Community health inpatient services

Transcription

1 Northern Devon Healthcare NHS Trust RBZ Community health inpatient services Raleigh Park, Barnstaple, Devon Ex31 4JB Tel: Date of inspection visit: 2-4 July 2014 Date of publication: September 2014 This report describes our judgement of the quality of care provided within this core service by Northern Devon Healthcare NHS Trust. Where relevant we provide detail of each location or area of service visited. Our judgement is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from people who use services, the public and other organisations. Where applicable, we have reported on each core service provided by Northern Devon Healthcare NHS Trust and these are brought together to inform our overall judgement of Northern Devon Healthcare NHS Trust Northern Devon Healthcare Trust Community Inpatients September

2 Summary of findings Contents Page Overall summary 3 Background to the service 3 Our inspection team 4 How we carried out this inspection 4 Why we carried out this inspection 4 The five questions we ask about core services and what we found 5 What people who use the service say 19 Good practice 19 Areas for improvement Northern Devon Healthcare Trust Community Inpatients September

3 Overall summary Overall rating for this core service Good Overall, community health adult inpatient services were good. Services were found to be safe, effective, caring, responsive and well led. Staff had a good understanding of incident reporting. Though lessons learnt were shared, staff were not always aware of how or why changes to practice had occurred. Areas were clean, and appropriate infection control practices were followed. Staffing levels were being reviewed and, while there were considerable vacancies in some hospitals, these were being managed, with the use of agency and NHS Professionals staff. However, vacancies had also resulted in the closure of some community beds, meaning at times patients were not able to be cared for in the community hospital closest to their home. Staff reported good access to training and training statistics showed good attendance by staff across the community hospitals. There was very good multidisciplinary and integrated working between staff, who were caring and respectful. There was good local leadership for staff, and staff reported an open and supportive culture. However there was an absence of a local risk register to allow for the monitoring of risks at each community hospital. All risks were held on the corporate risk register which held both hospital and community risks. Innovative practices were in place to prevent admission and to expedite hospital discharge. Background to the service The Northern Devon Healthcare NHS Trust operates across 1,300 square miles, providing care for people for Axminster to Bude and from Exmouth to Lynton. Adult community services are provided at 17 community hospitals, of which 15 were open to inpatients at the time of the inspection. During the announced inspection, we visited the following 10 hospitals: Ilfracombe, Bideford, Holsworthy, South Molton, Okehampton, Whipton, Tiverton and District, Honiton, Ottery St Mary, Exmouth. In addition, we also undertook two unannounced inspections at Sidmouth and Crediton hospitals Northern Devon Healthcare Trust Community Inpatients September

4 Our judgements were made across all of the hospitals visited, where differences occurred at particular hospitals we have highlighted them in the report. Acute hospital services were provided by North Devon District Hospital (the acute site for the Northern Devon Healthcare NHS Trust) in the north of the locality and the Royal Devon and Exeter Hospital (Royal Devon & Exeter NHS Foundation Trust) in the south of the locality. During the inspection, we spoke with 145 staff, including nurses, occupational therapists, physiotherapists, pharmacy technicians, hotel services staff, admin and clerical support staff, GPs and visiting consultants. We also spoke with 34 patients, 18 relatives and we reviewed 32 sets of care records. We also placed comment cards around the community hospitals and received 40 comments, all of which were positive. Our inspection team Our inspection team was led by: Chair: Jan Filochwski recently retired Chief Executive from Great Ormond Street Hospital for Children NHS Foundation Trust Team Leader: Mary Cridge, Care Quality Commission (CQC) The inspection teams included CQC inspectors, specialist advisers in community nursing, a palliative care specialist nurse, a rehabilitation therapist, Allied Healthcare professionals, a sexual health nurse, community matrons and a GP. How we carried out this inspection To get to the heart of the care that people who use this service experienced, we always ask the following five questions of every service and provider: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? Before visiting, we reviewed a range of information we held about the core service and asked other organisations to share what they knew. We carried out an announced visit on 2, 3 and 4 July During the visit, we held focus groups with a range of staff who worked within the service, such as nurses, doctors and therapists. We talked with people who use services. We observed how people were being cared for and talked with carers and/or family members, reviewing care or treatment records of the people who used the services. We met with people who used the services and their carers, who shared their views and experiences of the core service. We reviewed comment cards, which were completed by patients and relatives. We carried out unannounced visits on 7 and 8 July Why we carried out this inspection We inspected this core service as part of our comprehensive Wave 2 pilot community health services inspection programme. The trust is an aspirant Foundation Trust Northern Devon Healthcare Trust Community Inpatients September

