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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

Reports


Inspection carried out on 15 January 2019 to 7 February 2019

During a routine inspection

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.


CQC inspections of services

Service reports published 30 April 2019
Inspection carried out on 15 January 2019 to 7 February 2019 During an inspection of Community end of life care Download report PDF | 733.44 KB (opens in a new tab)Download report PDF | 3.91 MB (opens in a new tab)
Inspection carried out on 15 January 2019 to 7 February 2019 During an inspection of Community health inpatient services Download report PDF | 733.44 KB (opens in a new tab)Download report PDF | 3.91 MB (opens in a new tab)
Inspection carried out on 15 January 2019 to 7 February 2019 During an inspection of Community health services for adults Download report PDF | 733.44 KB (opens in a new tab)Download report PDF | 3.91 MB (opens in a new tab)
See more service reports published 30 April 2019
Inspection carried out on 21 December 2017

During an inspection to make sure that the improvements required had been made

Our rating of the trust stayed the same. We did not have sufficient evidence to rate, however we found:

Inspection carried out on 3-6, 10 & 16 November 2015

During an inspection to make sure that the improvements required had been made

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 3 – 6 and 10 and 16 November 2015 and included Wonford Hospital and Mardon Neuro-Rehabilitation Centre

We did not inspect the following locations:

Royal Devon & Exeter Hospital (Heavitree)

Honiton Hospital

Okehampton Community Hospital

Tiverton District Hospital

East Devon Satellite Kidney Unit

Exmouth Hospital

Axminster Hospital

South Devon Satellite Kidney Unit

Victoria Hospital Sidmouth

North Devon Satellite Kidney Unit

We rated the Royal Devon and Exeter NHS Foundation Trust as good overall. Wonford Hospital was rated as good overall with two services, urgent and emergency care being rated as outstanding overall. The teams in these areas demonstrated they were very well led clinically and went the extra mile in caring for their patients. The Mardon Neuro –rehabilitation Centre was rated as requires improvement overall. At trust level safety was rated as requires improvement and we rated it as good for effective, responsive and the well-led key questions. As well as the two services – A&E, and critical care, where caring was judged to be outstanding, all other services were rated as good for caring with an overall trust rating of outstanding for this domain.

Our key findings were as follows:

  • 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 reviews all incidents that are categorised as amber or red. The culture of reporting incidents was seen to be good with all staff being aware of their responsibilities.
  • 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.
  • There had been no grade 3 or 4 hospital acquired pressure sores for 10 months prior to the inspection. Where increases in pressure ulcers and falls had occurred staff worked together to review practice and implement new ways of working to reduce risk and maintain patient safety. Of note was the emergency department, where staff worked closely with the ambulance service to identify patients at risk of pressure damage prior to arrival. This meant measures to further reduce risk were put in place in a timely way.
  • Survival rates for patients who suffered a cardiac arrest were double the national average. An area the trust had worked hard to improve outcomes for patients.

  • Medical records were not always kept secure to prevent unauthorised access. We have raised this in the areas of concern for the trust to take action.
  • The trust had not met the cancer referral to treatment targets for some months but had worked to put in place additional urology and endoscopy lists and was anticipating being back on target by December 2015.
  • 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.
  • We observed good interactions between staff, children, young people and their families. We saw that these interactions were very caring, respectful and compassionate. Parents were encouraged to provide as much care for their children as they felt able to, whilst young people were encouraged to be as independent as possible.
  • Meeting the needs of people living with dementia was being developed on Kenn and Bovey wards with activities such as knitting, reading and discussion. The staff had recognised the need to relieve patient boredom which may have resulted in patients challenging behaviour.
  • 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.
  • Outcomes for patients were good in all services and outstanding in emergency care. All participated in programmes of audit in line with national guidelines and evidence based practice. The trust performed well in a number of these including patient reported outcomes of hip and knee surgery and audits for lung and bowel cancer.
  • In line with national changes to guidelines, the trust and specialist palliative care team had responded to the 2013 review of the Liverpool Care Pathway by putting temporary guidelines in place to ensure appropriate care was maintained. The hospital was one of only three acute hospitals in the UK to have wards recognised to meet the standard of the Gold Standards Framework for the care they provide to patients who are nearing the end of their lives. This was awarded to Yeo and Yarty wards.
  • Leadership in the majority of services was seen to be good and at times outstanding, with governance systems and culture driving improvements in treatment and person centred care.
  • Access and flow was managed and overseen by the bed management team who met three times a day to assess the flow and bed status of the hospital. These daily meetings included a range of senior staff attending. We saw that a cohesive approach to the anticipated number of admissions, discharges and any other operational issues were discussed and plans to maintain flow reviewed at each meeting.

