Archived: Northern Devon Healthcare NHS Trust

The Northern Devon Healthcare NHS Trust operates across 1,300 square miles and provides both acute hospital care and community services. The North Devon District Hospital in Barnstaple provides a full range of district general hospital services. The community services included 17 community hospitals in North, East and Mid Devon, of which 15 were open to inpatients at the time of the inspection.

We carried out a comprehensive inspection because Northern Devon Healthcare NHS Trust is an aspirant foundation trust. Trusts wanting to become a foundation trust have an inspection as part of that process. The inspection took place between 2 and 4 July 2014. We also undertook unannounced visits in community services on 7 and 8 July 2014 at Sidmouth and Crediton hospitals and an unannounced visit to North Devon District Hospital on 14 July 2014.

During the announced inspection, we visited the following 11 hospitals:

• North Devon District Hospital
• Ilfracombe Tyrrell Hospital
• Bideford Hospital
• Holsworthy Hospital
• South Molton Hospital
• Okehampton Hospital
• Whipton Hospital
• Tiverton and District Hospital
• Honiton Hospital
• Ottery St Mary Hospital
• Exmouth Hospital

At this inspection a team also looked at Urgent care services provided by the minor injuries units. This was part of a pilot and although that part of the inspection has been reported on that service has not been rated.

Overall Northern Devon Healthcare NHS Trust has been judged as requiring improvement. The trust provided services that were effective and caring. Improvements were needed in the safety, responsiveness and leadership of some services.

Our key findings were as follows:

• Patients, carers, families and visitors were overwhelmingly positive and complimentary about the care, kindness and dedication shown by the staff that provided care in the acute hospital, the community hospitals and in the community. The care provided in the acute medical care service was judged to be outstanding.
• Stakeholders and partners were positive about the trust and many commented on the culture of patient safety and a focus on the quality of care.
• There was a positive atmosphere at the trust, both at the acute hospital and in the community services. We found that staff engaged with us and were willing to support the inspection process. Staff told us about an open and honest culture with strong teamwork.
• We saw the hospitals were clean, however the infection control policies of the trust were not being consistently followed by all staff.
• Mortality rates were not raised as a concern at this trust.
• Nutrition and hydration was managed well for patients although improvements were needed in this area in maternity services.
• Nursing and medical staff training was encouraged. Staff told us that mostly they were supported and encouraged to attend training to develop the care standards at the service. Not all areas, for example A&E, had a competency framework for nursing staff.
• There are some staffing issues, including the challenge of filling vacancies, the age profile of the current workforce and higher than expected sickness absence in some areas. There was also the challenge of attracting specialists to what is a relatively isolated part of the country. However, the Human Resources team had a grip on those issues, could demonstrate progress and was creative in finding solutions.
• Although the Board had recognised the need for the whole hospital to take ownership of A&E performance it would appear that this had not yet happened. The delays in admitting patients, the relatively high number of patients not admitted to the most appropriate area (outliers) and the number of patients being moved at night raised questions about the overall effectiveness of arrangements. The team felt that this was unusual given the relatively low occupancy rate in the North Devon District Hospital, the availability of community hospitals and the highly developed model of integrated health and social care.
• Although all but two services were judged to be good at the acute hospital there were aspects of safety, responsiveness and leadership that required improvement.
• The financial challenges in the wider Devon healthcare economy and the uncertainties about the future provision of community services in East Devon were taking up significant executive and non-executive time and were contributing to some strained relationships with some other acute providers in Devon.
• The leadership of the organisation appeared stable despite the significant turnover in the executive team with the loss of the Chief Executive, Director of Operations and Director of Human Resources within the last few months. A new Chief Executive, previously the Medical Director, has been appointed and interim arrangements are in place for key roles before permanent replacements take up post.
• The inspection team felt that the trust had considerable potential to improve services further.

We saw several areas of outstanding practice including:

• The multidisciplinary approach in community services, including mature and developed ways of working with adult social care services, was delivering a very good service to patients. Patients were receiving a holistic service that promoted independence and delivered services as close to home as possible. The teams were successful in preventing or delaying hospital admissions and supporting people leaving hospital. Staff referred to the positive professional working environment and patients and their families spoke very highly of the service.
• The nursing leadership of the acute stroke service was very highly regarded by medical, therapy and nursing staff. Staff felt valued and the service itself was very patient focused.
• The care of patients with a diagnosis of dementia on Alex ward was outstanding. A robust dementia policy was in place. This ensured the highest standards of personalised care using all therapeutic staff. There was thoughtful and compassionate care for patients with dementia on Capener ward.
• Teamwork and team spirit in theatres was very good despite staff shortages.
• The wards on the medical unit each had two ward clerks working extended hours. This meant that clinical staff were able to concentrate on clinical duties while administrative duties were undertaken by the ward clerks.
• The Trust’s successful involvement with Project Search, an innovative scheme that supports young people with learning difficulties to find permanent work, was modelling outstanding practice to local employers. The trust had provided 12-month internships to seven young people, all of whom had successfully completed the programme and had found permanent jobs, six of them with the trust in areas such as medical records and catering.

However, there were also areas of poor practice where the trust needed to make improvements.