5 The five questions we ask about core services and what we found Are services safe? Summary Good Community health adult inpatient services were safe. Staff reported incidents and, in general, received feedback. Learning from incidents occurred within community hospitals and there was evidence that learning occurred across the community. There were regular and systematic cleaning processes in place to ensure hospitals, wards and public areas were clean and staff carried out effective and appropriate infection control practices. Audits were undertaken that demonstrated this. Where concerns had been identified, actions had been taken. There was sufficient equipment, which was clean and well maintained. Medicines were appropriately stored and administered. Each hospital received some input from either a pharmacist or a pharmacy technician. Staff were aware of safeguarding processes and knew how to make referrals. Most staff had completed safeguarding training across all hospitals. We saw evidence of the Deprivation of Liberty Safeguards process being managed well for two patients. However, we had concerns in Crediton Hospital regarding the management of a patient at risk of wandering and falling. This was raised with the matron at the time. Individual patient risks were well managed. However, not all anticipated risks had processes in place to manage them. In particular, the processes used to open more beds in order to manage increased demand. Staffing levels were, in the main, sufficient for patient acuity and where additional need was identified, more staff were recruited from agencies whenever possible. However, the staffing levels meant registered nurses often worked unsupervised, particularly at night and at weekends. This meant they were unable to take a break during their shift. In addition, the registered nurse would, at times, be an agency or NHS Professionals staff member, who could be unfamiliar with the hospital and patients, which posed a risk. Vacancy factors were as high as 33% within the registered nurse establishment, which posed a risk to the service overall. The trust was undertaking a staffing review to reduce the impact of this, with the ultimate aim of having one registered nurse to eight patients in all community hospitals with a minimum of 16 beds in any unit. Detailed findings Incidents, reporting and learning Staff reported incidents on the trust-wide electronic reporting system. This was available in all ward and department areas via the trust intranet home page. Staff in all community hospitals told us this was relatively simple to do, and many we spoke with had reported incidents. However, at Exmouth Hospital, some staff told us they were unaware of how to report incidents themselves, leaving it to more senior nursing staff. We saw examples where incidents had occurred, such as a fall. These incidents had been reported immediately. However, there were also examples where incidents were not reported. For example, at Crediton Hospital, we reviewed the notes for one patient who had received a skin abrasion injury during moving and handling. This had not been reported and the patient was not seen by a doctor until they were called out of hours 3 days later to review the skin abrasion after it was suspected of being infected Northern Devon Healthcare Trust Community Inpatients September

6 Initial feedback from incidents occurred via the electronic system. Staff had the option to enter their address, which triggered an automatic response to their submission. Individual and detailed feedback was the responsibility of the local managers. Staff we spoke with described receiving more feedback recently, though the speed of feedback varied across the hospitals visited. One staff member spoke of submitting incident reports and not having received feedback one month later. However, this did not appear to be the case everywhere. Most staff spoke of receiving feedback from their local managers. Learning from incidents occurred within the local community hospitals. However, while there was evidence that learning from serious events in other community hospitals within the trust occurred, this learning was not linked to incidents. For example, following a review of a serious event, staff at Bideford Community Hospital told us they had changed their procedure for conducting handovers, to ensure patients remain visible at all times. Bedside handovers now took place, with only sensitive information in the form of a safety briefing occurring in the office. We saw bedside rounds occurring at some other hospitals. Staff in one hospital told us this was a change in practice, and that they were getting used to it. However, they were unaware of why the change had been brought about. Cleanliness, infection control and hygiene All areas visited appeared clean. Each ward area had a large board at the entrance, which displayed ward-specific information. We saw the results of hand hygiene audits and cleanliness audits on these boards in all of the community hospitals visited. Scores ranged from % compliance. In addition, wards also posted the number of days since the last episode of a hospitalacquired infection. These were seen to range from days. Entrances had large signs advising visitors of the need for good hand hygiene. However, there were no hand sanitising gel dispensers nearby for them to use. Cleanliness audits were undertaken by hotel services staff, and hospitals had patient-led assessments of the care environment (PLACE) audit undertaken. We saw how the findings of these audits informed actions such as targeted cleaning and upgrading the fabric of the building, for example, at Sidmouth Hospital. Overall, PLACE assessments gave a cleanliness score of 92.22% across all 17 locations inspected between April and June Staff had access to personal protective equipment (PPE), such as gloves and aprons. We saw instances of patients being cared for in side rooms, due to infection risks. Staff were seen applying gloves and aprons before entering, washing hands and using hand sanitising gel following their encounters with patients. Community hospitals had infection control link nurses who liaised with the trust infection control team in the mid and east of community locality, and in the south of the community locality, with the infection control nurses from the Royal Devon & Exeter NHS Foundation Trust. We saw the infection control nurse from the Royal Devon & Exeter NHS Foundation Trust visit one of the community hospitals and provide advice to staff who were concerned regarding a patient with diarrhoea. Staff had already instigated correct infection control procedures in the form of isolation and barrier nursing, prior to them coming to the ward. Equipment had I am clean stickers on it, which were easily visible. These documented the last date and time equipment, such as pumps and commodes, had been cleaned. During the inspection of Crediton Hospital, an external provider was undertaking a community hospital wide sharps bin audit. We reviewed the tool used and saw they audited for example, that only sharps were disposed of in sharps bins, overfilling did not occur and that safety lids were in place. Results of the audits were fed back to each hospital. All hospitals had side rooms to allow for nursing patients who had an infection. We saw this in practice in several of the hospitals visited. Signage was clear on doors and there was a supply of gloves and aprons at the entrance to the room. At Whipton Hospital, we saw staff using disposable blood pressure cuffs when undertaking patient observations. We saw maintenance staff enter a room where a patient was being nursed in isolation due to an infection risk. Following this, we saw them wash and use hand sanitising gel on their hands appropriately. When asked, they reported nursing staff had advised them of the infection risk and of the correct procedures to follow regarding hand hygiene, prior to them undertaking the maintenance Northern Devon Healthcare Trust Community Inpatients September

