Royal Devon University Healthcare NHS Foundation Trust

Updated 26 May 2023

The Royal Devon University Healthcare NHS Foundation Trust was established in April 2022 following the integration of Royal Devon and Exeter NHS Foundation Trust and Northern Devon Healthcare NHS Trust, combining resources and expertise to provide acute, community and specialist services across North Devon, Mid Devon East Devon and Exeter. Corporate and clinical services are in the process of being merged.

The trust provides services for 615,000 people across 2 acute hospitals, 17 community hospitals and a range of community, specialist and primary care services. Services cover more than 2000 square miles across Devon and some specialist services cover the whole of the peninsula. The trust has 15,000 staff.

We carried out a short notice announced focused inspection of medicine and surgery services at North Devon District Hospital and Royal Devon & Exeter (Wonford) site. We also carried out a comprehensive inspection of diagnostic services at both sites. We inspected medical care based on concerns and information we had received. We inspected surgery as the trust had 16 Never Events between March 2021 and November 2022. We previously inspected the Royal Devon and Exeter hospital in December 2017 also in response to concerns we had following a series of never events within surgery. We carried out this short notice announced comprehensive inspection for the diagnostic and imaging service as we had not previously inspected or rated diagnostic imaging as a stand-alone service at these locations.

Our well led inspection, planned for January 2023 was postponed due to pressures in the NHS. We completed the well led inspection on 3 and 4 May 2023. We rated well-led (leadership) from our inspection of trust management, taking into account what we found about leadership in individual services. We rated other key questions by combining the service ratings and using our professional judgement. Use of Resources was not assessed during this inspection.

Our ratings for the core service inspection:

For Medicine at both locations, we rated the service as requires improvement in safe and well-led. According to our methodology the remaining key questions were 'inspected not rated' due to using the focused inspection methodology. This meant that Royal Devon and Exeter (Wonford) site for medicine moved from good to requires improvement overall. North Devon District Hospital remained requires improvement for medicine overall. The remaining domains effective, responsive and caring reflect the historical ratings of the inspection carried out in 2019 for Royal Devon and Exeter (Wonford) and July 2021 for Northern Devon District Hospital.

For Surgery at both locations, we rated the service as requires improvement in safe and well-led. We only inspected the remaining key questions of responsive and effective which were 'inspected not rated' due to using the focused inspection methodology. This meant that Royal Devon and Exeter (Wonford) site for surgery moved from good to requires improvement overall. North Devon District Hospital also moved from good to requires improvement overall. The domains of effective, responsive and caring reflect the historical ratings of the inspection carried out in February 2016 for Royal Devon and Exeter (Wonford) and November 2014 for North Devon District Hospital.

For Diagnostic Imaging at both locations, we rated the service as good. This was good for the key questions of caring, responsive and well led, and requires improvement for the key question of safe. We inspected but did not rate the key question of effective which was in line with our current methodology.

Our rating for the well led inspection:

We rated the trust well led as requires improvement because:

• The trust and Devon were in a national oversight framework segment 4 due to financial performance and delivery against performance targets.
• The trust had a challenging financial position and a financial plan with a planned deficit of £28 million (2.8%). Although safety remained the highest priority within the organisation, we were told at times quality may be impacted.
• There had been an impact on the quality of data for audit while the electronic reporting system was embedding. The response to this had not been completed at pace.
• The trust needed to continue to address culture and work on equality, diversity, and inclusion within the organisation. As a newly integrated trust, culture and inclusivity was a key focus and the trust recognised there was work to be done to bring the cultures together and build a culture that is all inclusive. Staff satisfaction was mixed, however, improving the culture and staff satisfaction was seen as a priority.
• The trust had a high number of never events, these are serious incidents which are wholly preventable. The response time to never events lacked in pace and processes to implement actions and share widely lessons learned were not always effective.
• There were significant delays in investigating complaints and serious incidents.
• Community services were not well represented within the board service and performance measure.

However:

• Leaders had the experience, capacity, capability, and integrity to ensure the strategy can be delivered and risks to performance addressed. The leadership team were cohesive, patient centered and knowledgeable about the issues and priorities for the quality and sustainability of services and understood the challenges.
• There was a clear statement of vision and values driven by quality and sustainability and translated into a realistic strategy. The strategy was aligned to local plans in the wider health and social care economy and services were planned to meet the needs of the local population.
• The board and other levels of governance in the organisation functioned effectively and interacted with each other appropriately. Structures, processes, and systems of accountability were clearly set out, understood and effective. Staff were clear about their roles and accountabilities.
• Safety remained a priority over performance. There were processes to manage current and future performance. There was an effective and comprehensive process to identify, understand, monitor, and address current and future risk. Performance issues were escalated to the appropriate committees and the board through clear structures and processes.
• The trust had undergone a digital transformation implementing an integrated electronic patient record system and making personal health information accessible to patients. The integrated electronic patient record system enables advancements in many aspects of patient care and service delivery across the trust. There were arrangements to ensure the confidentiality of identifiable data, records and data management systems, and information governance breaches were reported. There were arrangements to ensure data or notifications were submitted to external bodies as required.
• There was a collaborative relationship with system and external partners to share an understanding of challenges and the needs of the local population. Staff were engaged and involved. The trust included the patient voice to help shape and improve services.
• There was a focus on continuous learning and improvement at all levels of the organisation, including appropriate use of external accreditation and participation in research. There was knowledge of improvement methods and arrangements to support people to develop their ideas in a structured way. Internal and external reviews were used to identify learning and make improvements.

You can find further information about how we carry out our inspections on our website: www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 30 April 2019

Updated 30 April 2019

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.

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.

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.