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Provider: Royal Devon and Exeter NHS Foundation Trust Good

On 30 April 2019, we published a report on how well Royal Devon and Exeter NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

Inspection Summary


Overall summary & rating

Good

Updated 30 April 2019

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

We rated trust wide well led as good. This was the same rating as the previous inspection.

Medical care was rated good overall. For medicine we rated all five domains of safe, effective, caring, responsive and well led as good. This was an improvement for safety from requires improvement to good and all other domains remained the same.

Renal services was rated outstanding overall. For renal services we rated safe as good and the remaining domains of effective, caring, responsive and well led as outstanding. This service has not been inspected before.

Outpatients was rated good overall. For outpatients we rated safe, effective, caring and well led as good and responsive as requires improvement. This was an improvement for safety from requires improvement and all other domains remained the same.

Community health services for adults was rated good overall. For community health services for adults we rated effective, caring, responsive and well led as good and safety as requires improvement. This service has not been inspected before.

Community health inpatient services was rated good overall. For community health inpatient services or adults, we rated effective, caring, responsive and well led as good and safety as requires improvement. This service has not been inspected before.

Community end of life care was rated requires improvement overall. For community end of life care we rated safe, effective, responsive and well led as requires improvement. We rated care as good. This service has not been inspected before.

Urgent care was rated good overall. We rated all five domains of safe, effective, caring, responsive and well led as good. This service has not been inspected before.

Mardon Neurological Rehabilitation Centre was rated good overall. We rated safe, effective, responsive and well led as good and caring as outstanding. Safe, caring and well led went up one rating from the last inspection.

Inspection areas

Safe

Requires improvement

Updated 30 April 2019

Our rating of safe stayed the same. We rated it as requires improvement because:

In medical care we found Improvements had been made to the storing of potentially hazardous substances and Improvements had been made to the management of patients with mental illness within the acute medical unit. There were systems and processes in place to prevent and protect people from healthcare-associated infection.We saw evidence that staff identified and responded appropriately to changing risks to people who used services. Staff wore protective personal equipment and washed their hands before and after patient contact. Staff we spoke with in each area had demonstrable knowledge of learning from incident investigations. 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 and some liquid medications and topical remedies did not have the date of opening recorded.

In renal services, we found the service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service controlled infection risk well. Standards of cleanliness and hygiene were maintained. The arrangements for managing waste and linen kept patients safe. The maintenance and use of equipment kept patients safe. Staff identified and responded to changing risks to patients who used services, including deteriorating health and wellbeing, medical emergencies or challenging behaviour. The service had enough medical and nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm. Staff kept clear and detailed records of patients’ care and treatment. service followed best practice when prescribing, giving and recording medicines. However, Staff did not always complete and update risk assessments for each patient.Care planning documentation was not always up-to-date and individual care records, including clinical data, were not managed in a way that kept patients safe.

In outpatients, staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Risk assessments were carried out for patients and were developed in line with national guidance. Staff could describe the processes involved when managing a deteriorating patient. Records were clear, up-to-date and available to all staff providing care. There were arrangements which ensured the safety of controlled drugs and chemotherapy given in outpatients. Staff understood their responsibilities to report patient safety incidents and staff had a good understanding of the duty of candour and could describe when it would be used. However, there were some gaps in checking of resuscitation equipment in medical outpatient clinic. In the respiratory clinic, patient group directions had not been signed by staff and medical staffing continued to be a risk for the trust due to vacancies and sickness.

In community health services for adults we found Staff did not always complete and update risk assessments for each patient. There was no clear process to monitor patient deterioration and sepsis across the community adult service and Individual care records were not always fully integrated or consistently managed. However, the service provided mandatory training in key skills. The service controlled infection risk well. There were enough staff with the right qualifications, skills, training and experience to keep people safe. Staff followed best practice when prescribing, giving and recording medicines and Staff understood their responsibilities to raise concerns.

In community health inpatient services we found Staff were provided with training in safety systems, processes and practices, however not all staff had met the trust target for training compliance. At Tiverton hospital, the control of infection was not consistently practiced. There was maintenance and refurbishment work waiting to be carried out at Exmouth hospital. At Tiverton hospital, staff did not consistently follow a system to track and record the FP10 prescription pads and The independence of patients was not always supported as they were unable to fully self-administer their own medicines. However, Systems, processes and practices kept people safe and safeguarded from abuse. Standards of cleanliness and hygiene were maintained. The maintenance and use of facilities, equipment and premises kept people safe. Risks to people were assessed and Staff reported incidents and lessons were learned and improvement made when things went wrong.

