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Royal Devon & Exeter Hospital (Wonford) Good

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 30 April 2019

Our rating of services stayed the same. We rated it them as good because:

In medical care we found staff were completing mandatory training and there were systems and processes in place to safeguard adults and children and protect them from harm. Systems and processes to manage the control of infection, cleanliness and hygiene were consistently followed to keep patients safe. We found medication was managed well and that Staff identified and responded appropriately to changing risks to people who used services, including deteriorating health and wellbeing or medical emergencies. Patients had their assessed needs, preferences and choices met by staff with the appropriate skills and knowledge.There was excellent multi-disciplinary working that was patient focused and caring.The trust had been proactive in making improvements to the access and flow of patients. Action had been taken to improve the flow of patients on their respective pathways, avoid admission where appropriate and possible, and improve the coordination of patient discharge.The medical division was provided with good leadership that encouraged openness and transparency, and promoted good care and there was a positive culture in the hospital.

In renal services we found there were comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training exceeded the trust target. Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. All staff were actively engaged in activities to monitor and improve quality and outcomes.Care and treatment was delivered in line with current best practice. Policies and procedures were based on national best practice guidance. Staff cared for patients with compassion. Services were tailored to meet the needs of individual patients and were delivered in a way to ensure flexibility, choice and continuity of care. Patients could access support and treatment close to their home. Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Managers at the renal services had the right skills, commitment and encouraged supportive relationships amongst staff.

In outpatients we found records were clear, up-to-date and available to all staff providing care. Training had been introduced for staff to encourage them to ask patients if they smoked and offer them referral to the smoking cessation advisor. In the National Cancer Survey 2018, the trust performed well and was in the top 10 nationally. The hospital developed its own in house course called ‘ERICA’ (Exeter recommendation Insulin Carbohydrate Adjustment) for newly diagnosed type-1 diabetics. The gynaecology department used innovative ways to publicise and improve cervical screening. In the pain clinic, compassion based therapy was used to help patients cope with chronic pain symptoms. At the last inspection in February 2016, leadership and accountability structure of the medical outpatient service was lacking. The recent appointment of the new matron had improved senior leadership visibility and helped build better relationships with other outpatient areas. All medical records were secure in every department we visited. This was an improvement from the last inspection in February 2016.

However:

In medical care we found that nursing vacancies and recruitment on some wards, particularly the elderly care wards, presented challenges to the existing teams. We found not all fridges storing medication were having their temperatures regularly checked and recorded. We found some liquid medications and topical remedies did not have the date of opening recorded. and that not all paperwork relating to capacity assessments was completed consistently.

In renal services we found risk assessments were not always completed or updated for patients receiving haemodialysis and that care planning documentation on the haemodialysis units was not always up to date and patients’ records were not stored securely to prevent unauthorised access. Medicine trolleys were not monitored for their temperature to makes sure medicines that were temperature sensitive were stored at the correct manufacturer’s recommended temperature and we found complaints were not always managed in a timely way.

In outpatients we found medical staffing continued to be a risk for the trust due to vacancies and sickness. We found clinical supervision was not embedded in clinical practice for nursing staff. We found in the physiotherapy outpatient clinic, patients could hear other patient’s consultation which did not allow privacy whilst being treated. Following a significant increase in demand, there was a clear disparity between outpatient clinics’ capacity to see patients, and the demand for services. This was most evident in Cardiology, Ophthalmology and Orthopaedics. There was a backlog of typing for clinic letters. There was also no strategic oversight of the inadequacies of the triage system.Five specialties were below the England average for non-admitted pathways, four specialties were below the England average for incomplete pathways.The trust performed worse than the operational standard for people being seen within two weeks of an urgent GP referral. The trust failed to meet the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral. Patients continued to wait too long for their treatment for cancer. Outpatients did not have its own risk register as risks were contained within the speciality and division risk register. Most of the risks had been updated within the past six months. However, two risks had not been updated since July and October 2017.

