Torbay Hospital

Torbay and South Devon NHS Foundation Trust is an integrated organisation providing acute health care services from Torbay Hospital, community health services and adult social care. The Trust runs Torbay Hospital and nine community hospitals in Devon. The trust serves a residential population of approximately 375,000 people, plus about 100,000 visitors at any one time during the summer holiday season.

This report covers the acute services provided from the Torbay hospital location. Torbay hospital has 293 beds and in 2014/15 had 70,000 inpatient admissions, 77,000 emergency department attendances and 424,000 outpatient attendances.

We inspected Torbay hospital as part of our programme of comprehensive inspections. The inspection team inspected the standard eight core services for an acute hospital. This was the first inspection undertaken at Torbay hospital using the comprehensive inspection methodology. We inspected Torbay hospital between 2 and 5 February and on 15 February 2016.

Overall we rated Torbay hospital as requires improvement.

Our key findings were as follows:

Safety

• Nurse staffing was at expected levels in most areas. However, the emergency department was not always staffed by appropriately qualified, experienced and skilled nursing staff. Nurse staffing on the Louisa Cary ward (children and young people) was often below guideline levels. The numbers of nurses on medical wards regularly fell below the established minimum number.
• Medical staffing was at expected levels in most areas. However, in the emergency department there were not enough consultants or a named paediatric consultant on each shift. In outpatients there was not enough medical staffing to allow the trust to address its significant backlog of follow up appointments.
• Infection prevention and control procedures were complied with, such as in the case of regular hand hygiene audits. Clinical areas were generally clean although we saw some unclean areas in the dermatology outpatient procedure rooms. Some patients without Methicillin Resistant Staphylococcus aureus (MRSA) confirmed status were being placed on surgical wards, which presented an infection risk to other patients. In dermatology minor surgical procedures were taking place in rooms that were not adequately ventilated or maintained.
• There was generally a positive culture around reporting, investigating and learning from incidents. However, in end of life care it was not clear how lessons were learned from incidents and we were not assured about the effectiveness of incident monitoring. In outpatients there was a mixed approach to incident reporting.
• In surgery, information on incidence of falls, pressure ulcers and urinary tract infections was displayed on ward boards giving transparency on their safety.
• Premises and equipment were not always fit for purpose. The facilities in the emergency department were not suitable or well maintained and compromised patient safety. In critical care intravenous fluids were not securely stored and the safety of babies on the children’s ward was compromised as breast milk was not securely stored. Cautery procedures were carried out in rooms without smoke extractors and without the use of masks.
• The management of medicines was generally in line with trust policy and legislation, although in outpatients there was inconsistent recording and monitoring of fridge temperatures and there were no records of stock rotation in some areas.
• There were some areas of records management that needed improvement. We found areas for improvement in surgery, children and young people’s services and end of life care.
• Staff understood their safeguarding responsibilities and was aware of the trust’s policies and procedures.
• While most services demonstrated an understanding of patient risk, there was an inadequate response to risk in other areas. In the emergency department, patients did not always receive an initial assessment within 15 minutes. This placed patients at risk. The National Early Warning Score (NEWS) system had been implemented in the emergency department but the scores did not always indicate the action needed.

Effective

• In most services patient’s needs were assessed and care and treatment delivered in line with legislation, standards and evidence-based practice.
• In some areas the equipment being used was not of an expected standard. In end of life care temporary fridges were being used on a permanent basis, without effective temperature monitoring. In outpatients aging equipment was preventing staff from providing effective services.
• Facilities did not always support effective services. The emergency department facilities were not suitable or well maintained. This compromised patients’ safety and experience. There was no designated space to assess patients with mental health conditions. The critical care unit did not meet currents standards although the building of a new unit had started. The design and use of some outpatient facilities did not keep patients safe at all times.
• Patients’ nutrition and hydration needs were being met.
• In most services there was evidence that patient outcomes were assessed. There were some areas where the trust was not meeting the national audit standard. In the emergency department patient outcomes varied, performance was mixed against national audits to benchmark performance and the results of audits were not always used to improve treatment, including management of Sepsis. Unplanned reattendances to the emergency department were not investigated to identify reasons.
• Staff were generally competent to deliver services to patients. In outpatients a nurse practitioner was performing procedures without formal qualifications.
• Multi-disciplinary working was evident in many services inspected. However some areas of multi-disciplinary working in the emergency department were not working effectively.
• Limited access for mental health services out of hours caused extended waits for patients in the emergency department.
• Staff demonstrated an understanding of their responsibilities in relation to consent, the Mental Capacity Act 2005 and the Deprivation of Liberty Standards (DoLS), although there was a mixed understanding of the Mental Capacity Act and limited knowledge of DoLS in critical care.

