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  • SERVICE PROVIDER

Royal Devon University Healthcare NHS Foundation Trust

This is an organisation that runs the health and social care services we inspect

Overall: Requires improvement read more about inspection ratings
Important: Services have been transferred to this provider from another provider

All Inspections

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.

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.

15 January 2019 to 7 February 2019

During an inspection of Community health inpatient services

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.

15 January 2019 to 7 February 2019

During an inspection of Community end of life care

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.

15 January 2019 to 7 February 2019

During an inspection of Community health services for adults

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.

21 December 2017

During an inspection looking at part of the service

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

3-6, 10 & 16 November 2015

During an inspection looking at part of the service

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.