Source · CQC inspection
Honiton Hospital
Provider Royal Devon University Healthcare NHS Foundation Trust
Type NHS Healthcare Organisation
Region South West
Last inspected 30 Apr 2019
Overall rating: Good View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Good
Responsive
Good
Well-led
Good
Earlier inspection findings
Must-do actions (13)
Must-do action 1 of 13
Must do
Responsive
Have a reliable trust-wide triage system for reviewing patients who are not able to book an appointment.
Must-do action 2 of 13
Must do
Responsive
Ensure patients do not wait too long for their treatment for cancer, therefore reducing the risk of deterioration of health because of delays.
Must-do action 3 of 13
Must do
Safe
Ensure all resuscitation trolleys in outpatients are checked in accordance with trust policy.
Must-do action 4 of 13
Must do
Safe
Ensure delivery of sepsis training to the whole of the community adult service workforce.
Must-do action 5 of 13
Must do
Safe
Ensure the development and implement the tools available to enable staff to monitor, and effectively escalate patients who may be at risk of deterioration or sepsis in a timely way, in line with national guidance.
Must-do action 6 of 13
Must do
Effective
The trust must ensure staff consistently have access to personalised care and treatment plans which specify individual needs, preferences and choices.
Must-do action 7 of 13
Must do
Safe
The trust must ensure all staff comply with the mandatory training and that the electronics system for maintaining training records is accessible and contains accurate information. A system should be in place to monitor and ensure that all staff receive an annual appraisal.
Must-do action 8 of 13
Must do
Effective
The service must ensure that staff follow best practice in relation to personalised care plan for all community end of life patients to meet their holistic needs in the last few days of life.
Must-do action 9 of 13
Must do
Safe
The service must ensure there are adequate comprehensive safety systems for the operation of the community mortuary at Tiverton Hospital, including infection control and security
Must-do action 10 of 13
Must do
Safe
The service must ensure that all relevant community staff maintain essential competencies and up to date knowledge specifically related to the end of life care they deliver.
Must-do action 11 of 13
Must do
Well-led
Governance and reporting mechanisms must provide adequate oversight of quality and safety indicators specifically related to the community end of life care service
Must-do action 12 of 13
Must do
Well-led
The service must ensure there is a comprehensive programme of audit to provide assurance of the quality and safety of community end of life care services
Must-do action 13 of 13
Must do
Safe
Registrar doctor cover was not consistently available as planned and impacted negatively on the time provided to the unit’s patients. The trust must ensure that sufficient junior medical staff are available as planned to enable the medical cover arranged to be met.
Should-do actions (77)
Should-do action 1 of 77
Should do
Effective
Ensure paperwork and recording relating to Deprivation of Liberty assessments and best interest decisions is correctly completed.
Should-do action 2 of 77
Should do
Safe
Ensure that fridge temperatures are checked and recorded at the correct intervals.
Should-do action 3 of 77
Should do
Safe
Ensure that all liquid medications and topical remedies are dated when opened.
Should-do action 4 of 77
Should do
Safe
Review their care records for patients having haemodialysis to make sure staff complete them in full, including care plans and risk assessments.
Should-do action 5 of 77
Should do
Safe
Implement their planned short-terms solutions to make sure patients’ records are stored securely.
Should-do action 6 of 77
Should do
Safe
Look at ways to monitor the temperature of their medicines trolleys and cabinets to make sure medicines are stored at the recommended manufacturers’ temperatures.
Should-do action 7 of 77
Should do
Responsive
Look at ways of meeting the trust’s target for responses to complaints.
Should-do action 8 of 77
Should do
Safe
Confirm all patient group directions are signed by staff in the respiratory clinic.
Should-do action 9 of 77
Should do
Safe
Continue to recruit medical staff to fill vacancies.
Should-do action 10 of 77
Should do
Effective
Have a more robust system for all clinical staff to receive adequate clinical supervision to support them in their role.
Should-do action 11 of 77
Should do
Safe
Check that all outpatient departments submit regular hand hygiene audits.
Should-do action 12 of 77
Should do
Effective
Improve appraisal rates in medical outpatients to meet the trust target.
Should-do action 13 of 77
Should do
Caring
Maintain patient privacy in outpatient clinics, especially in the surgical and fracture clinics.