In community end of life services, we found the service did not ensure that staff maintained essential skills and up to date knowledge of safety systems specifically relevant to end of life care. Records in community settings were not always available to staff providing care and did not contain all information relevant to the care of end of life patients. The trust did not use safety performance data to specifically monitor the safety of the community end of life care service and There were insufficient assurance mechanisms to mitigate the risk of cross contamination in the community mortuary. However, The service managed patient safety incidents well. Staff understood how to protect patients from abuse. Staff could access appropriate safety equipment for patients. When patients deteriorated, there were clear systems to communicate the agreed pathway of emergency treatment escalation for individual patients. Staff completed essential risk assessments for each patient and there was appropriate staffing to meet the needs of the patient.

In urgent care we found staff were knowledgeable about the risks to vulnerable adults. Systems were used to report, investigate and learn from incidents. Cleanliness, infection control and hygiene were well managed. The premises were suitable for their purpose and maintained to ensure patient safety. Staff responded appropriately to changing risks including deteriorating health and wellbeing. Staffing levels were consistently maintained. All records were fully completed, legible, signed and dated and Medicines were managed in a way that kept patients safe. However, Although a programme of mandatory training was provided for all staff to keep patients safe, mandatory training compliance did not meet the trust’s target of 75% completion. Security alarm systems were under consideration to ensure safety of staff and patients. Out of hours and at weekends, when reception staff were not employed. Delays to emergency patients being transferred by ambulance to the acute hospital were not raised as incidents or monitored.

In Mardon Neuro-rehabilitation Centre, we found mandatory training was completed by nursing, medical and non-clinical staff. Safeguarding systems, processes and practices were used to keep patients safe. There have been improvements in how medicines are managed at the Mardon centre. The service controlled infection risk well. The maintenance and use of facilities, premises, and equipment generally kept people safe. Each patient was assessed to ensure their needs were identified and managed. Staffing levels and skill mix were planned, implemented and reviewed to keep patients safe. However, Access to new wheelchairs was not always timely with delays in process. Registrar cover was not consistent. Occupational therapy and psychology staff numbers were lower than the BRSM guidelines. The results of the safety thermometer were not publicly displayed to enable patients and staff to see the results.

Effective

Good

Updated 30 April 2019

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

In medical care we found, Policies and procedures provided for staff referenced national guidelines and legislation. Patients admitted onto the acute medical unit were seen and reviewed promptly by a consultant to maximise continuity of care. Patients’ nutrition and hydration needs were assessed and met in line with national guidance. The trust took part in the Sentinel Stroke National Audit. Patients had their assessed needs, preferences and choices met by staff with the appropriate skills and knowledge.All necessary staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. All staff had completed training. However, Not all paperwork relating to capacity assessments was completed consistently and some best interest assessments were not fully documented.

In renal services, the service provided care and treatment based on national guidance and evidence of its effectiveness. Water testing and disinfection of the water plant and haemodialysis machines were all carried out in line with best practice guidelines. Staff gave patients enough food and drink to meet their needs and provided dietary support to improve their health. Staff assessed and monitored patients regularly to see if they were in pain. Managers monitored the effectiveness of care and treatment and used the findings to improve them. Information about the outcomes of patients’ care and treatment was routinely collected and monitored. Staff supported patients to be in involved in monitoring their health. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care.

In outpatients, patients’ care, treatment and support achieved good outcomes, promoted a good quality of life and was based on the best available evidence. Consent to care and treatment was sought in line with legislation and guidance. Staff had access to information required to deliver effective care. Patients’ physical, mental health and social needs were holistically assessed. Patients’ pain was assessed and managed including those with difficulties in communicating. In surgical outpatients, staff monitored the effectiveness of care and treatment and used the findings to improve them. Training had been introduced for staff to encourage them to ask patients if they smoked and offer them referral to the smoking cessation advisor. The service made sure staff were competent for their roles. Patients were empowered and supported to manage their own health, care and wellbeing to maximise their independence. However, clinical supervision was not embedded in clinical practice for nursing staff and appraisal rates in medical outpatients did not meet the trust target.

