Royal Devon & Exeter Hospital (Wonford)

Updated 15 March 2024

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Royal Devon and Exeter hospital.

We inspected the maternity service at Royal Devon and Exeter hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

Maternity services include an outpatient department, labour ward / delivery suite, triage, midwifery led unit, antenatal & postnatal wards and one maternity theatre. Between April 2022 and March 2023 approximately 3497 babies were born at the Royal Devon and Exeter hospital.

This location was last inspected under the maternity and gynaecology framework in 2016. Following a consultation process CQC split the assessment of maternity and gynaecology in 2021. As such the historical maternity and gynaecology rating is not comparable to the current maternity inspection and is therefore retired. This means the resulting rating for Safe and Well-led from this inspection will be the first rating of maternity services for the location. This does not affect the overall Trust level rating.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this hospital went down. We rated it as Requires Improvement because:

• Our rating of Requires Improvement for maternity services changed the ratings for the hospital overall. We rated maternity as Requires Improvement in safe and well led.

We also inspected one other maternity location run by Royal Devon University Healthcare NHS Foundation Trust. Our report is here:

The North Devon District Hospital– https://www.cqc.org.uk/location/RH801

How we carried out the inspection

We provided the service with 2 working days’ notice of our inspection.

We visited labour ward / delivery suite, triage, midwifery led unit, antenatal & postnatal wards and one maternity theatre.

We spoke with 15 midwives, 4 doctors, 5 support workers, 2 women and birthing people. We received no responses to our give feedback on care posters which were in place during the inspection.

We reviewed 12 patient care records, 5 Observation and escalation charts and 10 medicines records.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

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

Updated 26 May 2023

Updated 9 February 2016

Services for children and young people were judged to be good. We found that services were safe, effective, caring, responsive and well-led.

Risk was managed and incidents were reported and acted upon with feedback and learning provided to most staff. Staff adhered to infection prevention and control policies and protocols. The units were clean and well organised and suitable for children and young people.

Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines. There was excellent multidisciplinary team working within the service and with other agencies.

Children and young people were at the centre of the service and the priority for staff. Innovation, high performance and the highest quality of care were encouraged and acknowledged.

Care and treatment of children and support for their families was delivered in a compassionate, responsive and caring manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their families. Children, young people and their families were respected and valued as individuals. Feedback from those who used the service was consistently positive. Children received excellent care from dedicated, caring and well trained staff who were skilled in working and communicating with children, young people and their families.

Staff understood the individual needs of children, young people and their families and designed and delivered services to meet them.

There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.

All staff were committed to children, young people and their families and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the units as a place to work. They spoke highly of the culture and levels of engagement.

There was a good track record of lessons learnt and improvements when things went wrong. This was supported by staff working in an open and honest culture with a desire to get things right.

Updated 9 February 2016

We have judged the overall critical care service as outstanding. Caring and leadership was outstanding. The safety, effectiveness and responsiveness of the service were good, with some elements of outstanding.

Treatment by all staff was delivered in accordance with best practice and recognised national guidelines. There was a holistic and multidisciplinary approach to assessing and planning care and treatment for patients. Patients were at the centre of the service and the overarching priority for staff. Innovation, high performance and the highest quality care were encouraged and acknowledged. All staff were engaged in monitoring and improving outcomes for patients. They achieved consistently good results with patients who were critically ill and with complex problems and multiple needs. The whole service had a collaborative approach with a multidisciplinary attitude to patient care.

Patients were truly respected and valued as individuals. Feedback from people who had used the service had been overwhelmingly positive. Staff went above and beyond their usual duties to ensure patients experienced compassionate care and that care promoted dignity. People’s cultural and religious, social and personal needs were respected. Innovative support for patients, such as the development of patient diaries, was encouraged and valued. Staff took the time to ensure patients and their families understood and were involved with care plans.