Caring

• Feedback about the care received was consistently positive.
• We saw examples of caring interactions between staff and patients.
• In critical care we found examples of staff going ‘above and beyond’ expectations to support patients and relatives during difficult times.
• Patients and their relatives were often involved in their care planning.
• In end of life care staff we talked to had a good understanding of the impact that a person’s care, treatment or condition might have on their wellbeing and of those close to them.
• In maternity patients’ choices were important when planning and delivering care.
• In children’s services parents and children spoke highly of the service. Children were involved with the planning of their care wherever possible. In outpatients we saw relatives and carers being included in decision making.

Responsive

• Poor patient flow across the hospital impacted on the emergency department. There was also a lack of decision makers available in the emergency department, which affected the flow of patients out of the department.
• Delays in admitting patients to a hospital bed meant the emergency department was often full, and could not immediately treat new patients. Not all patients received their initial clinical assessment in 15 minutes.
• Bed pressures also impacted on timely discharges from the critical care unit. Elective (planned) surgery was affected by the lack of bed availability in critical care.
• In surgery the pressure on bed availability within the hospital meant patients were not always receiving timely surgery. Numbers of patients who had their surgery cancelled remained above the average for England. The trust continues to work with commissioning and partner organisations to reduce waiting times for surgery.
• In maternity there was a public health midwife to support people to make lifestyle changes and the service had systems to make adjustments for patients living with learning or physical disabilities.
• The gynaecology service introduced enhanced recovery procedures to improve the flow of patients through the service.
• The children and young people’s service provided responsive planned and emergency care, although there were delays accessing mental health services.
• The end of life service collected some information about numbers of deaths of patients on end of life pathway and whether they died in their preferred place of care or not. Most end of life patients had a treatment escalation plan including a resuscitation decision.
• Plans were in place to increase clinics in outpatients. However at the time of the inspection patients were frequently not able to access services in a timely way for follow up appointments due to a follow up back log and the capacity of clinics.
• We saw evidence of person-centred care. In surgery patients living with dementia or learning disabilities had their needs met. Children and young people were at the centre of their care and paediatric services were highly responsive.
• There was a positive culture around dealing with feedback and complaints and learning lessons. In some areas such as the children’s and young peoples’ service this included identifying trends and themes to embed learning.

Well led

• Service visions and strategies were developed in most areas but there was a disconnect between acute medicine and the emergency department. As a result patients did not always experience appropriate access and flow. There was not a coherent strategy in place to deliver the vision staff had for end of life care within the integrated organisation.
• While governance, risk management and assurance systems were in place for the services reviewed, these were not always operating effectively for example, in the emergency department, medical and critical care services.
• There was evidence of leadership supporting change in many services. However, the emergency department had been working under pressure for a considerable period without effective changes to improve the situation. In medicine there was a lack of leadership oversight in some areas and in outpatient services leaders were not always highly engaged with their teams.
• Staff generally spoke positively about the culture within services. Recurrent themes were of the openness and transparency such as in relation to raising concerns. However, staff did not always feel supported or empowered to make changes to improve services.
• There was evidence of innovation in many service areas reviewed. For example, in surgical services, there was an embedded culture of finding ways to reduce the length of stay for patients in hospital with more operations being undertaken as day cases.

We saw several areas of outstanding practice including:

• Staff in the emergency department were positive and professional under pressure, maintaining a supportive role to patients. They were always kind and thoughtful, ensuring that patient’s anxieties were relieved as much as possible.
• The trust was the highest achieving in the south west peninsula for cancer treatment targets and had the highest survival rates in the south west. The trust was also the highest achieving cancer centre in the patient survey and in the 10 nationally.
• We spoke with one patient on the surgical ward who was going through a distressing time as they found out their daughter was admitted for emergency care. The staff in the hospital had arranged and facilitated to take them down to see their daughter and had constant updates from the medical team involved in their care.
• In the middle of the surgery recovery room there was a large clock with four faces on it pointing in different directions. This allowed patients to orientate themselves with the time as soon as they woke up after theatre reducing confusion and distress.
• We found that WHO checklists were completed using a large whiteboard in every theatre allowing all staff to observe and act upon it. These were being developed further to be interactive projection boards where each patient would have a bespoke WHO checklist depending on its requirements.
• The innovative way in which the hospital was managing capacity by making traditionally inpatient surgical stays as an outpatient procedure.
• The innovate way in which technology had influenced the educational facilities at Torbay Hospital. Particularly around the use of virtual reality headsets to train staff for specific situations such as the surgical checklist.
• The use of video calling over the internet using portable tablet devices in the critical care unit was an example of outstanding practice. This technology primarily allowed doctors to have a ‘face-to-face’ discussion with relatives who were not in the country, but also allowed those relatives to see and speak to their loved ones being treated on the unit.
• The critical care unit’s rehabilitation programme was exceptional. As well as having focus on patients while they were in the unit, there was rehabilitation support and follow-up routinely provided in the hospital for patients who had been discharged. This service was then further extended into the homes of patients who had been discharged from the hospital. Because the programme worked so well, the unit’s occupational therapist had been invited to speak nationally on the subject to encourage other hospitals to look at ways they could deliver a similar service.
• The care being provided by staff in the critical care unit went ‘above and beyond’ the day-to-day expectations. We saw staff positively interacting with all patients and visitors and evidence of staff going out of their way to help patients. Patients and visitors gave overwhelmingly positive feedback.
• There was a perinatal mental health team based in the maternity unit. This had led to consistent care for women with mental health conditions and provided multidisciplinary care to women during and following their pregnancy.
• The divisional quality manager provided ‘critical incident stress debriefing’. This involved group sessions where people who had been involved in critical incidents or difficult situations were invited to talk through the process and any issues that had arisen.
• The maternity services had secured funding to have short videos produced that were available on the trust website. They were designed to build on the information given to women at the start of and during their pregnancy as it was realised that people do not take in all the information they are given by healthcare professionals. The videos could be watched at people’s leisure and aim to provide women with all the information they need to make informed choices for example around screening tests and methods of delivery.
• When women called in to say they thought they were in labour instead of being asked to come into the unit to be triaged a midwife would offer to visit the woman at home to establish if they were in labour or not. Choices about how and where they would like to have their baby could then be decided upon. This had facilitated some unplanned home births which were seen as a positive outcome. The midwives found it had meant less unnecessary attendances at the maternity unit.
• One of the general theatres operating department practitioners had noticed there were sometimes communication issues between midwifery and general theatre staff. They had carried out a project to improve multidisciplinary communication. As a result of the project a caesarean section and obstetric emergencies information chart had been produced, that was laminated and displayed in the labour ward and a theatre ‘do’s and don’ts’ also laminated and displayed for staff to follow.
• We saw a good level of involvement of children and young people in consultant interviews.
• In end of life care, bereavement officers gave out feedback cards to bereaved relatives and comments which were then discussed with the bereavement officers line manager. This had resulted in the trust introducing free parking to relatives of patients at end of life. Bereavement officers had also been able to reduce the time that death certificates took to be issued through project work. This had increased the efficiency of the process and reduced some of the emotional impact on relatives at a stressful time.
• The medical records department had consistently supplied 98-99% of records to clinics on or before the clinics, with note preparation carried out to suit consultant’s individual preferences, and had plans to electronically track notes on a live system.
• The physiotherapy direct referral service, allowed patients to access physiotherapy without the need for a GP referral. Patients using this service normally received an appointment within 72 hours of self-referral.
• In the oncology outpatient department, there was a home delivery service for some oral chemotherapy medicines. Patients received telephone consultations with their consultants for three appointments, and then came into the clinic on their fourth for a review.
• The virtual triage clinic in Fracture clinic had reduced the numbers of unnecessary fracture clinic appointments by 15%.
• The diagnostic imaging department had turned 93-99.9% of reports around within one week across all specialties and patient types. In particular, there was a dedicated inpatient-reporting radiologist for every session, which had reduced the average turnaround time for an inpatient report to six hours. The department also produced run charts to identify any outliers, and investigated the delay in their reports.
• Bereavement officers gave out feedback cards to bereaved relatives and comments were were then discussed with the bereavement officers line manager. This had resulted in the trust introducing free parking to relatives of patients at end of life. Bereavement officers had also been able to reduce the time that death certificates took to be issued through project work. This had increased the efficiency of the process and reduced some of the emotional impact on relatives at a stressful time.