Importantly, the trust must:

• Review and improve arrangements for the assessment and management of the prevention, detection and control of the spread of healthcare-associated infection. This includes ensuring that suitable equipment is provided and used, that all areas are kept clean and tidy and ensuring that staff are consistently following trust policies.
• Evaluate and improve the effectiveness of the current patient flow and escalation policies. Action must be taken to improve the flow of patients from the A&E department and across the trust. The policies and procedures for patients who are not admitted to the most appropriate ward (outliers) need to be clear, focused on the best interests of patients and consistently applied. The criteria to be applied to decisions on the movement of patients and the protocols to be followed must be clear.
• Ensure that an accurate record in respect of each service user is in place relating to their end of life care, which shall include appropriate information in relation to the care and treatment provided. The trust must make sure that staff are aware of and consistently apply these arrangements.
• Ensure that the facilities for the antenatal sonography service are such that the safety, privacy and dignity of patients can be maintained. Rooms used by antenatal sonography staff must have a system for calling for help in the event of an emergency.
• Ensure that there is a system in place, supported by guidance, for the completion of HSA1 (grounds for carrying out an abortion) and HSA4 (abortion notification). These records must be completed accurately and consistently and forwarded to the Department of Health as required

Professor Sir Mike Richards

Chief Inspector of Hospitals

The Northern Devon Healthcare NHS Trust provides community healthcare services to a population of around 484,000 and provides services at any one time to approximately 6,000 patients who live in their own homes.  The care and treatment is provided under the regulated activities, including: diagnostics and screening, family planning, nursing care and treatment of disease, disorder and injury.  We visited community teams based in South Molton, Holsworthy, Bideford, Exmouth, Ottery St Mary, Honiton, Tiverton, Exeter, Crediton, Sidmouth and Okehampton.

We spoke with 129 members of staff, including community nurses, occupational and physiotherapists, specialist nurses, managers, healthcare assistants and administrative staff to understand their experiences of working within the trust.

We contacted and spoke with 76 patients and 12 relatives of patients, to seek their views of the service provided to them.

The inspection teams included CQC inspectors, specialist advisers in community nursing, palliative care specialist nurse, rehabilitation therapist, Allied Healthcare professionals, a sexual health nurse, community matrons and a GP.

During the inspection, we looked at patient-care documentation and associated records, observed care in patients’ homes and clinics and spoke with staff and patients individually and as part of groups.

Patients made positive comments about the service provided to them.

Community services for adults provided by Northern Devon Healthcare NHS Trust were judged as good overall.

The services provided safe and effective care and treatment to people who lived in their own homes, or attended clinics run by the trust.  Staff were able to report incidents to the trust and found action was taken to address issues, although they had not always received feedback regarding the outcome.  The community teams promoted the control of infection and followed trust policies to prevent the spread of infection.

Staff were aware of how to report any safeguarding concerns and support was available to them through dedicated members of staff and their managers.

Staffing levels were sufficient to ensure patients received care and treatment in order to meet their assessed care needs, although there were vacancies in some staff teams.  Lone working systems were in place locally to ensure the safety of staff where they worked alone in a department or clinical area.

Identified risks to patients and staff during the provision of community care services were recorded on both local and trust-level risk assessments.  Action had not always been taken promptly to address the risks.

Integrated team working was evident across the area and staff were positive about their roles, both within their local team and across the wider multidisciplinary team.

We observed some areas of outstanding care and treatment during our inspection visit. We found a day service for patients with dementia care needs provided excellent care, support and treatment.  A community nurse-led clinic provided responsive care and treatment to patients who were able to attend the clinic, thus promoting independence and providing good clinical outcomes for patients.  Multidisciplinary team meetings identified care needs for individual patients and ensured these were met by appropriate staff.

Overall rating for this core service

Overall, community end of life services were good. Services were found to be safe, effective, caring and responsive.

Our inspection of end of life community services included visits to community nursing services and community hospitals across a network of 17 community hospitals and nine integrated health and social care community clusters.  At the time of our visit, we saw very few patients who were considered to be at the end of life. 

We saw that patients and their needs were placed at the centre of their care.  There was a high regard for safety and we saw that lessons learned included the sharing and the cascading of information to relevant professional groups across the trust.  We viewed the use of Treatment Escalation Plans (TEP) that highlighted end of life care decisions, including do not attempt cardio-pulmonary resuscitation (DNA CPR) decisions.  We saw that the TEPs we viewed were mostly completed correctly, although staff told us they had experienced some inconsistencies with this and this was supported by the results of an audit we saw.  Inconsistent completion of TEP forms could result in patient decisions about treatment and care being unclear to the staff caring for them.   

We viewed evidence of effective end of life care services with evidence of an end of life care plan being introduced to replace the Liverpool Care Pathway.  End of life link nurses had been introduced to community hospitals to raise the standard and profile of end of life care in community settings. 

Patients, relatives and staff were positive about the services received and we observed staff caring for patients with respect and dignity.  We observed services being delivered through multidisciplinary teams and good partnership working and we saw evidence of responsive care, particularly in relation to rapid discharge home when patients wanted to be cared for in the community at the end of their life.  Staff told us that local leadership of services was good, but that they were not always aware of whom the trust-wide leaders were. However, we viewed plans for increasing trust-wide leadership visibility in community services.