In community health services for adults we found the service provided care and treatment based on national guidance and evidence of its effectiveness. Staff assessed and monitored patients regularly to see if they were in pain. Managers monitored the effectiveness of care and treatment and used the findings to improve them. Managers made sure they had staff with a range of skills needed to provide high quality care. Staff from different disciplines worked together as a team to benefit patients and staff supported patients to make decisions on their care for themselves.

In community health inpatient services we found care, treatment and support provided to patients achieved good outcomes, promoted a good quality of life and was based on the best available evidence as included within policies and procedures. Patients’ nutrition and hydration needs were met and outcomes were monitored. Staff teams and services within and across organisations worked together to deliver effective care and treatment. Consent to care and treatment was always sought in line with legislation and guidance. However, Not all staff were familiar with which national guidelines were in use and not all policies were up to date. Also, not all staff had an up to date appraisal.

In community end of life services, we found There were no systems to ensure that the service provided care and treatment based on national guidance and evidence of its effectiveness. Managers did not have any objective information regarding the quality of the community end of life care service for patients living in their own homes. Community nursing staff were not consistently assessing and reviewing patients pain in a comprehensive way. Nursing team managers did not have systems to provide assurance that staff maintained ongoing competencies in critical end of life care tasks and The trust did not routinely monitor and record clinical supervision. However, New staff participated in an induction programme and in therapy services. Staff followed processes to provide continuity of care. Staff of different kinds worked together as a team to benefit patients in the last few days of life and Staff understood their roles and responsibilities under the Mental Capacity Act 2005.

In urgent care we found the trust’s policies and services were developed to reflect best practice and evidence-based guidelines. Pain management was well organised and established as part of triage and treatment. The trust reviewed the service they provided for effectiveness. Staff had the right qualifications, skills and knowledge to do their jobs effectively. The MIU staff worked with organisations to deliver effective care and treatment. Patients had access to information to help them understand their care and treatment and promote good health and patients’ consent to care and treatment was sought in line with legislation and guidance.

In Mardon Neuro-rehabilitation Centre, we found policies and guidelines had been developed in line with national policy including the National Institute for Health and Care Excellence (NICE) guidelines. Patients had their nutrition needs and hydration needs met. Staff assessed and managed patients’ pain effectively. Standard and non-standard assessments were undertaken and monitored to show that sufficient therapy support was provided and that the rehabilitation service met patient’s needs. Staff worked collaboratively with other health professionals. Training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) is included in the trust’s safeguarding adults training module. However, data collected monthly to monitor the service was not reliably recorded. Mardon House staff received an appraisal, less than the trust target of 80% and Mental capacity assessment for one patient had not been fully completed.

Caring

Outstanding

Updated 30 April 2019

Our rating of caring stayed the same. We rated it as outstanding because:

In medical care, we found Patients were treated with kindness, dignity, respect and compassion when in receipt of care and treatment and Patients were given appropriate and timely support and information to cope emotionally with their care, treatment or condition.

In renal services, staff cared for patients with compassion. There was a strong, visible patient-centred culture. Staff gave time to patients and their relatives and they were not hurried for responses. Staff were motivated to offer care which promoted people’s dignity. Staff provided emotional support to patients to minimise their distress. Staff could signpost patients to additional support about their condition and staff involved patients and those close to them as active partners in making decisions about their care and treatment.

In outpatients, we found staff cared for patients with compassion. In the National Cancer Survey 2018, the trust performed well and was in the top 10 nationally. Staff took the time to interact with people who used the services in a respectful and considerate way. All staff could identify how they would respond to somebody in distress to help preserve their privacy and dignity. Patients were given support and information to cope emotionally with their care, treatment or condition and advised how to find other support services both locally and nationally and staff involved people who used services and those close to them in planning and making shared decisions about their care and treatment. However, patients were not always able to speak to the receptionist without being overheard.

In community health services for adults we found staff treated patients with compassion and kindness and showed an encouraging, sensitive and supportive attitude. Staff understood the impact that patient care, treatment or their condition had on their wellbeing and on those close to them, both emotionally and socially. Staff involved patients and those close to them in decisions about their care and treatment and Patients’ carers, advocates and representatives including family members and friends were identified, welcomed, and treated as important partners in the delivery of care.

In community health inpatient services, we found the service involved and treated patients with compassion, kindness, dignity and respect. Patients and those close to them were provided with emotional support when needed. Relatives, friends and carers were able to choose the time they visited the wards and staff supported people to express their views and be actively involved in making decisions about the care.