Should-do action 14 of 77
Should do
Responsive
Consider improvements to signage for patients with special requirements.
Should-do action 15 of 77
Should do
Effective
Consider how staff from other NHS trusts who work in the hospital can access the information they need for patient sessions.
Should-do action 16 of 77
Should do
Responsive
Continue to deal with the backlog of typing for clinic letters.
Should-do action 17 of 77
Should do
Responsive
Improve the response time for complaints for outpatients and prevent complaints remaining open past 45 days.
Should-do action 18 of 77
Should do
Well-led
Demonstrate that learning has been acted upon from the serious incident in cardiology.
Should-do action 19 of 77
Should do
Well-led
Review and update outpatient risk registers regularly.
Should-do action 20 of 77
Should do
Safe
Have all staff are compliant with mandatory training targets.
Should-do action 21 of 77
Should do
Safe
Complete and regularly review and update risk assessments for patients according to their individual needs.
Should-do action 22 of 77
Should do
Safe
Make improvements to the patient safety handover to provide consistency in terms of quality and depth of discussion across the six clusters.
Should-do action 23 of 77
Should do
Well-led
Update all trust policies.
Should-do action 24 of 77
Should do
Safe
Explore a process to assess whether the staffing needs for the community adult service is aligned with the demand for the service and acuity and dependency of the patients using the service.
Should-do action 25 of 77
Should do
Safe
Stored all patient records securely.
Should-do action 26 of 77
Should do
Safe
Continue to develop plans to provide medicines training for community nursing teams to enhance their knowledge and skills.
Should-do action 27 of 77
Should do
Effective
Implement a process to review care and treatment compliance against evidence-based guidelines used across the community adult service teams.
Should-do action 28 of 77
Should do
Effective
Continue to work on implementing systems to enable the integration of patient care records.
Should-do action 29 of 77
Should do
Responsive
Continue to work on collecting data to provide assurance the urgent care response teams are meeting the internally set target of seeing patients within two hours.
Should-do action 30 of 77
Should do
Responsive
Consider how to improve the process for patients who are under the care of more than one team from the community adult service to ensure a joined-up approach to patient care which is clear for the patient.
Should-do action 31 of 77
Should do
Effective
Make sure pain is consistently assessed and managed for patients.
Should-do action 32 of 77
Should do
Well-led
Consider how to improve the environment for the out of hours community nursing teams so they have a private area to carry out supervisions sessions, appraisals or have some privacy if required.
Should-do action 33 of 77
Should do
Responsive
Continue to work on therapy waiting times targets so patients are seen in a timely way.
Should-do action 34 of 77
Should do
Responsive
Continue to work with the wider system to address the challenge of the gap in domiciliary care provision and its impact on the community team’s capacity.
Should-do action 35 of 77
Should do
Safe
Address the lack of clarity around the use of a ‘safeword’ for community lone working and whether the policy is working for all staff.
Should-do action 36 of 77
Should do
Well-led
Improve morale within the out of hours community nursing teams.
Should-do action 37 of 77
Should do
Well-led
Look at the consistency of advice provided by human resources to the community teams and in relation to the contract of the individual staff member in question.
Should-do action 38 of 77
Should do
Safe
The trust should ensure that staff practice and promote the control of infection at all times, including when isolating a patient with an infection.
Should-do action 39 of 77
Should do
Safe
The trust should carry out maintenance and refurbishment work in a timely way in the community hospitals.
Should-do action 40 of 77
Should do
Well-led
The trust should have oversight to monitor and report on the safeguarding referrals specifically raised within the community inpatients services.
Should-do action 41 of 77
Should do
Safe
The trust should ensure there is a process in place to ensure staff consistently monitor and record the use of all prescription pads–FP10s.
Should-do action 42 of 77
Should do
Safe
The trust should ensure staff follow a system to ensure medicines are used as per the manufacturers guidelines. For example, not all creams or liquid medicines identify a date of opening.
Should-do action 43 of 77
Should do
Safe
The trust should ensure staff follow a system to accurately reflect the stock of CDs stored on the wards.
Should-do action 44 of 77
Should do
Safe
The trust should provide a system which when followed, will inform staff equipment is safe to use and has been regularly serviced or maintained.
Should-do action 45 of 77
Should do
Effective
Staff should be able to consistently have access all the information needed to deliver care and treatment to people.
