30 November and 1 December 2022, 3 and 4 May 2023
During a routine inspection
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.