In community end of life services, we found staff cared for patients with compassion. Staff were consistently caring. Community nursing staff tried wherever possible to protect patients’ dignity and treated patients with respect. Staff involved patients and those close to them in decisions about their care and treatment. Staff provided emotional support to patients to minimise their distress and Staff showed empathy and kindness towards patients’ relatives/carers.

In urgent care, we found Staff treated patients with kindness, dignity, and respect. Staff showed an encouraging, supportive and sensitive attitude to patients and those close to them. Patients’ privacy and confidentiality was respected and staff understood the importance of involving relatives and carers in the treatment of some patients.

In Mardon Neuro-rehabilitation Centre, we found throughout our inspection, we observed patients were treated with the highest levels of compassion, dignity and respect. Staff were kind and supportive to patients and their relatives. Staff understood the impact the care, treatment or condition might have on patients and families and Patients told us that they felt involved and included in decisions about their care.

Responsive

Good

Updated 30 April 2019

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

In medical care, we found the trust planned and provided services in a way that met the needs of local people. Care and treatment was consistently delivered with consideration of patients’ individual needs, including those in vulnerable circumstances. All staff received training in dementia and delirium. The trust had been proactive in making improvements to the access and flow of patients and the service treated concerns and complaints seriously, investigated them and learned lessons from the results.

In renal services, the needs of local people were central to the planning and delivery of tailored services within the renal care. People could access the service when they needed it. The service reflected the needs of the population served and provided flexibility and choice for patient care. The service took account of patients’ individual needs and their preferences were central to the delivery of tailored services. Services were planned to consider the needs of different patients to enable them to access care and treatment. Specialist services for younger adults’ patients were available. There were arrangements to provide treatment for patients with complex needs or learning disability. However, not all complaints were responded to with an outcome within the trust target.

In outpatients, there was a clear disparity between the clinics’ capacity to see patients, and the demand for services. There was not always sufficient car parking available on site. The environments of some clinics were not arranged to optimise the privacy and dignity of patients. Outpatient departments were clearly signposted but there were no environmental adaptations of signage for patients with special requirements. There was a backlog of administrative work that was creating delays between clinics and letters being typed. There was not a reliable trust-wide reliable triage system for reviewing patients who were not able to book an appointment. The trust performed worse than the operational standard for people being seen within two weeks of an urgent GP cancer referral. The trust failed to meet the operational standard for cancer patients receiving their first treatment within 62 days of an urgent GP referral. However, The trust had an accessible information and communication needs policy for staff members to help and support communication needs of patients and carers associated with a disability and services provided by the trust reflected the needs of the population served and tried to offer flexibility, choice and continuity of care.

In community health services for adults we found patients could usually access the service closest to their home when they needed it. Services were delivered, made accessible and coordinated to account for the needs of different people. Reasonable adjustments were made so that patients with a disability could access and use services on an equal basis to others. The service understood the importance of meeting patients’ mental health needs. Staff worked across services to coordinate involvement with families and carers and the service treated concerns and complaints seriously. However, the need for the community adults service teams to provide cover for the lack of domiciliary care was reducing the capacity of the teams to support patients. Also, some patients were not always able to access therapy treatment at the right time.

In community health inpatient services People received personalised care that was responsive to their needs. The staff took account of patient’s individual needs, including for patients who lived with dementia, learning disability, physical disability and sensory loss. People could access the right care at the right time within the community hospitals and complaints were listened and responded to and used to improve the quality of care.

In community end of life services, we found managers did not have processes to know whether the service provided was meeting the needs of their population in relation to end of life care. There were no protocols for identifying patients in the last 12 months of life and staff were not completing individual personalised care plans to meet the holistic needs of dying patients. However, there were localised examples of proactive planning at a local level to meet the needs of community end of life care patients. service took some account of individual need. There were systems to ensure equitable access to the community end of life service and patients could access the service when they needed it.

In urgent care, Services provided reflected the needs of the local population where possible, and were responsive to patients’ needs. The minor injury unit took account of patients’ specific individual needs. Patients accessed care and treatment in a timely way. We observed patients being treated promptly and teamwork between staff ensured patients were booked in, triaged, treated and discharged quickly and safely and complaints were handled in accordance with trust policy and within the provided timescale.

In Mardon Neuro-rehabilitation Centre, we found services were planned and delivered in a way that met the needs of the local population. Patients were treated as individuals with treatment and care being offered in a flexible way and tailored to meet their individual needs. The needs of each patient were considered when planning and delivering the service and patients had access to information about how to make a complaint and complaints were taken seriously by the trust.

