality Commission inspectors and seven specialist advisors and an expert-by-experience. Our Pharmacist looked at medicines management in three community hospitals, Teignmouth, Paignton and Brixham. We spoke with approximately 60 staff, 25 patients and 7 relatives.

We rated safety in the community inpatients to require improvement. We found there were good systems in place for reporting, investigating incidents and sharing learning from them. Medicines were not consistently managed and stored in a way that would keep people safe from avoidable harm. The ward environments across all community hospitals were clean and tidy. Patient records were completed to a high standard. They were detailed, up to date and showed evidence of multidisciplinary team input. There were reliable systems in place to prevent and protect people from a healthcare associated infection and staff followed appropriate infection control procedures. Staffing levels, skill mix and caseloads were not effectively planned and reviewed to ensure people received safe care and treatment at all times. Staff of varying seniority across all community hospitals expressed concerns about staffing levels. This related to the staffing of escalation wards and to staffing at night in particular. Recruitment of staff was an on ongoing concern. Bovey Tracey hospital inpatient beds were temporarily closed and patients and staff were transferred to Newton Abbott wards due to ongoing issues with retention and recruitment there. Staff felt concerned about staffing levels and skill mix on escalation wards. There was a high use of agency staff on these wards who did not have the right skills to manage stroke patients in particular. Staff of all seniority felt lessons from the previous year’s escalation ward management had been discussed but not consistently applied.

We judged effectiveness within community hospitals as good. Staff followed national guidelines and recommendations to deliver effective care and treatment and ensured patients’ pain was well managed.

Patients’ care and rehabilitation goals were identified on admission to the hospital. Referrals to therapists and specialists were made in a timely way that would best support their reablement and recovery. A variety of quality and audit information was collected at each community hospital which was used to improve the quality of patient care. Length of stay for each community was shorter than the national average of 28 days.

Multidisciplinary team working supported effective planning and delivery of care for adults being cared for in the hospital and for their ongoing care following discharge. Staff engaged with patients’ families and carers to ensure patients were discharged into the right setting with appropriate care and treatment in place.

We judged the care of community inpatients to be good. Patients and relatives across all eight hospitals provided positive feedback about patients’ care and treatment. We saw staff treating patients with kindness, respect and dignity. Staff responded sensitively to patients’ needs when patients experienced physical pain, discomfort or emotional distress. Patients and their relatives felt involved in their care and were supported emotionally. Patients we spoke with said staff took time to explain their care and treatment in a way they could easily understand. Relatives felt involved in the planning of patients care ready for when they returned home. Patients’ call bells were answered quickly. Staff support and empowered patients to manage their own health, care and wellbeing to maximise their independence.

We judged the community inpatient services were responsive to patient’s needs. The trust and staff from community hospitals worked with local commissioners of community services and partner organisations to ensure the division provided services that met local people’s needs. Community hospital staff worked closely with community nursing and therapy teams, GP practices and social services to ensure patients access to ongoing care and treatment. Staff did their best to meet the needs of the patient and were sensitive to their personal, cultural, religious needs, or sexual preferences. Services were planned, delivered and coordinated to meet the needs of patients living in vulnerable circumstances, such as those patients living with dementia. Staff demonstrated a good level of awareness of how to best care for patients living with dementia, so that they were able to respond to their needs appropriately. People had timely access to initial assessment, diagnosis and treatment. However, some staff expressed concerns that some patients were transferred too late at night. Patients told us they felt they could ask questions or raise concerns if the felt they needed to, at any time during their stay. The complaints system was easy to use and posters and leaflets displayed around the community hospitals outlined the procedure. The trust RAG rated the number of complaints relating to community hospitals as green. The RAG rating system classified green as positive or above target and red as below target or negative, etc.

We judged the inpatients service to require improvement in its leadership. There was an organisational vision in place for the integrated care organisation overall. However, a strategy and vision for community inpatients had not been fully developed or communicated to staff. A number of staff felt the merger had gone well, whilst others felt disconnected from the rest of the organisation. This meant that staff did not always know or understand the organisational strategy and their role in achieving it. Risk registers were in place across the community hospitals, which fed into the divisional risk register. Matrons and senior ward staff were not always able to articulate what their top three risks were but were clear about issues in relation to staffing. Lines of accountability including clear responsibility for cascading information upwards to the senior management and downwards to the clinicians and other staff on the front line were not always clear. However, staff were clear about who their local leaders were and found them to be open and approachable. It was identified that there was a lack of clarity between the Trust Executive and the community senior leadership in relation to the use of a community bed status report which incorporated a staffing tool. As such, this identified a gap in assurances regarding safety going back up to the board, in particular in relation to safe staffing and skill mix at night and on escalation wards. While the board recognised that staffing in the community needed to be reviewed, they had not fully understood the shortcomings of the tool used to align staffing levels to patients’ care needs. Staff did not always feel actively engaged so that their views were reflected in the planning and delivery of services. The organisation and community hospitals engaged with the local community to seek feedback in order to shape service and kept the public informed about the changes within the organisation.

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.

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.

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.

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.

Urgent care services

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.

End of life care

Requires improvement

Updated 7 June 2016

Overall we rated the trust as requires improvement for community end of life care services. They required improvement in order to be safe, effective and well-led although were good in relation to being caring and responsive.

  • There was poor completion of treatment escalation plans (TEPs), particularly within the community hospitals where more than half of those we reviewed had not been completed in line with trust policy in relation to recording of do not attempt pulmonary resuscitation (DNACPR) decisions.

  • Where patients did not have capacity to be involved in decisions about resuscitation we saw inconsistent recording of mental capacity assessments and we did not see best interest discussions with relatives being recorded.

  • At Brixham and Totnes community hospitals healthcare assistants were checking controlled drugs and syringe drivers without being trained or competency assessed.

  • There was inconsistent end of life care training for registered nursing staff working in the community hospitals with some having received training in the end of life care resources while others had not

  • Not every community hospital had end of life care link nurses.

  • There was no trust-wide community and acute multi-disciplinary meeting

  • There was no end of life care strategy in place that described the priorities for the trust as an integrated organisation, the future structure of services and how they were going to move forward in terms an integrated end of life care service.

However:

  • We saw evidence of good local leadership of wards, community nursing teams and the end of life care service.

  • There was good use of audit and evidence of learning from incidents being used to improve performance.

  • There was a passion and commitment among the trust staff to deliver high quality end of life care. Staff were seen to be caring and compassionate and focused on patient choice and involvement in their care. Relatives and people close to those at the end of life were supported.

  • We saw a particular example of outstanding practice in the development of a carers course where people caring for loved ones with life limiting illnesses could access an ongoing support group.

Other specialist 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 The Speciality Dental Service provision which is as a secondary care dental service located in Torbay Hospital.

Torbay Hospital – Secondary Care Dental Service is for the treatment of complex dental problems which are considered too specialised for the patient’s general dental practitioner.

Overall we found dental services provided safe, effective, caring, responsive and well led care. We observed and heard practitioners were providing an excellent service in the locations with exceptionally 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 feedback we saw demonstrated patients 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 the location 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 this location e.g.

  • Staff were passionate about working within the service and providing good quality care for patients.

  • Patients feedback demonstrated they felt it was an excellent service. We evidenced highly trained and experienced staff with excellent application of knowledge and skills in practice to meet the complex needs of patients treated by the service.