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. All the senior staff were committed to their patients, their staff and their unit with an inspiring shared purpose. There was strong evidence and data to base decisions upon and drive the service forwards from a clear programme of audits and national evaluative studies. Staff, patients and their families were actively engaged with to identify areas of good practice, as well as areas that could be improved. There was a high level of staff satisfaction, with staff saying they were proud of the unit as a place in which to work. They spoke highly of the culture and consistently high levels of constructive engagement. The leadership drove continuous improvement and staff were accountable for delivering change. Innovation and improvement were celebrated and encouraged, with a proactive approach to achieving best practice and sustainable models of care.

There was a good track record on safety, and lessons were learned and improvements made when things went wrong. This was supported by staff working in an open and honest culture and by a desire to get things right. There were reliable systems and staff received training to keep people safe from abuse. The environment did not meet all the requirements for modern critical care units, being an older unit, and this was recognised by the trust. The unit was generally clean and well organised. Staff adhered to infection prevention and control policies and protocols. There were good levels of nursing staff meeting the Core Standards for Intensive Care Units (2013) to keep patients safe. However, overnight medical cover did not meet the core standards and there were times when a doctor was not available on the unit because they were attending a medical emergency call elsewhere in the hospital.

The critical care service responded well to patients’ needs. Communication aids, including translation services, were available for patients who could not otherwise communicate easily or effectively. There were bed pressures in the rest of the hospital that meant about 50% of patients were delayed in their discharge from the unit, but the numbers of these incidences were below the NHS national average. Very few patients were discharged onto wards at night and there was a very low rate of elective surgical operations being cancelled because a critical care bed was not available. The facilities for patients, visitors and staff in critical care were good. There was quick input from consultants and nurses when new patients were admitted. Patients were treated as individuals, and link nurse roles were used to support specific aspects of patient need.

Updated 26 May 2023

Updated 9 February 2016

End of life care was judged to be good overall. The service had enough staff with the appropriate skills to provide care. Although the trust had identified vacancies across nursing and medical staff posts this had not affected end of life care. Trust staff and the end of life team followed systems, processes and practices to keep patients safe. Staff kept adequate patient records, which were audited, and we found evidence of continuous improvement in record-keeping.

The service learned lessons from incidents and complaints, and made improvements when things went wrong and had followed duty of candour process.

Patients’ care, treatment and support achieved good outcomes, promoted a good quality of end of life and was based on the best available evidence. Staff assessed patients’ needs and provided care and treatment in line with legislation, standards and evidence-based guidance including well managed pain and nutrition and hydration. The service monitored patients’ care and treatment outcomes through audit, which compared well with other similar services. Specialist staff had the skills, knowledge and experience to provide effective end of life care. Training rates in relation to end of life could be improved across the trust. End of life care documentation (for instance, treatment escalation plans) and recording in patients’ notes had improved but use of some forms and sharing of information needed improvement which had been noted in audit outcomes.

Staff treated patients and those close to them with kindness, dignity, respect and compassion. Hospital staff demonstrated an understanding of patients personal, cultural, social and religious and spiritual needs. Patients and bereaved relatives were involved as partners in their care contributing to patient records and engaging in bereavement groups set up by the trust. Support was available to enable patients and those close to them to have the support they needed to cope emotionally with their care, treatment or condition with the provision of support from volunteers and chaplaincy services.

Services were planned and provided to meet the needs of patients and those close to them, taking account of the needs of patients including those with learning disabilities and those with dementia,. Patients could access care and treatment in a timely way with a few exceptions such as occasional delays in discharge. There were excellent communication links between specialist palliative care team members, palliative discharge team and community nursing staff and others. Patients and those close to them who raised concerns and complaints were listened and responded to, and staff used the experience and information shared to improve the quality of care.

The leadership of end of life care was evident from all staff. The service had a clear vision and strategy to provide good quality end of life care, and leaders recognised that progress was still needed. The governance framework ensured that responsibilities were clear and lead roles within the trust and specialist palliative care team had a detailed service level agreement.

The trust encouraged openness and transparency and promoted good quality care. Patients and others who used the service, the public and staff were engaged and involved in the delivery and development of it.