7 Maintenance of environment and equipment While all hospitals visited were clean and well maintained, the environment in which patients were cared for varied. For example, in Sidmouth Community Hospital, an improvement programme had taken place. This had been led by The League of Friends. During the inspection, the final stages of the refit were being undertaken, with signage being put in place. At some other hospitals the environments were older and were more cramped and cluttered. We spoke with maintenance staff, who told us how they were notified of issues requiring repair. Nursing and administration staff showed us the process for accessing maintenance. Staff reported this as being undertaken quickly after reporting, particularly when this related to a safety or hygiene issue. We reviewed the records, which were kept to confirm emergency equipment, including resuscitation equipment, was checked every day. We saw this had taken place. However, we noted the contents of the resuscitation trolleys were not secure, meaning the contents could be tampered with. Pressure-relieving equipment was available on site in all hospitals. Where additional equipment was needed, staff told us they were able to order more, which would be delivered for patients within 24 hours. We checked a random sample of equipment and noted that all equipment was labelled when it was last seen and had been subject to a safety check. All equipment had been checked in recent months. Most community hospitals had access to outside space, which was well maintained. Medicines Records confirmed that drug fridge temperatures were taken daily. However, we noted that room temperatures where medication was stored were not routinely recorded. Therefore, we could not be assured that medication was stored at an appropriate temperature at all times to ensure they remained effective. Pharmacist support was available across all hospitals. Most hospitals had reviews undertaken by the pharmacist or pharmacy technician one to two times per week but all had access to 5 days a week support if needed. Audits were undertaken into omitted medication doses. These were displayed in some hospitals. For example, in Tiverton and District Hospital, where 99.6% of medicines were recorded as being given on time. We observed medicine rounds occurring in several of the hospitals visited. Some used a drugs trolley, while others stored patient medicines in a locked box at their bedside. We observed staff carrying out appropriate checks to confirm identity and spent time giving medicines to people, explaining what they were for and remaining with them while the medicine was swallowed. On one occasion, we noted a drug trolley had been left outside of the day room unattended and unlocked. We raised this immediately with the staff concerned, who promptly locked the cupboard. We reviewed medicines administration records and noted they were correctly completed, including when it came to listing allergies. We saw there were instances where a medication had not been given, the reason the medicine was not given was recorded using codes. Safeguarding Staff we spoke with had a good understanding of safeguarding. Staff were able to identify the types of abuse, and how to report suspicions. However, most staff were not aware who the named safeguarding lead was. Most staff had completed safeguarding training. The trust s training records demonstrated that 98% of the staff working in community inpatient areas had completed Safeguarding Adults Awareness training. Records Nursing staff recorded care in notes held separately to the rest of the multidisciplinary team. In most hospitals, these were held at the patient s bedside, with medical and therapies documentation held separately. At Sidmouth Hospital, these were held in a secure, locked trolley. However, this was not the case in most of the hospitals visited, where the general practice was to store patient notes in the office or in trolleys behind the nurse s station Northern Devon Healthcare Trust Community Inpatients September