Inspection areas

Safe

Requires improvement

Updated 30 April 2019

Effective

Good

Updated 30 April 2019

Caring

Outstanding

Updated 30 April 2019

Responsive

Good

Updated 30 April 2019

Well-led

Outstanding

Updated 30 April 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 30 April 2019

Our overall rating of this service stayed the same. The rating for safe improved from requires improvement to good.

We rated it as good because:

  • Staff were completing mandatory training.
  • The trust had systems and processes in place to safeguard adults and children and protect them from harm. Staff completed safeguarding training.
  • Systems and processes to manage the control of infection, cleanliness and hygiene were consistently followed to keep patients safe. Standards of cleanliness and hygiene were maintained. Action had been taken to improve the storage of some cleaning materials potentially hazardous to patients.
  • Medication was well managed and appropriately audited.
  • Staff identified and responded appropriately to changing risks to people who used services, including deteriorating health and wellbeing or medical emergencies.
  • Policies and procedures provided for staff referenced national guidelines and legislation.
  • Patients had their assessed needs, preferences and choices met by staff with the appropriate skills and knowledge.Staff were having regular clinical supervision and annual appraisals.

  • There was excellent multi-disciplinary working that was patient focused and caring.
  • Patients were treated with kindness, dignity, respect and compassion when in receipt of care and treatment.
  • The trust planned and provided services in a way that met the needs of local people. Where shortfalls were identified action was planned or being taken to address the issues.
  • The trust had been proactive in making improvements to the access and flow of patients. Action had been taken to improve the flow of patients on their respective pathways, avoid admission where appropriate and possible, and improve the coordination of patient discharge.
  • The medical division was provided with good leadership that encouraged openness and transparency, and promoted good care.
  • There was a positive culture in the hospital. Staff we spoke with said worked well together with their immediate colleagues and their wider teams.

However:

  • Nursing vacancies and recruitment on some wards, particularly the elderly care wards, presented challenges to the existing teams.
  • Not all fridges storing medication were having their temperatures regularly checked and recorded.
  • Some liquid medications and topical remedies did not have the date of opening recorded.
  • Not all paperwork relating to capacity assessments was completed consistently and some best interest assessments were not fully documented.
  • Not all staff were up to date with their appraisal.

Outpatients

Good

Updated 30 April 2019

We rated it as good because:

  • Records were clear, up-to-date and available to all staff providing care. Patient records were stored securely in all outpatient clinics we visited. This was an improvement since the last inspection in February 2016.

  • Training had been introduced for staff to encourage them to ask patients if they smoked and offer them referral to the smoking cessation advisor. Outpatients had referred 70 patients to the service since November 2018

  • In the National Cancer Survey 2018, the trust performed well and was in the top 10 nationally.
  • The hospital developed its own in house course called ‘ERICA’ (Exeter recommendation Insulin Carbohydrate Adjustment) for newly diagnosed type-1 diabetics.

  • The gynaecology department used innovative ways to publicise and improve cervical screening. This good practice was to be shared at a national conference.
  • In the pain clinic, compassion based therapy was used to help patients cope with chronic pain symptoms and staff reported dramatic changes to some patients.

  • At the last inspection in February 2016, leadership and accountability structure of the medical outpatient service was lacking. The recent appointment of the new senior nursehad improved senior leadership visibility and helped build better relationships with other outpatient areas.
  • The Trust had a very strong mental health strategy driven by the Trust’s Medical Director. The Trust was working closely with the neighbouring mental health trust and jointly enrolled onto a national quality improvement programme. The national programme involved looking to develop and clinically lead the redesign of healthcare pathways to improve patient flow through outpatients.

However:

  • Medical staffing continued to be a risk for the trust due to vacancies and sickness.

  • Some aspects of care in the outpatient’s service were not effective. Clinical supervision was not embedded in clinical practice for nursing staff.
  • There was a lack of privacy at the reception desk when patients booked into the surgical and fracture clinic. In the physiotherapy outpatient clinic, patients could hear other patient’s consultation which did not allow privacy whilst being treated.

