Torbay and South Devon NHS Foundation Trust

Updated 3 November 2023

Torbay and South Devon NHS Foundation Trust was created on 1 October 2015 bringing together adult social care, community and acute services. This brought together South Devon Healthcare NHS Foundation Trust, which ran Torbay Hospital, with Torbay and Southern Devon Health and Care NHS Trust, who provided community health and adult social care services.

The trust covers a wide geographical area including parts of Dartmoor along with Torbay and the South Devon areas around Totnes and Dartmouth. The trust delivers care in people’s homes and across more than 15 sites. The trust’s purpose is to support the people of Torbay and South Devon to live well. The local population has a significant level of health inequality and high levels of deprivation, with Torbay being the most highly deprived community in the South West. This includes many children who start their lives at a disadvantage, with high numbers of looked after children and children with protection arrangements. There are some of the highest rates of self-harm and suicide in the country. There is a larger proportion of older people than the national average.

The trust has more than 6,500 staff with an additional 534 people on bank only contracts and more than 400 volunteers.

The trust receives most income from NHS Devon commissioners, with the responsibility for the adult social care budget delegated via Torbay Unitary Council. There is a memorandum of understanding with Devon County Council to run social care services in a joined-up way. The trust is the lead provider for the Children and Family Health Devon service, in April 2019 the alliance of NHS providers was awarded the contract to provide community health services for children and young people across Devon and Torbay.

We carried out a short notice announced focused inspection of medical care, outpatients, and the emergency department on the 24 and 25 May 2023.

We inspected medical care based on concerns and information we had received around stroke performance, staffing, referral to treatment times and cancer performance.

We inspected outpatients because of waiting times and waiting list management plus the associated risk of oversight and management of these lists.

We inspected the emergency department because of ongoing delays in ambulance handovers and emergency department waiting times. Additionally, the trust performance against the 4-hours standard continued to be challenged.

We carried out a short notice announced comprehensive inspection for the diagnostic and imaging service on 21 and 22 June 2023. We did this because we had not previously inspected or rated diagnostic imaging as a stand-alone service at this location.

We completed the well led inspection on 12 and 13 July 2023. We did this because we had not inspected well led since 2018 and there had been numerous changes in organisational structure and leadership since our last inspection.

Our ratings for the core service inspections:

Our core service inspections were based at Torbay Hospital, we did not visit other sites as part of this inspection although relevant trust wide information was used where appropriate to the services inspected.

For Diagnostic Imaging we rated the service overall as requires improvement. We rated safe and well led as requires improvement and we rated caring and responsive as good. We inspected but did not rate the key question of effective which was in line with our current methodology.

For Urgent and Emergency Care the rating remains as requires improvement. We rated safe as requires improvement which is an improvement from July 2020 when we rated it as inadequate. We had enough evidence to re-rate well led which improved and was now rated as good. According to our methodology the key questions of effective, caring, and responsive were 'inspected not rated' due to using the focused inspection methodology. Therefore, the July 2020 ratings remain of requires improvement in effective and responsive, and good for caring.

For Medical Care the rating remains as requires improvement. We rated safe and effective as requires improvement, this is the same rating as in July 2020. According to our methodology the key questions of responsive and well led were 'inspected not rated' due to using the focused inspection methodology. We did not inspect caring during this inspection. Therefore, the July 2020 ratings remain of requires improvement in effective and well led, and good in caring and responsive.

For Outpatients the rating went down to requires improvement, it was previously rated good in May 2018. We had sufficient evidence to re-rate safe and responsive, safe went down to inadequate and responsive went down to requires improvement. According to our methodology the key questions of caring and well led were 'inspected not rated' due to using the focused inspection methodology and therefore both remained as rated good. We did not inspect effective.

Our rating of the trust wide well led:

The well led inspection was trust wide and we spoke with groups of people from services we did not cover in the core service inspection.

We rated the trust well led as requires improvement. We had not rated the trust well led since 2018 when it was rated as good, our planned inspection of well led in 2020 was cancelled due to the Covid-19 pandemic. Use of Resources was not assessed during this inspection and was last inspected in 2020 and rated requires improvement.

A summary of our findings include:

Trust wide

We rated trust wide well led as requires improvement because:

• The trust and Devon were in NHS system oversight framework segment 4 due to financial performance and delivery against performance targets.
• The trust had a challenging financial position but had a plan to address this.
• There were inequalities among the workforce and staff did not feel they were always treated equitably and shared negative experiences. Sufficient action had not been taken in a timely way to address the issues. There were poor results and outcomes for indicators across surveys, Freedom to Speak Up concerns and national workforce data sets, as well as in first hand experiences of staff who spoke with us. There was no equality, diversity and inclusion strategy at the time of the inspection, this was approved by the trust board in July 2023, and the resource available for the work was insufficient for the scale of the work needed. The equality business forum did not operate effectively and staff networks required further development and support.
• The IT infrastructure was outdated and provided barriers to sharing information and impacted on the confidence in the quality of data when pulling from lots of sources.
• Risk and governance discussions felt heavily acute focused rather than community and adult social care.
• Some staff felt depths of issues were not well understood by leaders or action taken in a timely manner to rectify or resolve issues and some board executives were not sufficiently aware of some of the key safety issues for clinical services at risk.
• Staff views and concerns were encouraged, but they were not always heard and acted on, staff were not consistently told about action taken to improve processes.