8 Records were securely stored for patients attending outpatient appointments. These were accessed ahead of clinics and were available for consultations. We reviewed 32 sets of care records and saw these contained detailed information on the patient involved, including completed and updated risk assessments and evaluations. Staff undertook record-keeping audits at various intervals, but most records were subject to a monthly audit. This usually involved a random selection of case notes, with findings fed back at ward and at team meetings. Not all documents reviewed had been completed thoroughly. For example, we saw food charts, were not always completed accurately. For example, they did not all include the amount the patient ate or drank. This meant staff were not able to monitor if patients nutritional and hydration needs had been met. Lone and remote working Staff working outside of the community were supported by a lone worker s policy. However, staff in some community hospitals could be isolated and remote at times. Staffing levels meant that, at times, in some hospitals where there were fewer beds, there would only be one registered nurse and two healthcare assistants in the building at night. Staff we spoke with told us this concerned them. At these times, the staff s point of help in the event of a security concern in the building was via the police. Assessing and responding to patient risk Within the care records we reviewed, we saw risk assessment booklets that staff had completed. These included risk assessments for nutrition, pressure damage and falls. These were reviewed regularly (in many cases daily) and updated when care needs altered. We saw evidence of actions as a result of risk assessments. Staff we spoke with told us they received information on anticipated admissions, which meant they could access appropriate equipment prior to the patient arriving in the hospital. Staff undertook patient at risk scores using an early warning system to identify patients at risk of deterioration. These were subject to regular audits by the matrons. Data provided by the trust showed that between June 2013 and May 2014, 92% of all early warning charts had been completed correctly. We reviewed the charts within the care records and saw where scores had increased, additional monitoring had been instigated. We saw evidence of medical advice being sought both in and out of hours. Staffing levels and caseload Regular recruitment drives occurred, though staff told us the overall recruitment process could be lengthy. Each hospital ward displayed a board at the entrance, which showed the number of nursing staff that should be on duty and the number there actually were. The number of therapists was not highlighted to visitors or patients. We saw the established staffing and the actual staffing levels were the same or greater in all hospitals during the inspection and in both hospitals during the unannounced inspection. Staff told us registered nurse to patient ratios had been increased and was generally set at one nurse to 10 patients. Although one nurse for 10 patients, with the support of healthcare assistants, could be sufficient for the acuity of patients, the community hospitals were mainly isolated. This caused problems for enabling staff to take regular breaks. For example, at Ilfracombe and Crediton Hospitals, the registered nurse was unable to take a break away from the ward for the whole shift. In addition, if the registered nurse was an agency nurse, they may not have worked at the hospital before, but would be in sole charge for the duration of their shift. The trust was undertaking a staffing review to reduce the impact of this, with the ultimate aim of having one registered nurse to eight patients in all community hospitals. On this basis, agency staff would not be left in charge of the hospital without another registered nurse support. Staff told us that, following the appointment of the new Director of Nursing, staffing levels had already improved to ensure a maximum of one registered nurse to ten patients Northern Devon Healthcare Trust Community Inpatients September

9 Staff members told us that staffing levels were a problem and there was high use of agency and NHS Professionals staff. Due to the small numbers of staff employed at each hospital, the loss of one or two staff members had a large impact. For example, at Ottery St Mary Hospital, the registered nurse vacancy factor was 22% and 18% for healthcare assistants. The matron at this hospital told us that temporary staff were booked as soon as the off-duty list was published (four weeks in advance) in order to be assured that staffing gaps would be filled. Though trust policy stated the use of agency to fill vacant shifts could only be actioned much nearer to the vacant shift, this was done with the agreement of the divisional manager which meant there was no shortfall. In the event of sudden sickness, staff told us they worked flexibly to provide cover, as last minute notice shifts were particularly difficult to fill. Due to the high numbers of agency and NHS Professionals staff being used, staff often worked with the regular nurses. However, staff told us they undertook induction with any new agency nurse prior to them commencing a shift. We spoke with an agency healthcare assistant who was providing one-to-one care for a patient in Sidmouth Hospital. They reported a good handover prior to commencing their shift. Staffing was raised as an issue at most community hospitals. Staff felt that recruitment into community hospital posts was particularly difficult, given the current community services review being undertaken by the local clinical commissioning group. Individual hospitals did not have a risk assessment detailing their staffing risks. However, the overall community staffing shortfall was reported on the trust risk register with a score of 16 (meaning a high risk). The trust risk register also identified as a score of 20 (meaning a very high risk) as a risk that temporary staff would not be booked, due to the electronic interface with NHS Professionals not functioning correctly. Staff were aware of the processes to follow to ensure this risk did not occur. Following a change in the role of hotel services staff, there was limited porterage occurring. While some hospitals did not find this a problem, others, such as Exmouth Hospital told us the lack of dedicated porters meant nurses were required to undertake these duties, which at the time conflicted with the need to carry out patient care. For example, the arrival of stores to be moved conflicted with meal times. Staff at Ottery St Mary Hospital informed us that they had been given short notice about the opening of additional beds during the winter time. Additional staffing was provided by agency and NHS Professionals. Medical staff coverage varied across the hospitals. Most had regular ward rounds from GPs. For some, this was Monday to Saturday with phone calls on Sundays and for others less frequently. Some hospitals had ward rounds ranging from daily, to once a week from visiting consultants. All staff were aware of how to access medical support both in day-time hours and in the evenings and at weekends. Deprivation of Liberty safeguards At two hospitals visited, Honiton and Sidmouth, we saw patients who were subject to a Deprivation of Liberty Safeguards order. We reviewed the records for these patients and saw a comprehensive mental capacity assessment had been undertaken and applications for Deprivation of Liberty Safeguards had been conducted correctly. This meant that, where people s liberty was being restricted, these had been undertaken legally. We saw these people had been assigned enhanced support in the form of one-to-one care to ensure their safety. Staff told us additional staff could be requested whenever enhanced nursing needs had been identified. However, at Crediton Hospital, we were told by one member of staff that, on the day before our inspection the ward had been in lock down, meaning the doors were locked to prevent patient access to the outdoor space. This was because they had a patient who was very confused and trying to wander. Staff told us this impacted on other patients when the weather had been very hot as they had been unable to open the doors for other patients. These doors were still locked at the time of our visit. As the patient who was at risk of leaving the ward was also at risk of falling, a pressure mat had been put in place which set off an alarm when they stood up. Staff told us the person did not like the alarm and continually stood up to go from their bed to their chair. The use of a pressure mat had not been risk assessed. A mental capacity assessment had been undertaken, but was general, not specific to their capacity to understand a specific action, such as the need to remain in hospital. We Northern Devon Healthcare Trust Community Inpatients September