  • Following a significant increase in demand, there was a clear disparity between outpatient clinics’ capacity to see patients, and the demand for services. This was most evident in Cardiology, Ophthalmology and Orthopaedics.
  • There was a backlog of typing for clinic letters. Although most departments achieved the trust standard, cardiology, neurology and respiratory did not.
  • There was not a trust-wide reliable triage system for reviewing patients who were not able to book an appointment. There was also no strategic oversight of the inadequacies of the triage system. This was identified immediately before the inspection and the trust had begun to action this.
  • Five specialties were below the England average for non-admitted pathways, four specialties were below the England average for incomplete pathways.
  • The trust performed worse than the operational standard for people being seen within two weeks of an urgent GP referral. There were high volumes of two week wait breaches within Gastro-intestinal surgery. This was unchanged from the last inspection in February 2016.
  • The trust failed to meet the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral. This was unchanged from the last inspection in February 2016.
  • In outpatients, 27 complaints remained open past 45 days. This was not in line with the trust policy.

  • Patients continued to wait too long for their treatment for cancer and remained at risk of deteriorating health because of the delay. This situation had not improved since the last inspection in February 2016.
  • The trust had a serious incident of a patient who experienced a long delay between the date of the clinic visit and the typing of the letter. Trust-wide learning from this incident had not been acted upon as cardiology and neurology remain the clinics with the most substantial backlog for typing. The administrative issue has still not been resolved.
  • Outpatients did not have its own risk register as risks were contained within the speciality and division risk register. Most of the risks had been updated within the past six months. However, two risks had not been updated since July and October 2017.

Renal

Updated 30 April 2019

We rated renal services as outstanding because:

  • There were comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training exceeded the trust target. Cleaning audits demonstrated that each of the dialysis units, renal day case unit (Sid ward) and Creedy wards were meeting the trust target and rated as ‘green’. Compliance with the national guidelines for checking water treatment rooms for patients undergoing haemodialysis was met by technical staff to make sure patients remained safe.
  • Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking and peer review were proactively pursued, including participation in approved accreditation schemes. High performance was recognised by credible external bodies. Outcomes for patients who used services were positive, consistent and regularly exceed expectations.
  • Care and treatment was delivered in line with current best practice. Policies and procedures were based on national best practice guidance. Staff adhered to these and some case patients. In haemodialysis best practice was for patients to wash their fistula prior to dialysis. We observed this taking place.
  • Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Staff, teams and services were committed to working collaboratively to meet the needs of patients.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff took the time to interact with patients and those close to them in a respectful and considerate way. Patients valued their relationships with the staff team and felt they often go ‘the extra mile’ for them when providing care and support. Patients and those close to them were active partners in their care. Staff were fully committed to working in partnership with patients.
  • Services were tailored to meet the needs of individual patients and were delivered in a way to ensure flexibility, choice and continuity of care. Patients could access support and treatment close to their home. Community services were available to support patients who had treatment in their homes. Referral to treatment times exceeded the trust target which meant patients did not have long waiting times. There was a proactive approach to understanding the needs and preferences of different groups of patients and to delivering care in a way that met those needs, which was accessible and promoted equality.
  • Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Managers at the renal services had the right skills, commitment and encouraged supportive relationships amongst staff. Their strategy for improving their services was based on the trusts main visions to improve care for patients. There was a fully embedded and systematic approach to improvement.

However,

  • Risk assessments were not always completed or updated for patients receiving haemodialysis.
  • Care planning documentation on the haemodialysis units was not always up to date and patients’ records were not stored securely to prevent unauthorised access. This issue had been identified by senior staff and they were looking to implement short term solutions until the trust’s electronic system was introduced.
  • Medicine trolleys were not monitored for their temperature to makes sure medicines that were temperature sensitive were stored at the correct manufacturer’s recommended temperature.
  • Complaints were not always responded to with an outcome within the trust target.