We saw several areas of outstanding practice including:

  • The emergency department had agreed with the ambulance service that crews would radio ahead to tell staff that that they were bringing a patient with a suspected broken hip. This gave nurses time to inflate a pressure relieving mattress for the trolley on which the patient would be treated. In this way, pressure ulcers would be prevented but X-rays could still be carried out without moving the patient.
  • The computer system would alert staff when a child with a long-term illness arrived in the emergency department. Care plans for each child were immediately available so that they received treatment and care that was specific to their condition.
  • The care being provided by staff in the critical care unit went above and beyond the day-to-day expectations. We saw patients’ beds being turned to face windows so they could see outside, staff positively interacting with all patients and visitors and evidence of staff going out of their way to help patients. Patients and visitors gave overwhelmingly positive feedback.
  • A member of staff was on duty at the reception area of the maternity wards to ensure the security and safety of the wards, women and babies. One member of staff employed through an agency to provide security was spoken of highly by patients and staff alike. They commented on their unfailing cheerfulness, politeness and support to them during visiting times and when staying in the hospital.
  • Royal Devon and Exeter NHS Foundation Trust is one of only three trusts in the country with recognition in achieving the Gold Standards Framework for end of life care, with three wards accredited and one deferred. Plans to extend the gold standard to further wards demonstrated an outstanding commitment by ward staff and the specialist palliative care team to end of life care.
  • A significant training programme 'opening the spiritual gate' had been invested in and had been rolled out to medical, nursing and allied health professional staff to offer spiritual care, especially around the end of life.
  • The cancer service was leading a project centred on the ‘Living with and beyond cancer’ programme. This programme was a two year partnership between NHS England and Macmillan Cancer Support aimed at embedding findings and recommendations from the National Cancer Survivorship Initiative into mainstream NHS commissioning and service provision. Patients in the cancer service who were deemed to be at low risk, were discharged and given open access to advice. In the gynaecology clinic, clinicians contacted patients by telephone to follow up treatment and in haematology; this process was done by letter. Results showed that 94% of patients who were participating in the programme rated it as good or excellent.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must take action to ensure that facilities for children in the emergency department comply with the national Standards for Children and Young People in Emergency Care Settings 2012.
  • Ensure patient information remains confidential through appropriate storage of records to prevent unauthorised people from having access to them in medical, surgical and maternity wards and outpatients departments.

  • Ensure staff have access to current trust approved copies of the Patient Group Directions (PGDs) and that only permitted professional groups of staff, as required under the relevant legislation, work under these documents.
  • Ensure the use of medicines are in line with trust policies and best practice. For example; covert administration, storage and disposal of medicines. 
  • The maternity service should review and record the staffing levels to ensure all maternity wards are safely staffed at all times including theatre and recovery
  • The critical care unit must ensure adequate medical staff are deployed at all times. Current overnight levels did not meet the ratio of one doctor to eight patients, as recommended by the Core Standards for Intensive Care Units (2013).

  • Chemicals and substances used for cleaning purposes that are hazardous to health (COSHH) were observed in areas that were not locked and therefore accessible to patients and visitors to the wards. The trust must ensure that cleaning materials including chlorine tablets are stored safely.
  • Ensure that adequate medical physics expert cover is available in the nuclear medicine service
  • Ensure there are sufficient staff deployed to meet demand in ophthalmology and gastroenterology outpatient clinics
  • Ensure patient privacy in outpatient clinics is maintained.
  • Ensure the steps put in place to reduce the length of time that patients living with cancer must wait for treatment are sustained to deliver services in accordance with the ‘cancer wait’ targets set by NHS England.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.