A shortage of children’s nurses and lack of mandatory training for emergency department nursing staff in general have been identified by inspectors, following a visit to North Devon District Hospital.
The Care Quality Commission returned to the hospital in the summer to look at accident and emergency services, maternity and gynaecology, and end of life care after concerns were raised during its last inspection in July 2014.
While noting some progress had been made, the CQC said all three services still required improvement.
The regulator found just one children’s nurse employed by the emergency department, which meant there was not enough to cover every shift.
“[There was] no clear and realistic strategy for end of life care with no plans available to see how the service was to be assessed and moved forward”
In addition, it said more staff should have completed paediatric life support training, and noted rates of mandatory training were low, with only 53% of nursing staff in A&E having completed resuscitation training this year.
While people were seen in the emergency department in an acceptable time, patient flow through the hospital was still a problem due to lack of bed capacity and delayed discharges, particularly when patients were receiving end of life care, said the CQC.
Meanwhile, staff on a number of wards did not always understand how to refer to the specialist end of life care team, said the regulator.
“We saw five out of 10 incidences when referral for patient’s symptom management could have been considered but was not, which may have had an impact on the patient in terms of pain and other symptom management being delayed or not being sufficient to meet their needs,” the CQC said in its report on the hospital.
Staff training in this area was also varied, said the report, with rates ranging from 30% of nursing staff in some wards to 74% in others.
“We found individually the medical and maternity staff were working very hard but they did not always seem to function well as a team”
Inspectors noted there was “no clear and realistic strategy for end of life care, with no plans available to see how the service was to be assessed, developed and moved forward”.
“The medical director and director of nursing , who lead on the end of life provision at the trust, confirmed that there was no formal strategy to ensure the service was provided to an agreed standard,” added the report.
In maternity services, communication between midwives and medical staff had still not sufficiently improved since the previous inspection.
“We found individually the medical and maternity staff were working very hard but they did not always seem to function well as a team,” said the report.
Inspectors called for a number of further actions to be taken including ensuring there were sufficient numbers of staff in the A&E department and a minimum of one children’s nurse every shift.
They also said the hospital must ensure staff knew when to refer to the specialist palliative care team and must improve the discharge process for patients at the end of life.
Team development within the maternity service must also be addressed.
“We are committed to completing the remaining actions and thank the CQC for their constructive comments”
CQC deputy chief inspector of hospitals Edward Baker said: “While there have been some improvements since our last inspection, the flow of patients from the emergency department into the hospital is still not being managed well.
“Although patients were being seen in a timely way within the department, some people were still having to wait too long to be admitted to a ward,” he said. “This inevitably has an effect on patient care and I expect the trust to address this as a priority.”
Northern Devon Healthcare trust, which runs the hospital, said it was pleased the CQC had recognised its improvements so far, and would continue to implement its action plan to address problems.
Trust chief executive Alison Diamond said: “Although the performance indicators show the trust has consistently met the national target across emergency and urgent care services we recognise that there is further work to be done to ensure that patients within the hospital can be discharged safely and on time.”
“We are committed to completing the remaining actions and thank the CQC for their constructive comments,” she added.