10 discussed our concerns with the manager that all patients were being deprived of their liberty through the process of locking all doors. The manager told us they would undertake a review and a mental capacity assessment of the patient concerned and provided enhanced nursing support, as required. The trust s training records demonstrated that 98% of the staff working in community inpatient areas had completed Safeguarding Adults Awareness training, with 76.8% having undertaken Mental Capacity Act 2005 and Deprivation of Liberty Safeguards training. Patients had treatment plans and resuscitation orders within their notes, as appropriate. Those reviewed had been completed correctly and where it was felt a patient lacked mental capacity, a mental capacity assessment had been undertaken. Managing anticipated risks Staff at some community hospitals had been alerted of the possible need to increase beds to support the increased demand during the winter period. This was, however, not accompanied by plans, procedures or check lists to ensure all aspects of opening an increased number of beds had been considered. For example, increased linen and other consumable stock availability. Staff reported that, when the decision to open beds was made, this was all done with great speed, and while the opening of additional beds was uneventful, the risks associated with it had not been managed in a systematic way. Where detailed discharge information was received in advance from the acute hospitals, patient risks (such as the moving and handling of bariatric patients) was well managed and planned, with staff ensuring equipment was in place, ready for admission. Major incident awareness and training Staff at some of the community hospitals reported having undertaken evacuation training. In addition, the major incident plan was available for staff on the intranet. Staff were aware of the bed pressures placed on the acute hospitals and had developed a pull system. This involved looking at the bed states and patients suitable for transfer from the acute hospitals on a daily basis, with the aim to expedite hospital discharges, thereby freeing up acute hospital beds. In addition, there was a virtual bed meeting held daily involving both the acute trust and the Onward Care Team based at the Royal Devon and Exeter NHS Foundation Trust. Are services effective? Good Summary Services provided effective care to patients. Care was provided in line with national policies, with excellent multidisciplinary working. However, there was variable emphasis on discharge planning across areas. This was reflected in the average length of stay, which varied from 17 days to 29 days. During the inspection, we saw some patients, at some hospitals, who had been inpatients for a period of time in excess of 90 days. Meals lacked variety for patients remaining in hospital for that length of time, or for those in need of a pureed diet. Detailed findings Evidence based care and treatment Policies and procedures were developed in line with national guidance and were available for staff on the hospital intranet site. We saw evidence that policies, such as the policy for the prevention and management of pressure ulcers, were followed. For example, staff took photographs of any pressure damage, either hospital acquired or present on admission. Staff carried out comfort rounding and promoted skin integrity through the use of SSKIN, a five step model for pressure ulcer prevention, which stands for: surface (of the bed/chair) make sure your patients have the right support, skin inspection early inspection means early detection (show patients and carers what to look for), keep patients moving, incontinence/moisture your patients need to be clean and dry and nutrition/hydration help patients have the right diet and plenty of fluids Northern Devon Healthcare Trust Community Inpatients September

