The Care Quality Commission
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Royal Devon & Exeter Hospital (Wonford)

Overall: Requires improvement read more about inspection ratings

Barrack Road, Exeter, Devon, EX2 5DW (01392) 411611

Provided and run by:
Royal Devon University Healthcare NHS Foundation Trust

Important: This service was previously managed by a different provider - see old profile

All Inspections

29 November 2023

During an inspection looking at part of the service

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.

1 December 2022

During a routine inspection

Royal Devon and Exeter NHS Foundation Trust and Northern Devon Healthcare NHS Trust is part of the Royal Devon University Healthcare NHS Foundation Trust which was established in April 2022. Stretching across Northern, Eastern and Mid Devon, the trust has a workforce of over 15,000 staff, making it the largest employer in Devon. The trust provides services for more than 615,000 people, covers more than 2,000 square miles across Devon. Some of the trust’s specialist services cover the whole of the peninsula, extending as far as Cornwall and the Isles of Scilly.

Royal Devon and Exeter Hospital (Wonford) is the largest hospital in the trust where many acute clinical services are based. This includes emergency department and a number of specialist units and centres. The Royal Devon and Exeter hospital is a teaching hospital, delivering undergraduate education for clinical professions. They are a leading centre for research and development in the South West peninsula.

Clinical services at Wonford include; maternity, breast, paediatrics, neonatal, diabetic medicine, ear nose and throat, oncology, dementia, orthopaedics, vascular, cardiology, respiratory, ophthalmology, healthcare for older people and neurology/Parkinson.

The medical care service includes 18 medical wards delivering specialist and general medical services. The combined medical admissions for the trust was 71,958 from March 2021 to Feb 2022.

The surgical service at Wonford includes 10 surgical wards and 10 operating theatres which provide access for colorectal, upper gastrointestinal, breast and endocrine, urology, vascular, maxillofacial, ears nose and throat, trauma, plastics and reconstructive surgery and 24-hour emergency surgery. The surgical services division also includes ophthalmology theatres, community theatres in Heavitree and Exmouth, the princess Elizabeth orthopaedic centre and intensive care unit.

The diagnostic imaging department has a large medical imaging department including general X-rays, fluoroscopy and Interventional procedures, Computed Tomography (CT), Magnetic Resonance Imaging (MRI), Nuclear medicine, Ultrasound imaging, Vascular Ultrasound, Mammography and Dual Energy X-ray Absorptiometry (DXA) scans. For the purposes of this report the different types of examinations taken will be referred to as modalities. In the 12 months up until the inspection the service had performed a total of 448,374 examinations across all modalities. This included 75,341 CT scans, 37,491 MRI scans and 251,156 plain film x-rays and DXA scans.

15 January 2019 to 7 February 2019

During an inspection looking at part of the service

Our rating of services stayed the same. We rated it them as good because:

In medical care we found staff were completing mandatory training and there were systems and processes in place to safeguard adults and children and protect them from harm. Systems and processes to manage the control of infection, cleanliness and hygiene were consistently followed to keep patients safe. We found medication was managed well and that Staff identified and responded appropriately to changing risks to people who used services, including deteriorating health and wellbeing or medical emergencies. Patients had their assessed needs, preferences and choices met by staff with the appropriate skills and knowledge.There was excellent multi-disciplinary working that was patient focused and caring.The trust had been proactive in making improvements to the access and flow of patients. Action had been taken to improve the flow of patients on their respective pathways, avoid admission where appropriate and possible, and improve the coordination of patient discharge.The medical division was provided with good leadership that encouraged openness and transparency, and promoted good care and there was a positive culture in the hospital.

In renal services we found there were comprehensive systems to keep patients safe which took account of best practice. Rates of compliance with mandatory training exceeded the trust target. 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.Care and treatment was delivered in line with current best practice. Policies and procedures were based on national best practice guidance. Staff cared for patients with compassion. 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. 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.

In outpatients we found records were clear, up-to-date and available to all staff providing care. Training had been introduced for staff to encourage them to ask patients if they smoked and offer them referral to the smoking cessation advisor. 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. In the pain clinic, compassion based therapy was used to help patients cope with chronic pain symptoms. At the last inspection in February 2016, leadership and accountability structure of the medical outpatient service was lacking. The recent appointment of the new matron had improved senior leadership visibility and helped build better relationships with other outpatient areas. All medical records were secure in every department we visited. This was an improvement from the last inspection in February 2016.

However:

In medical care we found that nursing vacancies and recruitment on some wards, particularly the elderly care wards, presented challenges to the existing teams. We found not all fridges storing medication were having their temperatures regularly checked and recorded. We found some liquid medications and topical remedies did not have the date of opening recorded. and that not all paperwork relating to capacity assessments was completed consistently.

In renal services we found risk assessments were not always completed or updated for patients receiving haemodialysis and that care planning documentation on the haemodialysis units was not always up to date and patients’ records were not stored securely to prevent unauthorised access. 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 and we found complaints were not always managed in a timely way.

In outpatients we found medical staffing continued to be a risk for the trust due to vacancies and sickness. We found clinical supervision was not embedded in clinical practice for nursing staff. We found 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. There was also no strategic oversight of the inadequacies of the triage system.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. The trust failed to meet the operational standard for patients receiving their first treatment within 62 days of an urgent GP referral. Patients continued to wait too long for their treatment for cancer. 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.

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 in which 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 FoundationTrust is one of only two 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.
  • 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.

