Chief Inspector of Hospitals finds that Northern Devon Healthcare NHS Trust requires improvement

England's Chief Inspector of Hospitals, Professor Sir Mike Richards, has published his first report on the quality of services provided by Northern Devon Healthcare NHS Trust.

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

The North Devon District Hospital was rated as Requires Improvement, although the care provided by staff was rated as Good throughout the hospital. In addition the care provided on the Medical Wards was rated as Outstanding. Community Health services were rated as Good. Full reports are available on the CQC website here.

The trust was inspected by CQC in July under its new inspection regime. The inspection team of 52 people which included doctors, nurses, hospital managers, trained members of the public, a variety of specialists, CQC inspectors and analysts spent three days at the trust. Inspectors also returned unannounced on three occasions.

Inspectors found that patients, carers, families and visitors were overwhelmingly positive about the care, kindness and dedication shown by the staff working in the North Devon District Hospital at Barnstaple, the 10 community hospitals that were inspected, and in the community services. The care provided in the acute medical care service was judged to be outstanding.

While most services were safe, improvements were required in A&E and end of life care. At North Devon District Hospital the system for receiving ambulance patients was not effective. The A&E department had not been consistently meeting the national standard that requires 95% of patients in A&E to wait less than four hours to be admitted, transferred or discharged. During the inspection, there were several occasions when ambulance crews and their patients were waiting in the corridor outside the major treatment area for more than 15 minutes even though there was space in the major treatment area for more patients.

Overall, people received care, treatment and support that achieved good outcomes and promoted a good quality of life. Generally there was a strongly developed multidisciplinary collaborative approach to care and treatment, with consistently strong examples of this throughout the community services and also in areas of acute care.

The community health services provided by the trust were judged to be responsive, although inspectors found that patients in the main acute hospital were not always cared for on the most appropriate ward and the critical care unit was not always able to accept or to discharge patients at the most appropriate time.

Inspectors identified a number of areas of outstanding practice, including:

• The multidisciplinary approach in community services, including ways of working with adult social care services, was delivering a good service to patients, in a way 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.
• The nursing leadership of the acute stroke service was highly regarded by doctors, therapists and nurses. Staff felt valued and the service itself was patient focused.
• The care of patients with a diagnosis of dementia on Alex ward was outstanding. A robust dementia policy ensured the highest standards of personalised care.
• The trust’s successful involvement with Project Search, a 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, who had successfully completed the programme and had found permanent jobs, six of them with the trust

There were also areas of poor practice where the trust needed to make improvements.

• The trust must improve arrangements for the prevention, detection and control of the spread of healthcare-associated infection.
• The effectiveness of the current patient flow and escalation policies must improve. Action must be taken to improve the flow of patients from the A&E department and across the trust.
• The must ensure that an accurate record is put in place for each patients receiving end of life care.
• There must be a system in place for the completion of records relating to grounds for carrying out an abortion as required.

CQC’s Chief Inspector of Hospitals, Professor Sir Mike Richards, said:

"Northern Devon Healthcare NHS Trust has a lot to be proud of. In particular I am very pleased to recognise the outstanding care on the medical wards, where we found high levels of patient satisfaction with the service. We've seen some outstanding examples of care: on one ward for instance, staff had thrown a 1940s street party for patients living with dementia. We found excellent specialist care for patients with a stroke or with dementia.

“Generally the trust impressed us with its forward-looking vision and services clearly focused on quality and safety. We found that the trust has a healthy, patient-focused culture with staff who feel well supported and valued.

"But we've also seen some examples of care which clearly require improvement. In A and E there were significant infection control issues, and on the wards at Barnstaple, we had concerns about the practice of moving patients overnight.

"It is a matter of concern that treatment escalation plans, including do not attempt cardio-pulmonary resuscitation decisions, were not always completed appropriately, with a significant number that did not show there had been discussions with patients or relatives. That must be addressed.

“On a wider note, I understand that that the financial challenges in the Devon healthcare economy and the uncertainties about the future provision of community services in East Devon have been taking up significant time. “But I am optimistic. Staff in both the acute and community services have described the culture of the trust as being open and positive - and my inspectors report that the trust has considerable potential to improve services further."

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The Chief Inspector of Hospitals, Professor Sir Mike Richards, is leading significantly larger inspection teams than before, headed up by clinical and other experts including trained members of the public. By the end of 2015, CQC will have inspected all acute NHS Trusts in the country with its new inspection model.

Whenever CQC inspects it will always ask the following five questions of every service: Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led?

Under the new inspection model, CQC has given individual ratings to each of these core services provided by Northern Devon Healthcare NHS Trust

• Accident and emergency, medical care (including older people’s care), surgery, critical care, maternity and family planning, services for children and young people, end of life care, and outpatients services.
• Community health services for adults, community inpatient services and End of Life care.

CQC inspectors have also reported on, but not rated, the minor injuries units at eight community hospitals.

During the inspection, CQC visited the following 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.

The Care Quality Commission has already presented its findings to a local Quality Summit, including NHS commissioners, providers, regulators and other public bodies. The purpose of the Quality Summit is to develop a plan of action and recommendations based on the inspection team’s findings.