11 Falls prevention is one of the NHS Institute for Innovation and Improvement's eight high impact actions, and was evident in all hospitals. Staff undertook falls risk assessments and completed postfall check lists following patient falls. Physiotherapists undertook falls prevention and strength and balance sessions at some of the hospitals. Pain relief Patients were prescribed pain relief, as appropriate. Most hospitals received daily visits (Monday to Friday) by GPs, who were able to adjust prescriptions for analgesia, as required. We saw patients had been prescribed regular analgesia, which had been given to prevent pain developing. Nutrition and hydration Meals were delivered precooked and frozen to all community hospitals. Some puddings and sandwiches were made in the hospital kitchens. Hotel services staff heated meals and served them according to patients choice. Breakfasts consisted of cereals and toast, lunches were cooked and on a four-week rotational menu and evening meals consisted of soup and sandwiches (a one-week repeating menu). We saw evidence of food and fluid charts in use. While some had been completed well, others contained little evaluation of what had actually been consumed by the patient, of either food or fluids. This meant patients were at risk of insufficient intake not being recognised. Staff reported there had been very few complaints regarding food and this was always questioned during matrons walk rounds, which occurred monthly. Staff had access to speech and language therapists and dieticians. Staff told us specialist staff were accessible and would provide advice and also review patients, as required. Protected meal times were in operation at the time of the inspection, meaning patients were not interrupted during their meals for investigations or therapy sessions. Patients admitted late in the day could have hot meals provided for them from a late arrivals menu. Patient outcomes Individual patient outcomes were monitored. Therapists used recognised outcome monitoring scores such as the Berg Balance Scale, a widely used clinical test of a person's static and dynamic balance abilities and the Modified Barthel Index, used to measure performance in activities of daily living. This allowed physiotherapists and occupational therapists the ability to monitor treatment outcomes and effectiveness for patients. Service or condition specific outcomes were not measured or analysed, therefore there was no oversight over the overall effectiveness of care the service provided. Information required to meet CQUIN (Commissioning for Quality and Innovation payment framework) targets set by the local CCG were monitored, such as the number of patients assessed as being at risk of pressure damage and nutritional screening needs. The average length of stay appeared to differ greatly across community hospitals. Staff told us this was mainly due to the difficulty in securing domiciliary care packages for complex care needs in more rural settings. However, there was no evidence to demonstrate reasons for variance had been audited, or that they were being actively addressed. The average length of stay varied from 17 days at Seaton Hospital to 29 days at Tiverton and District Hospital. Individual lengths of stay varied considerably. During the inspection, we saw some patients with complex needs at some hospitals had been inpatients for in excess of 90 days. Performance information Performance information was displayed on notice boards in the community inpatient areas. The information included figures for participation in the Safety Thermometer programme. For example, in falls and pressure ulcers. Safety crosses were in use, giving a clear indication of how many days had elapsed since a patient had suffered harm as a result of a fall, pressure ulcer or hospitalacquired infection. Staff were unable to tell us the average length of stay for patients in their community hospital Northern Devon Healthcare Trust Community Inpatients September

12 Competent staff Staff received annual appraisals and regular supervision sessions. While most staff we spoke with told us they had received appraisals, a review of the data provided by the trust showed an overall figure of 61.4% of staff having undertaken appraisals within the last year. Analysis across the community hospitals demonstrated wide variance ranging from 37% of ward staff in Sidmouth Hospital to 96% in Bideford Hospital Willow Community Unit. Staff we spoke with told us training was readily available and they were encouraged to attend. While some was delivered online, other training was delivered face to face, at a variety of locations across the locality to allow ease of attendance. Where it was recognised some staff had limited computer skills, online learning had, in the main, been converted to face-to-face learning. A review of data provided by the trust showed overall compliance with mandatory training as being above 74%. One GP we spoke with felt they would benefit from more specialist training being provided from the trust consultants. Use of equipment and facilities Most equipment was suitably stored, leaving corridors clutter free. Most hospitals had dining rooms, lounges and gardens, though we saw little evidence of use in some hospitals. For example, in Crediton Hospital, where the lounge was being used to store some equipment. Multi-disciplinary working and working with others Multidisciplinary working occurred primarily face to face, although telephone advice was available from specialist practitioners There was good communication between different healthcare professionals involved in the care and treatment of patients. As well as healthcare professionals, this also included very close working with social services. Hospitals had discharge facilitators, some of whom were employed by the trust and some by social services. Consultants visited some hospitals daily and others weekly. We attended several multidisciplinary meetings where the care of all patients was discussed. These were felt by our specialist advisers to be exemplary in their constitution (combining health and social care professionals) and in the detail and planning discussed, clearly placing the patient at the centre of care. Ward handovers were conducted by using updated printouts, which provided staff with brief details of the patients and their needs. Ward rounds occurred at the bedside with a safety briefing and discussion of any sensitive matters occurring in the office. Where domiciliary care agencies were being used to provide complex home care packages, staff from the agencies attended the wards prior to discharge in order to meet the patient and learn techniques to meet their individual needs, such as moving and handling. Co-ordinated, integrated care pathways Staff did not follow specific care pathways, rather, tailoring goals to the patient. We heard from one staff member how this had delayed discharge for one patient after information had not been sufficiently prepared for a community healthcare funding meeting. Are services caring? Good Summary Services provided within the community hospitals were caring. However, there were some areas where improvement should occur. Staff were mainly seen to be kind and compassionate and care was delivered with privacy and dignity in mind. Patients were encouraged to be independent and self-care was promoted. However, not all patients were aware of their predicted date of discharge Northern Devon Healthcare Trust Community Inpatients September