However:

• Leaders had the experiences, capacity, capability, and integrity to ensure the trust strategy could be delivered and risks to performance addressed.
• There was a clear statement of vision and values, driven by quality and sustainability. There was a realistic strategy with well-defined objectives and a focus on system-based working. These were developed in collaboration with people who use the service, staff, and external partners. The strategy was aligned to local plans in the wider health and social care economy.
• The governance and performance management had recently been reviewed and restructured to be strengthened. The new processes were clearly set out but were embedding across the organisation and staff were understanding where roles and responsibilities may have changed.
• Safety remained a priority in the organisation and leaders aimed to achieve a balance between finance and quality. There were processes to identify, understand, monitor and address current and future risk. Performance issues were escalated to the appropriate committees and the board through clear structures and processes. There were processes for clinical and internal audit.
• The trust engaged with relevant stakeholders to build a shared understanding of challenges to the system and understood the needs of the population and engaged with patients, families and service users to gather feedback.
• There was a focus on continuous learning and improvement, including appropriate use of external accreditation and participation in research. There had been significant investment in quality improvement, but this was not yet fully embedded across the organisation and staff found it difficult to have time to engage in quality improvement work. Internal and external reviews were used to identify learning and make improvements.

Diagnostic Imaging

We rated diagnostic imaging as requires improvement because:

• Not all relevant safety checks were being completed. Staff did not always document pregnancy checks for all eligible patients and staff did not always perform patient identification checks, both in line with IR(ME)R 2017. Checks to ensure the correct patient received the correct scan were not always effective and previous images and information were not always reviewed by staff when vetting imaging requests.

• Medicines management was not always well managed. There was no Patient Group Direction (PGD) to support radiographers to administer saline. There were no records to show temperature checks of stored contrast media. Patients who received medicines as part of their test in nuclear medicine did have these prescribed in line with legislation.
• Areas were not always designed to meet people’s needs. There were no dedicated waiting areas for children and CT scanners area did not have dedicated changing rooms.
• Governance and processes were not always clear, embedded or effective. There was no reject analysis audit programme. Standard scanning protocols used in MRI were not written down. There was no recorded process to show what non urgent routine CT and MRI scans could be vetted by non-medical staff. Some radiation risk assessments were out of date and needed reviewing. Some MRI equipment was not labelled as safe to enter the scan room.
• We found staff were not always up to date with manual handling and information governance training. Hand hygiene audits were not consistently carried out and some areas visited had no cleaning records. Information about chaperone availability was not on display in some patient areas.

However:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available to suit patients' needs.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
• Leaders ran services using information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and all staff were committed to improving services continually.

Medical Care

We rated medical care as requires improvement because:

• Mental capacity assessments were not always completed fully or contained the relevant detail required.
• Outcomes for patients were not always positive and consistent and did not always meet national standards. Patients were not always admitted to a stroke unit within 4 hours and did not always spend 90% of their time on a stroke ward in line with national guidance.
• Staff were not fully compliant in mandatory training and hand hygiene audits identified poor compliance.
• A dysphagia audit identified staff did not always provide patients with food and drinks in accordance with their care plan.
• There was not always enough staff with the right qualifications, skills, training and experience. Staffing numbers did not always meet planned levels and there was not always consultant cover out of hours. There was high use of agency, and we were not assured all agency had a full induction.
• The service did not always use systems and processes to safely prescribe, administer, record and store medicines.
• The trust experienced pressures due to bed capacity, availability of onward care and timely discharge.

However:

• Staff understood how to protect patients from abuse, and managed safety well. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff assessed risks to patients and acted on them. They kept good care records in most cases. The service managed safety incidents well and learned lessons from them.
• The service provided care and treatment based on national guidance and evidence-based practice. Patients had enough food and drink to meet their needs and had their pain assessed and managed. It was ensured staff were competent for their roles.
• People could access the service when they needed and received care promptly.
• Leaders had the skills and abilities to run the service and understood and managed the priorities and issues the service faced. Staff felt respected, supported and valued. There were differences in governance processes, but the trust was undergoing a restructure which would help align governance. There were systems to manage performance effectively and identify, escalate and monitor risks.

Urgent and Emergency Care

We rated urgent and emergency care as requires improvement because:

• The design, maintenance and use of facilities, premises and equipment did not always keep people safe. The design of the environment did not follow national guidance for children. The environment or estate that made up the emergency department was no longer fit for purpose. The area was not always maintained in good state to minimise the risk of cross infection.
• Patient records were not always stored securely. Some of the computer screens were left open by staff and unsupervised with patient records visible. The names and summary of a patient were shown, and we were able to enter and access the detailed records.
• Access and flow for patients remained a huge challenge for patients and staff. People could not always access the service when they needed it to receive the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
• Some areas of medicines management were not operating effectively. We identified patient group directions which had passed their review date, expired sterile fluids and oxygen cylinders which were not stored securely and safely.

However:

• Staff had training available in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment and managers monitored the effectiveness of the service and made sure staff were competent.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Governance processes had improved since our last inspection and were effective in developing the service.

Outpatients

We rated outpatients as requires improvement because:

• Risks to patients on waiting lists were not always identified. Harm had come to patients waiting to be seen in ophthalmology.
• People could not always access the service when they needed it and had long waits for treatment.
• The design of the facilities did not meet the needs of patients. The layout of the department was difficult to navigate for some patients.
• The service used multiple information systems as well paper records to manage appointments which increased the risk of error. This meant there was an over reliance on some staff to ensure patients were notified of their appointments.
• Prescribing documents were not always stored securely and safely.
• Patients’ privacy and dignity was not always maintained.
• Some areas of training needed to be considered and improved, to include manual handling, learning disability and autism, and mental health awareness.
• There were not always separate or segregated waiting areas for children or a policy to guide staff on these procedures.

However:

• Staff mostly had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients and acted on them.
• Staf treated patients with compassion and kindness and took account of their individual needs.
• Leaders operated effective governance processes and used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 2 July 2020

Updated 2 July 2020

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.

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.

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.

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.

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.

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.

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.