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Mardon Neuro-rehabilitation Centre Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 9 February 2016

We inspected Royal Devon and Exeter NHS Foundation Trust as part of our programme of comprehensive inspections of all NHS acute trusts. The trust was identified as a low risk trust according to our Intelligent Monitoring model. This model looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations.

Level 6 is the lowest level of risk which the trust had been rated since march 2014.

The inspection took place on 2 – 6 November 2015 and included Wonford Hospital and Mardon Neuro-Rehabilitation Centre

We rated the trust as good overall and Mardon Neuro-Rehabiliation as requires improvement overall.  

  • The chief executive had been in post for 18 years at the time of the inspection. It appeared that the Chair and Chief Executive had a supportive relationship and worked well together. The board overall had the experience, capacity and capability to lead effectively.
  • The trust culture is strongly focused on quality and safety with patients being the absolute priority. There was tangible evidence of the culture in trust policies and procedures. This was also a consistent theme in the feedback from staff at all levels in the focus groups and drop in sessions held during the inspection.
  • There was an incident review group which reports to the Clinical Governance Committee and reviews all incidents that are categorised as amber or red
  • The trust had no never events since 2013.

    Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. NHS trusts are required to monitor the occurrence of Never Events within the services they commission and publicly report them on an annual basis.

  • The trust performed well on infection rates having had no incidents of MRSA blood stream infection since 2011.

  • Staffing in wards was reviewed on a regular basis with evidence of skill mix changes and additional posts being created in some areas. Other areas were finding it hard to recruit with some reliance on bank or agency staff.
  • The overall trust target for mandatory training was 75% which had been achieved for topics such as safeguarding. There were some topics which were above the target and some slightly under the target.
  • Staff reported communication was good in their local teams through use of ‘Comm cells’. These took place regularly with discussions including training, complaints incidents and well as feedback of results of audits.
  • For the Mardon Neuro-rehabilitation centre there was a lack of strategy for the provision of a responsive service that delivered care as close to home as possible services seven days a week.

There were areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure medicines are administered to patients safely in line with policy and take into account their rights.
  • Ensure medicines are disposed of and returned to pharmacy in accordance with the trust’s policies and standard operating procedures.

In addition the trust should:

  • Ensure there are sufficient therapy staff deployed in order for patients to receive consistent care and according to their needs.
  • Ensure incidents are investigated and records are available with a robust process for disseminating information to all staff following incidents investigations.
  • Ensure discharge planning processes are pro-active and well co- ordinated to reduce delayed transfers out of the centre.
  • Ensure service strategies are clear and communicated effectively and development plans for the service are identified.
  • Identify a lead to develop the service and provide management support at operational level.
  • Review feedback from patient surveys and develop action plans to improve patient experience.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas


Requires improvement

Updated 9 February 2016



Updated 9 February 2016



Updated 9 February 2016



Updated 9 February 2016


Requires improvement

Updated 9 February 2016

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 9 February 2016

We have rated The Mardon Neuro-rehabilitation Centre as requires improvement overall. Effective, caring and responsive were rated as good and safe and well led rated as requires improvement.

Medicines were not always managed safely and according to best practice guidance to safeguard patients. This included the covert administration of medicines which were disguised in food.

There were not always sufficient numbers of therapists such as speech and language therapists to provide care and support to patients to meet their rehabilitation needs. Patients told us they received appropriate support from nursing staff. There was good multi-disciplinary working for the benefit of patients.

Incidents were monitored and staff followed procedures to report incidents and monitor patients’ risks. There was inconsistency in the way that investigations and learning from these were cascaded to staff at local level.

The environment was clean and equipment was well maintained. Infection control procedures were followed to protect patients from risk of cross infection. Staff had access to a variety of equipment to enable and support patients’ independence. Regular equipment checks were completed and records were maintained to ensure they were safe for use.

Staff had good understanding of action they would take to safeguard patients in vulnerable situations. The Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and mental capacity assessments were completed and reviewed. Although this principle was not followed when administering covert medicines.

Patients were assessed and care plans developed to manage risks. There was no tool used to assess deteriorating patients which could lead to inconsistency in their management. Records were stored securely and available to support patients’ care

Staff provided care based on national guidance such as National Institute for Clinical Excellence (NICE) guidelines and British Society of Rehabilitation Medicine guidance.

Staff received induction and other training and there was a formal process in place for staff to follow to meet requirements of the Duty of Candour. Patients received compassionate care that respected their privacy and dignity. Patients and relatives said they felt involved in decision making about their care.

There were effective governance arrangements that looked at incidents and risks. Staff felt supported by their managers and felt they worked for Mardon centre and were not connected to the wider trust.

The trust  had confirmed there was a strategy for Mardon. However this was not known at local level and was not embedded within the unit; for the provision of a responsive service that delivered care as close to home as possible seven days a week. There was a lead for the service, staff said they were not visible in the unit to develop the service and provide management support at operational level. They were and available by telephone and  visited infrequently. 

The trust routinely monitored case mix and outcome data for the purpose of benchmarking and quality monitoring annually as part of a national audit.