13 At most hospitals, we saw little meaningful activity to engage and stimulate people, aside from the occupational and physiotherapy sessions. Some patients had been in hospital for days with very little stimulation and activity. Detailed findings Compassionate care We saw evidence of staff responding to patients in a kind and compassionate manner. Staff appeared to have good rapport with patients, particularly those who had been inpatients for a period of time. Patients and relatives told us that nursing staff were very caring. We saw staff members respond with kindness and sensitivity to a particularly distressed patient. We spoke with one patient who told us, It s brilliant care everyone has been a rock. They then described how staff had noticed and spent time talking to them when they felt low in mood. The NHS Friends and Family Test was undertaken in all areas. The number of people who would recommend the hospital in all areas exceeded 75%. Dignity and respect Care was provided in a range of accommodation, from side rooms to four-bed bays. We observed staff using curtains and closing doors during episodes of care. Staff were observed knocking on doors before entering rooms. Patients were cared for in accordance with national same-sex accommodation guidelines. We observed lunch time at most hospitals we visited. At Crediton Hospital, patients had been encouraged to attend the dining room in order to eat lunch. Loud pop music was playing, which may not have been suitable or desirable for most patients. Lunch was being supervised by three healthcare assistants. We spent time observing how staff interacted with patients. The staff were seen standing with arms folded, watching people eat, with minimal engagement. Patient understanding and involvement On admission, patients signed forms titled Consent on admission form for nursing staff, which described the nursing care and usual interventions that would be undertaken. Prior to each entry in the notes, therapists were seen to have documented consent gained from the patient. At some hospitals, for example, Ottery St Mary Hospital, therapists developed contracts with patients. These detailed the therapy required and the level of commitment required from the patient to attain the goals. For example, to undertake 15 leg raises or to walk 10 metres, twice a day. These forms were then used by nursing staff to continue the therapy in the absence of the therapists or therapy assistants. We observed some patients using ipads to communicate with staff, others were seen to use wipe boards, which ensured they were able to express themselves if they were unable to speak. Most patients we spoke with, despite having been in the hospital for several days, did not know their predicted date of discharge. Emotional support Staff were seen comforting patients and relatives in a supportive manner. We spent time with a hospice nurse who was based one hospital. They described how staff were able to refer patients and relatives to them. They were also able to provide support to staff. Chaplaincy services could be arranged if required. Staff also described being able to access support for those of other religious denominations. Sidmouth, Axminster and Seaton Hospitals had access to a mental health nurse employed by the trust to provide advice and support to both patients and staff. Promotion of self-care The main focus for patients within the community was that of rehabilitation and recuperation with the aim of supporting discharge to the most appropriate place for the person to live as independently as they were able. We saw staff promote self-care in a variety of ways. For example, several hospitals held breakfast clubs where patients were encouraged to go to the dining room and make their own Northern Devon Healthcare Trust Community Inpatients September

