During our last inspection in January 2014 we found improvements were still needed to ensure the hospital always acted in accordance with legal requirements where patients lacked capacity in relation to "do not resuscitate" orders.

The trust told us they had introduced regular audits of the treatment escalation plans (TEP), that detailed end of life care decisions and mental capacity assessment forms to ensure consistent and sustained compliance. We saw completed TEP audit forms. The forms were completed shortly after each new admission and collated weekly to be sent to the safety team for collation.

The patients we spoke with told us they felt involved in their care and treatment. Two patients told us their wishes around resuscitation had been discussed with them and their wishes adhered to. All of the patients we spoke with knew about plans for their discharge and the current work with therapists in order to prepare them for discharge home. One said “they talk to me about what is going on with my exercises” another said “I see the physio every day and have seen improvements in what I can do”.

We looked at nine sets of care records, which included a TEP and associated medical records across both wards and found they were all fully completed.

We were told and saw evidence that the GPs responsible for completing the TEPs and mental capacity assessments had received training in completion of the documents and had received follow up information for reference.

On 28 November 2011 we received concerns from a person who had visited Twyford Ward, Tiverton and District Hospital, the day before. Those concerns related to staffing levels on Sunday 27 November 2011. They described patients having waited over an hour for their meal, there being insufficient food provided on that occasion and one person trying to summon help but their call bell not being answered for an hour. They spoke highly of the efforts of the staff on duty.

We decided to write to the Chief Executive of Northern Devon Healthcare NHS Trust asking them to investigate the events and report their finding to us by 12 December 2011.

However, on 29 November 2011 we received concerns from another source, which also related to events on 27 November 2011. We were told that a patient had been seen urinating near another patient in bed on the ward; no staff came into the bay for over an hour; male patients wandered into the female area of the ward and necessary communication aids were not in place. They also said that staff had been laughing about some of the events.

We are responsible for checking that every care provider that is registered with us meets important standards of quality and safety. However the duties we have been given by parliament do not include dealing specifically with complaints about these services. Although, by law, all NHS organisations must have an efficient procedure for dealing with complaints, the contact said they would not make a complaint themselves as they wanted to remain anonymous. We decided that we would conduct an unannounced visit to Twyford Ward and did so on 1 December 2011 spending 5 and half hours there. We looked at essential standard 4 (care and welfare),9 (safeguarding people from abuse) and 13 (staffing).

Most people were unable to communicate their feelings verbally. Two patients said they did not want to talk with us and one told us that the staff were very good. We saw that people looked well cared for and the standard of personal care provided was high. The majority of the care we observed was kind, thoughtful and respectful. There was consistency in all the information the five care workers told us; staffing arrangements; about patient's individual needs and vulnerabilities and how they are able to safeguard patients in their care from abuse.

Our findings are a combination of our visit and the report provided by the trust on the events which occured on 27 November 2011.

This unannounced inspection was carried out to follow up on compliance actions made at the previous inspection in May 2013. These related to consent to care and treatment, and staffing levels.

Since the last inspection the Care Quality Commission (CQC) had received two anonymous concerns about low staffing levels on Blackdown and Twyford wards. The first concern, received in October 2013, was referred to the Trust to respond too. The Trust told us there had been an increase in short term sickness at this time and they provided us with assurance that staffing levels were safe. The second concern was received by CQC in January 2014. We looked at this concern as part of this inspection.

Two CQC inspectors spent 10 hours at the hospital. We spoke with 17 patients and three relatives across the two wards. We also spoke with 18 members of staff, including nurses, health care assistants; members of the therapy team (occupational therapist and physiotherapist), senior nurse managers, the Matron and the senior manager responsible for Community Hospitals.

Patients expressed a high level of satisfaction with the care and treatment they received. They were particularly positive about the staff attitude and approach. Comments included, “They (staff) offer support in a very nice way”, “Staff don’t make me feel anything is too much trouble” and “I have been very happy with the care. I am feeling much better. The staff are a real help”.

Although the hospital had experienced staffing difficulties at times due to high levels of staff sickness, the Trust were committed to ensuring that adequate staffing levels were maintained. They had a number of mechanisms in place to deal with staff shortages, including regular use of bank and agency staff. Where staffing had not met the preferred levels, decisions were made to close admissions to vacant beds in order to mitigate risks to patients. Data showed that no significant harm had been caused to patients as a result of preferred staffing levels not being met.

We found improvements were needed to ensure the hospital always acted in accordance with legal requirements where patients lacked capacity in relation to "do not resuscitate" orders.