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

Importantly, the trust must:

• Make the management of the emergency department environment safe. Patients waiting on corridors to be seen must be reviewed and monitored to ensure their safety.
• Address the 24 hours a day, seven days week consultant cover for paediatrics in the emergency department and allocate a named consultant for each shift.
• Ensure that there is consultant cover provided to all medical wards and escalation wards seven days a week.
• Ensure risks to the health and safety of patients when identified are actioned. When Early Warning Scores indicate an increased level of observation that this level is consistently maintained.
• Ensure plans in place to monitor sepsis pathways are completed.
• Ensure there is timely access to psychiatric support in the emergency department. A safe room must be provided to ensure both patients and staff undertaking an assessment are safe.
• Review the process of medically expected patients having to wait in the emergency department.
• Ensure senior decision makers in the hospital are involved in the movement of patients through the emergency department.
• Ensure the escalation processes in place to support the emergency department during busy periods are effective to address the issues causing the escalation.
• Ensure the governance systems in place for the emergency department reflect the known issues and are used to address the concerns identified. The trust should ensure that when areas of anomaly such as the high readmission rates and rates of patients leaving before being seen are audited and investigated.
• Ensure there are sufficient numbers of suitably trained, competent and skilled staff deployed to meet the needs of patients. The trust must provide evidence of the sustainability of these increased levels and how monitoring of sufficient staffing is being maintained.
• Ensure ongoing monitoring of the initial time to initial assessment and clinical observation. Appropriate monitoring and actions must be undertaken to ensure the safety of patients.
• Ensure patients arriving at the emergency department are seen within an appropriate timescale by an appropriate doctor. The trust must ensure monitoring of this timescale to ensure the ongoing care and treatment of patients.
• Take action to ensure patients cared for on escalation wards, outlier wards and at weekends have access to medical input and review from appropriate clinicians.
• Take action to minimise the length of stay medical patients spent as outliers in surgical areas.
• Review staffing skill mix on Elizabeth and Warrington wards to ensure patients cared for there, particularly out of hours, are safe.
• Ensure patients cared for at weekends; in escalation wards or as medical outliers receive appropriate risk assessments.
• Review how staff are trained in fire safety on wards and ensure a named, competent fire warden is in place.
• Ensure critical care staff have a full understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards and that patients subject to these are appropriately assessed, supported and authorised.
• Review staffing levels on Louisa Cary ward to ensure they meet the recommended guidance (RCN 2013) particularly at night.
• Ensure the safe storage of breast milk on Louisa Cary ward and the special care baby unit was not secure which compromised the safety of babies. This was raised with staff at the time of the inspection.
• Ensure risks for end of life care are captured and reviewed effectively through the governance system.
• Ensure all staff that monitor and adjust syringe drivers are competent and have the skills to carry this out.
• Ensure minor surgical procedure rooms are clean and fit for their purpose and ensure these standards are maintained with regular monitoring.
• Ensure there is adequate ventilation and extraction in outpatient procedure rooms where cautery is carried out.
• Ensure emergency oxygen is checked and records kept.
• Ensure medicines stored in refrigerators are checked and to keep accurate temperature records.
• Take action to capture record and investigate post procedure infection rates in the dermatology general outpatients department.
• Ensure departments carry out regular hand hygiene audits in all outpatient areas and display the results for staff and patients.

In addition the trust should:

• The trust should ensure that the privacy and dignity of patients in the resuscitation area of the emergency department is maintained and not overlooked from the adjacent corridor.
• The trust should review the security of injectable medicines on trolleys that are widely accessible in the emergency department.
• The trust should ensure that sharps bins are used correctly and are not accessible to the public.
• Staff should be aware of consistent management of paediatrics through the emergency department and ensure children’s safety.
• The damaged areas of the emergency department should be repaired to ensure the safety of patients and reduce any risks of cross-infection.
• The trust should ensure staff are supported with sufficient training for the risks associated with mental health patients spending long periods of time in the emergency department.
• The trust should ensure staff are supported with sufficient training for the safeguarding of patients and protect them from avoidable harm
• The trust should ensure hand hygiene audits are completed for the emergency department.
• Staff appraisal rates for staff in the emergency department were low and the trust should ensure these are completed.
• The trust should ensure information communication is known consistently by all staff. This included the alerting of patients with a learning disability to the wider hospital.
• The trust should ensure doctors complete patient records with legible signatures, designations and the use of the General Medical Council stamp.
• The trust should ensure adequate stock control policies and procedures are in place to ensure expired clinical products are disposed of in a timely manner.
• The trust should ensure clinicians are aware of infection control procedures and comply with hand-washing guidelines when assessing and treating patients.
• The trust should ensure nurses and other staff working in clinical areas are offered a robust and timely response to concerns they raise and incidents they report.
• The trust should consider the provision of practical de-escalation and breakaway training for ward-based staff, particularly on the emergency assessment units and care of the elderly wards.
• The trust should consider providing staff on medical wards with de-escalation and breakaway training to support them in caring for people who present with dementia-related violence.
• The trust should do all that is reasonably possible to reduce the numbers of patients waiting over 18 weeks for treatment.
• The trust should reduce the numbers of operations being cancelled.
• The trust should improve the completion of care planning summaries within 24 hours.
• The trust should ensure that record keeping for emergency equipment checks are done in line with trust policy and therefore in line with national guidance from the resuscitation council.
• The trust should improve access into the surgical assessment unit to allow for stretchered patients to be assessed in that facility.
• Intravenous fluid storage in the critical care unit should be improved to ensure these cannot be tampered with.
• The recording of mandatory training compliance in critical care should be improved so that this is easily accessible and reportable.
• The trust should ensure plans to relocate the antenatal and gynaecology clinics and as a result, improve the privacy and dignity issues for women attending fertility clinics and the early pregnancy clinics, continue.
• The trust should continue to consider plans around delivering the Day Assessment Unit service to ensure women receive an effective service with adequate staffing levels and reduced waiting times when using the service.
• The trust should continue to consider the best arrangements for ensuring screening blood tests taken from babies reach the external laboratory in time for the sample to be read and that staff are all trained to complete the blood spot card effectively. This would mean fewer babies are called back for a repeat test.
• The trust should work with partners to eliminate unnecessary delays in accessing the Children’s and Adolescents Mental Health Services, particularly out of hours and at weekends.
• The trust should review facilities for parents on the special care baby unit to ensure sufficient chairs to enable mothers to nurse their babies appropriately.
• The trust should review access to the treatment room on the paediatric ward
• The trust should ensure clarity and consistency around care planning for children and young people on Louisa Cary ward.
• The trust should ensure the quiet room is maintained to an appropriate standard to provide a clean and pleasant environment for patients and their families.
• The trust should ensure incidents associated with end of life care are able to be collated to ensure the palliative care team are alerted and can access the incident reports.
• The trust should ensure palliative and end of life assessment of need, care planning and recording is consistent and utilises personalised end of life care planning documents available.
• The trust should ensure that recording of nutrition and hydration needs is consistent and utilises the trust tools provided for example the malnutrition universal screening tool.
• The trust should ensure clarity around key strategic roles for end of life care cross the organisation
• The trust should ensure there is an appropriate level of staffing available for mortuary services.
• The trust should ensure accurate audit data is available which can be used to support delivery of end of life care across an integrated organisation.
• The trust should ensure a coherent strategy is identified, disseminated and actions in place to deliver effective end of life care across an integrated organisation.
• The trust should ensure the mortuary staff and others such as specialist palliative care team have regular training in major incident awareness to ensure the trust can respond if required.
• The trust should ensure medicine fridges in outpatient areas are kept locked at all times.
• The trust should ensure medical records remaining in clinics overnight are locked away securely.
• The trust should ensure staff undertaking procedures have appropriate skills and knowledge to do so.
• The trust should ensure staff understand their role and responsibilities when holding clinics in generic rooms, with regard to cleaning, emergency equipment and medicine storage and monitoring.
• The trust should ensure all staff adhere to the uniform policy and cross infection guidance with regard to long hair below collar length.
• The trust should ensure staff do not eat or drink in areas where blood samples and other chemicals are found.
• The trust should consider CCTV for the monitoring of isolated patients in the radiology west department.
• The trust should consider improving the environment for children in the outpatients department as the mixed environment means it is not child-friendly.

Professor Sir Mike Richards

Chief Inspector of Hospitals