14 breakfast, with the support of staff. Most patients seen were dressed in day clothes. At most though not all community hospitals, there were occupational therapy assessment kitchens. In addition, staff were seen undertaking home assessments as part of the discharge-planning process. At Exeter Community Hospital, staff described how they had moved one patient into a side room in preparation for discharge. They were elderly and lived alone. Staff, therefore, wanted to simulate the patient s home environment. On discharge, they were to receive domiciliary care four times a day. In preparation for this, staff had agreed with the patient to enter their room and provide care in the same pattern. The discussion had been documented and staff had obtained written consent. At Ottery St Mary Hospital, patients living with dementia were encouraged to attend the Rowan Unit Day Centre, where they were able to engage in meaningful daytime activity. Some of the ideas within this unit were being rolled out to other hospitals within that cluster. However, at most hospitals, we saw minimal meaningful activity to engage and stimulate people, aside from the occupational and physiotherapy sessions. Are services responsive to people s needs? Good Summary Community health adult inpatient services were responsive to the needs of patients. Due to recruitment issues, beds had been closed, reducing the capacity of community hospitals. This meant, at times, patients were discharged to community hospitals that were not near to where they lived, as the local hospital was full. The large number of community hospitals meant they were often available in people s local towns. Outpatient clinics, physiotherapy and occupational therapy were provided at the majority making access to treatment easier in the rural areas. There were challenges relating to the discharge process for some patients. For example, for those in need of complex social care packages where provision of support on discharge home was out of the control of the trust. While 98% of staff had undertaken dementia awareness, the approach to patients living with dementia varied from hospital to hospital. Patients completed the This is me documentation, which gave staff information on their likes and dislikes, including what they liked to do and what upset them. We saw these completed in detail in the patient notes. Detailed findings Service planning and delivery to meet the needs of different people Staff were able to request additional nursing staff when it had been identified that a patient required enhanced support. The trust had completed the Association of UK University Hospitals (AUKUH) safe nursing care tool in May Due to the inability to recruit registered nurses, beds in some community hospitals had been closed as a result there was a reduction in the capacity of community hospitals to operate as either step up (with the aim to prevent hospital admission) or step down (to expedite discharge from acute hospitals).most hospitals we visited had all beds full. There were challenges relating to the discharge process for some patients, mainly where they lived in rural areas and were in need of complex care packages. Weekly multidisciplinary team meetings were held to review progress with social services; however, whilst outside of the control of the hospitals and wider trust, this meant some people remained in hospital longer than was required to meet their health needs. Access to care as close to home as possible The large number of community hospitals meant they were often available in people s local towns. Outpatient clinics, physiotherapy and occupational therapy were provided at the majority making access to treatment easier in the rural areas Northern Devon Healthcare Trust Community Inpatients September

15 Staff told us while the aim was to admit patients to their local community hospital this was not always possible. At times patients would be discharged from the acute hospitals to a community hospital away from their home, as this was the only hospital with an empty bed. If clinically appropriate, and with their agreement, patients were then repatriated to the nearest community hospital to their home when a bed became available. Access to the right care at the right time Staff reported out-of-hours medical support as being responsive to their calls. On call GPs provided telephone advice and came to the hospitals when requested. Some hospitals had therapy input at weekends, however, most only had physiotherapist and occupational therapist input Monday to Friday. Whist some patients had therapy plans and contracts to promote the continuation of the therapy at weekends, this was not a consistent approach across all hospitals. This meant patients were at risk of not continuing their therapy regimens seven days a week. Flexible community services Several community hospitals had a greater bed capacity than was currently in operation. This meant that options to increase capacity were available, if required. Senior staff we spoke with told us they would only be opened if adequately staffed. Community hospitals sat in clusters, with some being managed by the same matron. Staff told us this allowed greater movement of staff between hospitals to meet acute staffing needs. Meeting the needs of individuals Staff informed us that interpretation services could be accessed. We saw staff using wipe boards and ipads to support communication with some patients. Ninety eight per cent of staff had undertaken dementia awareness. However, the approach to patients living with dementia varied between hospitals. At Exmouth Hospital, staff described the negative impact patients living with dementia had on the ward. They spoke of having to manage violent outbursts from patients. At other hospitals, for example Ottery St Mary Hospital, the response from staff was more positive. There, the environment was more dementia friendly, with clear signage to rooms and bays and different coloured paintwork around the doors. Patients living with dementia and their carers were also able to access meaningful activity and support from the adjacent day unit. In addition, we saw one relative bring a patient s pet dog in to visit, which provided great comfort to the patient. Patients completed the This is me documentation, which gave staff information on their likes and dislikes, including what they liked to do and what upset them. We saw these completed in detail in the patient notes. We reviewed the care records of one patient who was living with dementia. We noted they had specific dietary needs and saw how these were fully met at lunchtime by the nurse who was providing one-to-one care. Some staff expressed concerns regarding the lack of choice in meals for patients. This was of concern, particularly for those who were inpatients for some time, or those who required a pureed diet, as there was no fruit on the menu choices. We observed meal times and sampled a selection of dishes. Meals were hot and tasty, however, when reviewing the menu, it could be seen how repetitive the meals were, particularly in the evenings. Staff also expressed concern regarding a lack of choice regarding food for some patients, particularly those who were in receipt of end of life, or palliative care. We were told, prior to changes in meal providers, when meals were cooked in house that special requirements could be met, such as soft boiled and scrambled eggs. Staff told us these were no longer an option. However, hotel services managers informed us these were possible if nursing staff cooked them. Moving between services Community hospitals were used to provide step-up and step-down care. GPs could admit patients directly, though staff reported that this occurred far less. In addition, hospice nurses could request GPs admit patients into community hospitals in order to gain symptom control or end of life care, if needed. Patients were also admitted from both North Devon District Hospital (the acute site for the Northern Devon Healthcare NHS Trust) in the north of the locality and the Royal Devon and Exeter Hospital (Royal Devon & Exeter NHS Foundation Trust) in the south of the locality Northern Devon Healthcare Trust Community Inpatients September