Should-do action 46 of 77
Should do
Caring
The trust should enable patient independence with their medicines when safe to do so.
Should-do action 47 of 77
Should do
Effective
The trust should implement a system to advise and equip staff to access and be familiar with national guidance and best practice recommendations.
Should-do action 48 of 77
Should do
Well-led
The trust should align all policies and procedures for the community hospitals with the acute trust.
Should-do action 49 of 77
Should do
Caring
The trust should ensure patient confidential and personal information is protected from being seen and that meetings are not overheard by unauthorised people.
Should-do action 50 of 77
Should do
Responsive
The trust should ensure information provided for patients, visitors to the ward and staff is consistently explicit and understandable.
Should-do action 51 of 77
Should do
Responsive
The trust should ensure that the environments of all community hospitals support patients with additional needs such as those living with dementia.
Should-do action 52 of 77
Should do
Safe
The trust should ensure there is a comfortable ambient temperature for all patient areas.
Should-do action 53 of 77
Should do
Effective
The trust should ensure all staff have access to clinical supervision.
Should-do action 54 of 77
Should do
Effective
The trust should ensure sufficient numbers of staff have access to an annual appraisal in order to meet the trust target.
Should-do action 55 of 77
Should do
Effective
The trust should ensure all staff were fully aware of the Deprivation of Liberty Safeguards (DoLS).
Should-do action 56 of 77
Should do
Safe
The trust should ensure appropriate oversight is carried out to ensure all medical staff are up to date with all training.
Should-do action 57 of 77
Should do
Responsive
The service should use a reliable system to identify patients in the last 12 months of life in order to capture and respond to the needs of these patients
Should-do action 58 of 77
Should do
Effective
The service should consider and seek to achieve best practice in relation to advance care planning for community end of life patients
Should-do action 59 of 77
Should do
Well-led
The service should seek to capture patient feedback specifically related to the community end of life service
Should-do action 60 of 77
Should do
Well-led
The service should engage with staff and patient groups to develop a clear vision and values for the community end of life service
Should-do action 61 of 77
Should do
Well-led
The service should develop a clearly documented, structured and measurable strategy for the community end of life service.
Should-do action 62 of 77
Should do
Well-led
The trust should review the leadership strategy for the community end of life service in order to drive at all levels of the organisation
Should-do action 63 of 77
Should do
Effective
Managers should maintain records of clinical supervision for all staff delivering community end of life care
Should-do action 64 of 77
Should do
Effective
Staff should be encouraged to use effective tools to assess and review pain for community end of life patients
Should-do action 65 of 77
Should do
Well-led
The service should consider how teams can learn from mortality and morbidity reviews in the community end of life service
Should-do action 66 of 77
Should do
Safe
Ensure staff are compliant with mandatory training, and compliance for the minor injury unit should meet the trust’s 75% completion target.
Should-do action 67 of 77
Should do
Safe
Continue to review security alarms systems in the minor injury unit to ensure the safety of staff and patients.
Should-do action 68 of 77
Should do
Safe
Review the provision of reception staff at the minor injury unit to ensure safe and effective management of patients and nursing staff out of hours and at weekends.
Should-do action 69 of 77
Should do
Safe
Consider recording and monitoring delays of emergency transfer by ambulance from the minor injury unit to an acute hospital.
Should-do action 70 of 77
Should do
Well-led
Be considered as part of the mortality review process.
Should-do action 71 of 77
Should do
Well-led
Ensure that all risks identified for the Mardon unit risk register are completed on their own template for recognition as part of the overall governance process.
Should-do action 72 of 77
Should do
Effective
Ensure that any future mental capacity assessments are correctly and fully recorded.
Should-do action 73 of 77
Should do
Effective
Ensure that all staff are annually appraised to support their development and practice.
Should-do action 74 of 77
Should do
Effective
Ensure that sufficient therapy staff are available to support patient rehabilitation.
Should-do action 75 of 77
Should do
Responsive
Ensure that access to important rehabilitation equipment, in this instance appropriate wheelchairs, was promptly available.
Should-do action 76 of 77
Should do
Well-led
Ensure that auditing national data collected is input correctly to ensure the information can be used to monitor the service effectively.
Should-do action 77 of 77
Should do
Well-led
Ensure safety thermometer is publicly displayed to enable patients and staff to see the results.