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Torbay Hospital still 'requires improvement'

Torbay Hospital has been told it 'requires improvement' in four out of five areas, but bosses say the 'whole system is working well under intense pressure'.

The Care Quality Commission has today released the findings of its latest inspecton, after it was previously rated as 'requires improvement' with  urgent and emergency care 'inadequate'.

Below is a summary of the findings (which can be read in full here

Importantly, the trust must:
• Ensure the secure storage of confidential patient records in all areas.
• Ensure all medical equipment in the emergency department is serviced in accordance with service schedules.
In addition the trust should:
• Ensure signatures on nursing, medical and prescription records are legible.
• Ensure risk assessments are consistently completed.
• Ensure resuscitation trolleys and emergency equipment are checked daily across all medical areas in line with trust
policies.
• Ensure systems aimed at ensuring the safety of medicines are effective, for example the checking of refrigerator
temperatures and expiry dates.
• Consider how staff can be better included in consultation processes where service changes may affect them.
• Ensure mandatory training targets, including adult and child safeguarding, are consistently met.
• Ensure fire escape routes are kept free from clutter and obstructions.
• Ensure all staff comply with minimum training attainment levels.
• Ensure appraisals for nurses are completed.
• Ensure that regular mortality and morbidity meetings take place and related issues are included in emergency
department clinical governance meetings.
• Ensure that appropriate and regular audit takes place.
• Ensure staff to patient ratios in the emergency department are appropriate to keep patients safe at all times.
• Ensure that intentional rounding frequency where critical observatuions are noted follow guidelines for all patients.
• Ensure patient confidentiality and privacy is protected in the emergency department.
• Ensure children waiting in the main waiting room of the emergency department are provided adequate privacy away
from waiting adults.
• Ensure resuscitation trollies and equipment in the emergency department are readily available and kept clean.
• Ensure the emergency department sluice is secured and that flammable products are not accessible to unauthorised
persons.
• Ensure Patient Group Directions used in the emergency department are signed by staff and counter-signed by
managers.
• Provide training for emergency department receptionists to support the recognition of red flag presentations.
• Ensure access to major incident equipment in the emergency department is not obstructed.
• Ensure the bereavement (viewing) room in the emergency department Is an appropriate environment.
• Review the location and visibility of surgical waste bins that are visible from the emergency department relatives'
room.
• Review the steps to support people in vulnerable circumstances, such as people living with dementia, or people with
a learning disability are adequat

In a statement, the hopsital said it had
·         More senior hospital doctors and nurses on duty 7 days a week to match the times of high demand for emergency care
·         Intermediate care teams working 7 days a week to prevent hospital admission and ensure ‘no delays’ in discharging patients who are no longer acutely unwell
·         Increasing the number of patients discharged before noon so they are ‘home for lunch’ and beds are freed up to reduce the time new patients wait for admission
·         A new rapid assessment area in ED running 24 hours, 7 days a week 
·         A separate waiting and treatment area for children in ED
·         A new psychiatric assessment suite in ED to provide a safe space for the care of patients in mental health crisis
 
 
 Chief Executive of Torbay and South Devon NHS Foundation Trust, Mairead McAlinden, said: "CQC inspections are really important as they provide an objective assessment of the safety and quality of care, so we are really pleased that this report reflects the hard work of our staff to make the improvements recommended in last year’s inspection. 
 
"The CQC came back in May and saw our whole system working well under intense pressure, but making the best use of all the services provided by our hospital and community teams to deliver ‘right care, right place, right time’. 
 
"Some of these changes have been difficult for staff – working different hours so care is available when needed, investing in services that support people to remain in their community by reducing our bed based care, and sharing professional responsibility to integrate health and social care delivery.   

"The positive improvements these changes have made to the care we provide is reflected throughout this report.  This is testimony to the commitment of staff teams across the Trust, they have embraced new ways of working and made these changes a success.  There is always more to do but this report shows excellent progress.
 