Updated 15 March 2024

Updated 30 April 2019

We rated it as good because:

• Records were clear, up-to-date and available to all staff providing care. Patient records were stored securely in all outpatient clinics we visited. This was an improvement since the last inspection in February 2016.

• Training had been introduced for staff to encourage them to ask patients if they smoked and offer them referral to the smoking cessation advisor. Outpatients had referred 70 patients to the service since November 2018

• In the National Cancer Survey 2018, the trust performed well and was in the top 10 nationally.
• The hospital developed its own in house course called ‘ERICA’ (Exeter recommendation Insulin Carbohydrate Adjustment) for newly diagnosed type-1 diabetics.

• The gynaecology department used innovative ways to publicise and improve cervical screening. This good practice was to be shared at a national conference.
• In the pain clinic, compassion based therapy was used to help patients cope with chronic pain symptoms and staff reported dramatic changes to some patients.

• At the last inspection in February 2016, leadership and accountability structure of the medical outpatient service was lacking. The recent appointment of the new senior nursehad improved senior leadership visibility and helped build better relationships with other outpatient areas.
• The Trust had a very strong mental health strategy driven by the Trust’s Medical Director. The Trust was working closely with the neighbouring mental health trust and jointly enrolled onto a national quality improvement programme. The national programme involved looking to develop and clinically lead the redesign of healthcare pathways to improve patient flow through outpatients.

However:

• Medical staffing continued to be a risk for the trust due to vacancies and sickness.

• Some aspects of care in the outpatient’s service were not effective. Clinical supervision was not embedded in clinical practice for nursing staff.
• There was a lack of privacy at the reception desk when patients booked into the surgical and fracture clinic. In the physiotherapy outpatient clinic, patients could hear other patient’s consultation which did not allow privacy whilst being treated.

• Following a significant increase in demand, there was a clear disparity between outpatient clinics’ capacity to see patients, and the demand for services. This was most evident in Cardiology, Ophthalmology and Orthopaedics.
• There was a backlog of typing for clinic letters. Although most departments achieved the trust standard, cardiology, neurology and respiratory did not.
• There was not a trust-wide reliable triage system for reviewing patients who were not able to book an appointment. There was also no strategic oversight of the inadequacies of the triage system. This was identified immediately before the inspection and the trust had begun to action this.
• Five specialties were below the England average for non-admitted pathways, four specialties were below the England average for incomplete pathways.
• The trust performed worse than the operational standard for people being seen within two weeks of an urgent GP referral. There were high volumes of two week wait breaches within Gastro-intestinal surgery. This was unchanged from the last inspection in February 2016.
• The trust failed to meet the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral. This was unchanged from the last inspection in February 2016.
• In outpatients, 27 complaints remained open past 45 days. This was not in line with the trust policy.

• Patients continued to wait too long for their treatment for cancer and remained at risk of deteriorating health because of the delay. This situation had not improved since the last inspection in February 2016.
• The trust had a serious incident of a patient who experienced a long delay between the date of the clinic visit and the typing of the letter. Trust-wide learning from this incident had not been acted upon as cardiology and neurology remain the clinics with the most substantial backlog for typing. The administrative issue has still not been resolved.
• Outpatients did not have its own risk register as risks were contained within the speciality and division risk register. Most of the risks had been updated within the past six months. However, two risks had not been updated since July and October 2017.

Updated 30 April 2019

We rated renal services as outstanding because:

• There were comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training exceeded the trust target. Cleaning audits demonstrated that each of the dialysis units, renal day case unit (Sid ward) and Creedy wards were meeting the trust target and rated as ‘green’. Compliance with the national guidelines for checking water treatment rooms for patients undergoing haemodialysis was met by technical staff to make sure patients remained safe.
• Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking and peer review were proactively pursued, including participation in approved accreditation schemes. High performance was recognised by credible external bodies. Outcomes for patients who used services were positive, consistent and regularly exceed expectations.
• Care and treatment was delivered in line with current best practice. Policies and procedures were based on national best practice guidance. Staff adhered to these and some case patients. In haemodialysis best practice was for patients to wash their fistula prior to dialysis. We observed this taking place.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Staff, teams and services were committed to working collaboratively to meet the needs of patients.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff took the time to interact with patients and those close to them in a respectful and considerate way. Patients valued their relationships with the staff team and felt they often go ‘the extra mile’ for them when providing care and support. Patients and those close to them were active partners in their care. Staff were fully committed to working in partnership with patients.
• Services were tailored to meet the needs of individual patients and were delivered in a way to ensure flexibility, choice and continuity of care. Patients could access support and treatment close to their home. Community services were available to support patients who had treatment in their homes. Referral to treatment times exceeded the trust target which meant patients did not have long waiting times. There was a proactive approach to understanding the needs and preferences of different groups of patients and to delivering care in a way that met those needs, which was accessible and promoted equality.
• Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Managers at the renal services had the right skills, commitment and encouraged supportive relationships amongst staff. Their strategy for improving their services was based on the trusts main visions to improve care for patients. There was a fully embedded and systematic approach to improvement.

However,

• Risk assessments were not always completed or updated for patients receiving haemodialysis.
• Care planning documentation on the haemodialysis units was not always up to date and patients’ records were not stored securely to prevent unauthorised access. This issue had been identified by senior staff and they were looking to implement short term solutions until the trust’s electronic system was introduced.
• Medicine trolleys were not monitored for their temperature to makes sure medicines that were temperature sensitive were stored at the correct manufacturer’s recommended temperature.
• Complaints were not always responded to with an outcome within the trust target.

Updated 26 May 2023

Updated 9 February 2016

Overall, we rated the emergency department as outstanding. There was a committed team of staff who demonstrated a cohesive, multidisciplinary approach to the care and treatment of their patients. They respected each other’s skills, experience and competencies in a seamless and professional manner that benefitted the people who used the service.

Openness and transparency about safety was encouraged. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. They were fully supported when they did so. When something went wrong, there was an appropriate and thorough investigation that involved all relevant staff. Lessons were learned and communicated widely to support improvement. Facilities for children did not fully comply with national standards. Children’s treatment rooms were not separated from adult areas and the equipment was not always suitable for a children’s environment.

Staffing levels and skill mix were planned, implemented and reviewed. Staff had received up-to-date and relevant training and were encouraged to develop their skills. Risks to people who used the department were assessed, reduced, monitored and managed on a day-to-day basis. All staff were actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review, accreditation and research were proactively pursued. High performance was recognised by credible external bodies such as the National Patient Safety Agency.

Feedback from people who used the service and those close to them was continually positive about the way staff treated them. They thought that staff went the extra mile and the care they received exceeded their expectations. There was a strong, visible person-centred culture. Staff were highly motivated to offer care that was kind and promoted people’s dignity. Interaction between patients, those close to them and staff was strong, caring and supportive.

Changes had been made to working practices in order to reduce delays. Waiting times and avoidable delays were minimal and managed appropriately. The department had been meeting the four hour target to admit or discharge patients since June 2015. Performance throughout the year had varied from 93% to 96% which was better than most other hospitals in England. There were very few delays for ambulance patients and people were kept informed of any disruption to their care or treatment. The needs of people with complex needs were well understood and addressed appropriately. People with dementia received care and treatment that was sympathetic and knowledgeable.

It was easy for people to complain or raise a concern and they were treated compassionately when they did so. There was openness and transparency in how complaints were dealt with. Governance and performance were proactively reviewed and reflected best practice. Lessons learned and changes in practice were communicated to staff via monthly governance meetings and newsletters. More immediate feedback was given to staff via thrice weekly “Communication Cells”. Leaders displayed a strong sense of shared purpose, strived to deliver excellent patient care and motivated staff to succeed.

There was strong collaboration and support between all groups of staff and a common focus on improving quality of care and people’s experiences. This led to high levels of staff satisfaction across all groups. Staff were proud to work in the department and spoke highly of the culture.