Well-led

Good

Updated 30 April 2019

Our rating of well-led stayed the same. We rated it as outstanding because:

In medical care, the medical division was provided with good leadership. The medical division had a clear set of objectives and targets around performance and the improvement of care. There was a positive culture in the hospital. There were effective structures, processes and systems of accountability to support the delivery of the strategy and good quality, sustainable services. The trust had effective systems for identifying risks and Patients and staff views and experiences were gathered and acted on to shape and improve the services and culture.

In renal services, managers at divisional and unit level had the right skills and abilities to run a service providing high-quality sustainable care. The senior leaders demonstrated enthusiasm for their roles and a commitment to improving the quality of the service. The strategy for renal services was aligned to local plans in the wider health and social care economy, and services have been planned to meet the needs of the population. Managers across the renal services promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There were mechanisms for providing all staff at every level with the development they needed, including high-quality appraisal and career development conversations. Renal services used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. There was a systematic programme of clinical and internal audit to monitor quality, operational and financial processes. Patients’ views and experiences had been gathered with plans to act on them to shape and improve the services and culture at the time of our inspection.

In outpatients, the trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Leaders were visible and approachable and there was a clear line of accountability from speciality level to members of the board. The trust had a comprehensive mental health strategy. Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. However, patients continued to wait too long for their treatment for cancer and remained at risk of deteriorating health because of the delay and outpatients did not have its own risk register as risks were contained within the speciality and division risk register.

In community health services for adults we found Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The trust had a vision for what it wanted to achieve. The culture of the service was centred on the needs of the local people who used the service. There a strong emphasis on the safety and wellbeing of staff. The trust had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The views and experiences of patients and staff were gathered and acted on and Leaders and staff strived for continuous learning, service improvement and innovation. However, there was low morale among staff in the out of hours nursing team.

In community health inpatient services there was leadership with the capacity and capability to deliver high quality sustainable care. The vision and strategy formed a base from which to deliver high quality sustainable care. Managers across the community hospitals promoted a positive culture that valued and support staff. The trust used a systemic approach to improve the quality of its services and safeguard high standards of care. There were clear and effective processes for managing risks, issues and performance. The trust engaged with and involved people who used services, their representatives, the public, staff and external partners to support high quality sustainable services and staff were supported with learning and continuous improvement.

In community end of life, we found managers did not monitor the quality and safety of the service and the governance structure did not provide an effective overview of specific quality indicators relevant to the community end of life service. The vision and strategy for the service did not provide adequate direction or impetus for service development and We were not assured that leaders were adequately focussed on the continual improvement of the service in the community. The trust-wide leadership and accountability structure for end of life care was not clear to staff delivering the end of life care in the community. The trust did not engage well with staff to plan and manage appropriate services and the culture of the service was not focussed on improving the overall quality of the patient experience. At a ward or team level, leadership of the community end of life service was not well defined. However, Senior managers were aware of the challenges to provision of the community end of life service and there were positive relationships with external partners. Managers across the trust promoted a positive culture that supported and valued staff and leaders at directorate level were visible and approachable.

In urgent care, Staff felt local leadership represented and enabled them, and hospital and divisional lead staff were accessible. Staff were aware of the vision and strategy for the minor injury unit as well as the wider trust strategy. There was a strong ethos of teamwork and staff felt very well supported. There was a structured and effective governance management framework to monitor and develop the minor injury service. risks were included as part of the emergency department governance and service performance measures were used to ensure the service was as effective as possible. However, Mortality reviews were not undertaken by the MIU staff and staff did not get learning from the trust mortality reviews.

In Mardon Neuro-rehabilitation Centre, we found ward leaders had the skills, knowledge and experience to lead teams effectively. Considerable work had been undertaken to develop inclusivity between the acute hospital and the Mardon unit. Staff could tell us about the visions and values of the trust and of the Mardon unit. There was a positive culture amongst staff. The Trust and the Mardon unit together now had processes to manage current and future performance. There were systems to engage with the public to ensure regular feedback on services and the leadership and staff were continuing to review the service provided. However, the risk register was under development and so the management of the trust could not provide us with the current version but could provide the content.