"The improved rating for these core services puts us in a good position to achieve an overall rating of good or outstanding in our next full inspection. Our staff should be very proud of what they have achieved and the positive feedback from CQC and our patients about the excellent care this trust provides."

Further points today unveiled by inspectors included

Safe:
• We rated both core services inspected as requires improvement for safe.
• Confidential patient records were not always stored securely, leaving them potentially subject to unauthorised
access.
• Completion of safeguarding training often fell below trust targets, which meant staff may not have had the most
up-to-date knowledge in order to keep vulnerable people safe.
• Processes for managing medicines and Patient Group Directions (PGDs) were not always effective. Some medicines
were found to be out-of-date, refrigerator temperatures were not always regularly monitored and PGDs were not
always signed.
• We found two fire escape routes on two different wards were cluttered, posing a risk in the event people were
required to evacuate the hospital.
• A significant amount of equipment had no evidence of regular servicing, which meant there was a risk these items
could fail or not function correctly.
• Regular auditing of record-keeping was not always completed.
• There was a positive incident reporting and learning culture. When things went wrong staff were encouraged and felt
able to report incidents. Incident investigations were used as opportunities to learn and improve services.
• Staffing levels had been reviewed using national tools and the numbers of staff on duty kept people safe most of the
time. Consultant cover had been reviewed and changes to rotas had improved availability of consultants.


Effective:
• We rated both core services as good for effective.
• Protocols and pathways were evidence-based and followed national guidelines. Compliance with these was regularly
audited and areas for improvement were identified and developed.
• Multidisciplinary working had improved and was working well across the two core services.
• Staff had a good understanding of the Mental Capacity Act 2005, including consent.
• Regular training opportunities were made available to staff to ensure they were competent to carry out their roles.
• Discharge summaries were not completed consistently, which meant other healthcare p

Responsive:
• We rated both core services as good for responsive.
• Patient flow through the hospital had been improved and weekend discharges increased. Work was ongoing with
partners and stakeholders to identify further strategies that could help improve patient flow.
• The trust's escalation process for responding to severe pressures and increased demand had been overhauled and
provided much improved communication and joint working across the healthcare system.
• Complaints were responded to promptly and areas for improvement identified within investigations.
• Performance against national standards was consistently high. For example, the trust performed better than the
England average for the numbers of patients discharged, admitted or transferred from the emergency department
within four hours (although this was slightly below the standard of 95%).
• The emergency department had taken limited steps to support patients living with dementia.
• A lack of space in the emergency department prevented patients who were waiting in the corridor from receiving
adequate privacy.


Well-led:
• We rated both core services as good for well-led.
• The improvements that had been delivered were testament to the leadership and staff engagement.
• Improvement plans and strategies had been developed with staff and were focused on delivering high-quality care.
• Strong governance processes were in place and these helped drive improvement. Risks were understood, regularly
discussed and actions put in place to reduce the risks where possible.
• Staff spoke of an open, supportive culture and felt able to raise concerns with the leadership teams.
• Mortality and morbidity reviews did not always take place regularly.
• Some staff felt divisional leaders were not visible at service level.
We saw some areas of outstanding practice, including:
• The trust had fully addressed the requirement notices from our inspection in February 2016. In particular we saw
significant improvements had been made in the emergency department in terms of safety, quality, performance and
patient experience. The department had streamlined processes and introduced a system of triage and rapid
assessment, which improved safety, efficiency and patient flow.
• We saw exceptional multidisciplinary working between the whole healthcare system in response to the trust's
escalation process
• A newly created mental health assessment room provided a safe, welcoming and calming environment, located
away from the hustle and bustle of the busy emergency department.
• There was a separate children's area in the emergency department, which was secure and was not overlooked by
adult patients and visitors. This area was staffed by a dedicated trained paediatric nurse workforce. In addition, adult
trained nurses received paediatric training as part of their induction and mandatory training.
• There were cooperative and supportive relationships amongst staff in the emergency department. We observed
excellent teamwork, particularly when the department was under pressure.
• Service improvement was everybody's responsibility in the emergency department. Staff had been engaged in the
improvement.

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