Royal Devon University Healthcare NHS Foundation Trust

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.

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.

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.

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.