Checks on specific services

Community health services for adults

Good

Updated 30 April 2019

We rated it as good because:

  • Overall, the service was mostly compliant with the trust target for mandatory training and safeguarding training compliance. Staff were aware of their role and responsibilities to report safeguarding issues. Staff were compliant with infection, prevention and control issues and the environment and equipment was largely fit for purpose. Patient caseloads were managed and a proactive approach was taken to manage the staffing challenges and demand for the service. However, patients’ risk assessments were completed to varying standards across the community nursing service. There was no clear system to monitor sepsis, although work was ongoing to introduce a tool for staff to use in March 2019. Care records were not integrated and were paper based.
  • Relevant and current evidence-based guidance, best practice and legislation was used to develop how the services, care and treatment were delivered, although this was not being fully monitored. The service reviewed patient outcomes and undertook a range of audits to promote best practice. Staff worked together to assess and plan ongoing care and treatment for patients and had the skills, knowledge and experience to deliver effective care and treatment. Consent to care and treatment was obtained in line with legislation, and where appropriate patients had their mental capacity assessed and recorded in line with legislation and guidance. Community nursing staff were complaint with the trust’s appraisal target.
  • Staff interacted with patients and those who cared for them compassionately and respectfully. Patients were encouraged to be active partners in their care and treatment. Staff also understood the need to include patients’ relatives and carers in discussions and decision making. Staff worked to support patients emotionally as they understood the impact a condition and the subsequent treatment could have on a patient’s emotional wellbeing.
  • Services were planned, tailored and delivered to meet the needs of the local population. Teams across the service met the needs of a variety of patients who used the service and treated them as individuals. Care and treatment was provided in a non-judgemental way and patients with disabilities could access the service on an equal basis. Staff understood the importance of managing patients’ mental health needs along with their physical needs. Complaints were dealt with in a timely and were investigated thoroughly. However, despite the issue of the service filling a gap in domiciliary care provision, which posed an ongoing challenge to the community adult service, work was ongoing with system wider partners to address this issue. Work was ongoing to ensure patients received more timely access to care and treatment from the therapy teams.
  • There was a clear vision and strategy, with patient-centred care being embedded in the culture of the community adults service. Leaders understood the challenges to quality and sustainability which they faced and could clearly discuss how issues were being managed. The governance process ensured good oversight of quality, safety, performance and risk was understood and managed effectively. There was a strong emphasis on the safety and wellbeing of staff. The staff and patients were engaged to shape the future planning and delivery of the service. However, there was low morale among staff in the out of hours nursing team workforce. This had been identified and action was being taken to make improvements for the staff.

Community end of life care

Requires improvement

Updated 30 April 2019

We rated it as requires improvement because:

We rated safe, effective, responsive and well-led as requires improvement. Caring was rated as good.

Systems to manage and share information were uncoordinated. Records did not contain holistic assessments or individualised care plans. Staff did not always have all the information needed to deliver high quality care. Safety systems at the community mortuary were not adequately monitored. There was no mandatory training for end of life care and uptake of optional training was low. Teams did not initiate advance care planning for patients in the last 12 months of their lives. Managers did not check that staff were following evidence based care guidelines and did not measure the quality of the service for patients living in their own homes. Managers did not check that nursing staff were competent for their roles on an ongoing basis. Managers did not monitor the quality and safety of the service provided for community end of life patients.The leadership and systems of governance did not always support the delivery of high-quality person-centred care and governance arrangements for this service had not been reviewed. Leaders were not aware of all risks within the service. The strategy did not provide adequate direction or impetus for service development and was not clearly documented or communicated to staff delivering care.

However,

There were reliable systems for reporting incidents and safeguarding concerns. Patients were supported, treated with dignity and respect were involved in their care. Patients could access care in a timely way. Staff worked well together as a multidisciplinary team. Leaders encouraged compassionate, inclusive and supportive relationships among staff so that they felt respected, valued and supported.

