We carried out an unannounced focussed inspection of the emergency department at Torbay Hospital on 11 February 2019.

We did not inspect any other core services or wards at this hospital or any other locations or services provided by Torbay and South Devon NHS Foundation Trust. During this inspection we inspected using our focussed inspection methodology. We did not cover all key lines of enquiry. We did not rate this service at this inspection.

Torbay Hospital (unscheduled care) provides an emergency medicine service through a Type 1 Emergency Department (ED) including trauma. There is a minor injuries service provided by the emergency nurse practitioner service with consultant-led support.

Our key findings were:

• There were appropriate processes for the initial assessment, triage and streaming of patients who presented via the front-door. Patients conveyed to Torbay Hospital via ambulance received timely initial assessments before being transferred to the rapid assessment and treatment area for subsequent clinical management.

• The department implemented patient safety initiatives including early warning systems and patient safety checklists.

• Care and treatment was planned and carried out in a timely way.

• The leadership team had worked to reduce the total nurse vacancy factor so that by the end of April 2019 there will be approximately 1.5 whole time equivalent vacant Band 5 posts. Departmental leaders reviewed the competency and skill mix of staff to ensure sufficient numbers of staff were deployed across the department.

• Compliance against constitutional standards remained a challenge. However, new models of care and the introduction of well-rehearsed escalation protocols were starting to show signs of some incremental improvement.

• The department had a strategy to ensure patients were managed as safely and effectively as possible, especially during times of surge activity.

• Professionals from across the hospital took responsibility for the delivery of the emergency care pathway. Strong team working and a multi-disciplinary approach was evident. A "Can do" attitude was present with staff reporting good morale across the department and wider hospital.
• Risks were identified and well managed. The trust acknowledged areas for improvement which they were responsible for delivering.
• Staff reported some concerns over the commissioning arrangements for some cohorts of patients, including those who presented with mental health conditions. Staff recognised more needed to be done to address a perception of health inequality for this group of patients.

However:

• The environment in which patients received care and treatment remained a challenge. Staff acknowledged the constraints of the department and had developed plans to improve the department through a new build which had received capital investment.

Whilst we do not consider the provider to be in breach of regulations we have identified some areas which require improvement. Specifically, the provider should:

Ensure the mental health assessment room continues to meet national service specifications at all times.

Ensure children are directed to an appropriate waiting area in accordance with national service specifications.

Dr. Nigel Acheson

Deputy Chief Inspector of Hospitals (South)

We inspected Torbay hospital to check on improvements made following an inspection we performed in September 2012. During the inspection in September 2012 we found shortfalls in the surgical checks the hospital were using. We also found two of the 18 wards at the hospital were not as clean as others.

Following the inspection the trust sent us an action plan detailing how they would make improvements and gave us timescales in which they expected to achieve the improvements.

At this inspection we found the surgical safety checks used at the hospital had improved and cleanliness levels on the wards had also improved.

Since our last inspection the trust had introduced a new surgical safety checklist which mirrored the one recommended by the National Patient Safety Agency (NPSA). Staff said was now embedded in everyday practice.

On ward areas we saw many areas of improvement including new staff job roles, improved cleaning schedules and replaced equipment.

During our site visits to South Devon foundation trust (Torbay Hospital) Centre, we went to 13 ward and clinical areas in addition to the outpatient clinics at the hospital. We spoke to over 60 patients and visitors. We also spoke with many members of staff.

We were told that patients thought their privacy was protected and that they felt staff were respectful during their visit to the hospital. Patients also told us that they had felt involved in planning their care or treatment.

Patients said they felt safe and said staff were very kind to them.

One patient had been admitted and moved several times due to her condition, her feelings were that all the moves were needed to give her the best treatment, she was kept informed of why she was being moved and all was done with respect and good humour.

Patients said they were pleased with the way they received their medicines in hospital. They told us staff are “excellent”, “marvelous” and “brilliant”. Patients told us they were happy with the way they received their medicines and that staff are helpful if they had any questions. One patient told us that the staff “couldn’t be faulted, nothing is too much trouble”.

Patients thought staff worked very hard to keep ward areas clean. Patients appreciated the mobile shop that visits each area every day.

Staffing levels were satisfactory patients said their needs were being met. We had many positive comments about staff. One patient said, “The staff are fabulous, I can’t fault them; another comment made was “ask and it is done for you” Frequent comments made were “nothing is too much trouble” “so kind, even it’s when busy”

Patients told us they knew how to complain and that if they had any concerns they would raise them straight away with the staff on the ward. Patients also knew about the Patient Advisory and Liaison (PALS) team.

For a summary of our findings, see the ‘What we found’ section of this report.