Community health inpatient services

Good

Updated 30 April 2019

We rated it as good because:

  • Systems, processes and practices kept people safe and safeguarded from abuse. Staff were knowledgeable and understood how to safeguard patients against abuse and worked with other agencies when needed to do so.
  • Standards of cleanliness and hygiene were maintained and there were systems in place which staff generally followed to prevent and protect people from healthcare associated infections. Patients we spoke with were positive about the cleanliness of the wards and two patients complemented the food hygiene practiced by staff.
  • The maintenance and use of facilities, equipment and premises kept people safe. Improvements were being made to increase the storage facilities at each hospital.
  • Risks to people were assessed, and their safety monitored and managed so they were supported to stay safe. Staff reported incidents and lessons were learned and improvement made when things went wrong.
  • Staffing levels and skill mix of staff were planned and reviewed so that people received safe care and treatment. Staff had the necessary skills, knowledge and experience to deliver effective care, support and treatment. Staff teams and services within and across organisations worked together to deliver effective care and treatment.
  • The care, treatment and support provided to patients achieved good outcomes, promoted a good quality of life and was based on the best available evidence. The care and treatment outcomes for patients were monitored and compared favourably to other similar services.
  • Patients’ nutrition and hydration needs were identified, monitored and were mostly met. Patients were complimentary about the meals they were provided with and the choices available to them.
  • Staff assessed and managed the pain experienced by patients, including those who had difficulties in communication.
  • Patients were supported to live healthier lives and where the service was responsible it improved the health of its population.
  • Consent, Mental Capacity Act and Deprivation of Liberty Safeguards. Consent to care and treatment was always sought in line with legislation and guidance.
  • The service involved and treated patients with compassion, kindness, dignity and respect. Patients and those close to them were provided with emotional support when needed. The staff supported people to express their views and be actively involved in making decisions about the care, support and treatment as far as possible. People received personalised care that was responsive to their needs. The service took account of the needs and choices of different people.
  • People could access the right care at the right time within the community hospitals. The staff took account of patient’s individual needs. including for patients who lived with dementia, learning disability, physical disability and sensory loss.
  • Concerns and complaints were listened and responded to and used to improve the quality of care.
  • There was leadership with the capacity and capability to deliver high quality sustainable care.
  • The vision and strategy formed a base from which to deliver high quality sustainable care to people using services and a robust plan to monitor the delivery of care.
  • Managers across the community hospitals promoted a positive culture that valued and supported staff. Staff we spoke with were proud to work for the trust at the community hospitals. The trust used a systemic approach to improve the quality of its services and safeguard high standards of care. A series of governance meetings were held across the community services to ensure issues, risks and positive outcomes were discussed, assessed and shared with the wider trust as necessary.
  • There were clear and effective processes for managing risks, issues and performance. All incidents and risks were reviewed by senior managers.
  • Appropriate and accurate information was available to staff to support their work.
  • The trust engaged with and involved people who used services, the public, staff and external partners to support high quality sustainable services.
  • The trust had a system in place to enable staff to raise innovative ideas and apply for funding to support these. Staff said the senior nurses were approachable and willing to discuss staff ideas and would support them to forward these ideas to the trust for approval.

However:

  • Not all staff had met the trust target for training compliance. The electronic system used to record this was not reliable and so did not provide an accurate and updated reflection of training completed.
  • At Tiverton hospital, the control of infection was not consistently practiced by all staff which resulted in a risk from cross infection.
  • The trust did not consistently ensure the proper and safe use and administration of medicines. For example there were PGDs which required updating and medicines were not always dated on opening.
  • There was maintenance and refurbishment work waiting to be carried out at Exmouth hospital. This meant areas of the ward were cold. The environment did not always support patients with additional needs such as those living with dementia to orientate themselves around the wards.
  • Staff did not consistently have access to the information they needed to deliver care and treatment to patients. Individual care plan documentation was not consistently in sufficient detail to reflect the individualised care needs and preferences of the patients. The care plans provided brief guidance on the care required.

  • At Tiverton hospital, staff did not consistently follow a system to track and record the FP10 prescription pads. This meant there was a risk of the prescription pads being misused.

  • The independence of patients was not always supported as they were unable to fully self-administer their own medicines as there was no system to enable them to access their medicines independently.
  • Not all staff were familiar with which national guidelines were in use and therefore underpinned their practice and the policies and procedures followed.
  • Not all policies and procedures had been reviewed and aligned since the community hospitals had become part of the acute trust.
  • Divisional risk registers were in operation. Not all staff were familiar with their local risk registers or what was included on it.
  • The staff notice board at Exmouth hospital was not relevant for public display. The staffing noticeboard at Exmouth hospital was not clear to visitors to the ward as there was no explanation of the additional numbers and times included on the staffing information notice board. The numbers referred to the staff rest breaks and although the staff understood the chart and provided an explanation when asked it was not clear to visitors to the ward.
  • Not all staff had received an annual appraisal and the trust target was not met in all areas.