In addition the trust should:

  • Ensure that there is sufficient space to treat patients requiring resuscitation and major treatment in the emergency department.
  • Ensure that all patients in the emergency department waiting room can be observed by staff at all times.
  • Ensure that there is band 7 nurse in charge of the emergency department on each shift in line with NICE recommendations.
  • Ensure that accurate, complete and detailed patient records are maintained.
  • Medicines must be stored securely and safely at all times. Intravenous fluids should be stored securely so as not accessible to the public and patients.
  • Ensure that appropriate measures are put in place on admission to the AMU for patients who are at risk from attempting suicide. This should include the appropriate assessments of risk for staff to follow and a suitable and safe environment for patients.
  • Ensure where patients between the ages of 16 and 18 are admitted to the AMU that this is agreed to be the most appropriate environment for them.
  • 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
  • Ensure that all areas used by children are child friendly and should particularly consider improving the environment for children in the outpatients department and theatre recovery rooms.
  • Ensure staff on the critical care unit are fully aware of their duty to report incidents, including near misses and no-harm incidents.
  • The critical care unit should review compliance against the Department of Health’s building note HBN 04-02
  • Resuscitation trolleys in the critical care unit should be tamper-evident.
  • Staff in the critical care unit should have a thorough understanding of the Deprivation of Liberty Safeguards.
  • Mandatory training updates and annual appraisals for critical care staff should meet trust targets.
  • There should be access to a follow-up clinic for patients discharged from the critical care unit.
  • The hospital should improve the access and flow of patients in order to reduce delays from critical care for patients being discharged to wards and reduce occupancy to recommended levels.
  • Screening of patients who were admitted as an emergency to hospital for gynaecology care and treatment should consistently be screened for MRSA.
  • Action should be taken to address the shortfalls identified in staff hand hygiene audits in the maternity services.
  • The labour ward should ensure that emergency resuscitation equipment was checked regularly and a record maintained to show it was ready to use.
  • Care plans should be consistently completed to provide staff with full detail regarding the patients’ assessed care needs. End of life documentation in patient records is completed consistently.
  • The trust should take action to ensure compliance with national guidelines regarding baby identification labels.
  • The maternity service should provide evidence to demonstrate women received pain relief in labour within appropriate timeframes. Sufficient equipment should be available, for example pumps to self-administer analgesia, for women during labour.
  • Ensure all decisions around ‘do not attempt resuscitation’ status and treatment escalation plans are communicated at nurse-doctor handover
  • Review the leadership and accountability structure of the medical outpatient service
  • The hospital should review the facilities available for children in the outpatient service.
  • Ensure staff in the orthopaedic outpatients department are able to access equipment to take patients height and weight.

  • Ensure that all clinical staff receive adequate clinical supervision to support them in their role

Professor Sir Mike Richards

Chief Inspector of Hospitals

5, 6, 13 March 2014

During a routine inspection

We carried out a planned inspection at the Wonford site on 5, 6 and 13 March 2013. We focused on looking at patient discharges from the hospital to other registered providers. There had been a recent safeguarding incident relating to concerns about an individual discharge process and some information shared with us by health professionals and other registered providers. It should be noted that these discharges are often more complex and make up a small percentage of overall discharges from the hospital. For example, from 1 January 2014 and 31 March 2014 (from which we took our samples) there were 3,212 planned admissions and 9,891 unplanned admissions overall. Three inspectors, a specialist advisor and an expert by experience carried out the inspection. We also made follow up calls over two days to 37 nursing and residential homes, five domiciliary care agencies and four community district nurses. We asked them about the discharge experience for 45 patients who had been discharged from the hospital to these other providers in the last three months.

During our site visits we spoke to a wide range of health professionals including the Chief Nurse/Chief Operating Officer, Head of Governance, Operations Director, Operations General Manager, Occupational Therapy Project Manager and the previous project manager- Discharge Project, Head of Access and Flow, Lead for Early Supported Discharge, two consultants (urologist and lead for Hospital at Home scheme), Deputy Chief Pharmacist, Acting Deputy Chief Nurse, the Trust Lead for Patient Flow and the Project Manager of the GOOD (discharge) Project. We spent time on ten wards including medical and surgical wards and two outpatient clinics. At ward level we spoke to staff including six matrons, a student nurse, two doctors, a senior nurse, five staff nurses, a health care assistant, three occupational health therapists and a care manager. We also spoke on-site with 21 patients (not all were being discharged to other registered providers) and 12 relatives.

We found that overall the trust had themselves been focussing on discharge improvement for some time through various discharge projects. For example, the 'Discharge Olympics 2012'. This was a ward based project which focussed on timely and effective discharge planning with individual wards receiving scores based on their achievements. This had resulted in the implementation of multidisciplinary daily board rounds at ward level where each patients' discharge plans were discussed. There was evidence that work on discharge plans to drive improvement was ongoing and that investment had been made, such as in specialist discharge teams and a pilot scheme of ward based discharge facilitators. We saw that discharge planning was implemented on the wards as soon as possible following an admission and there was clear verbal dialogue between the multidisciplinary teams. There were comprehensive processes and records for managing complex discharges such as patients who had changed needs or required community care packages. For example, including the teams for 'Onward Care', 'Early Supported Discharge for Stroke', 'Short Stay Rehabilitation Service', or those who met criteria for the 'Hospital at Home' team. We also saw from a presentation and from audits that discharges after planned admissions, for example for surgery, had good outcomes for patients.

However, the tools available on some wards did not ensure that standard discharges were robust so that information would always be brought together and shared with the other registered provider. This affected some of those patients whose care needs remained stable meaning that the discharge process would be brought together by the nurse on duty at the time of discharge, rather than a specialist team. Out of 45 discharges to other providers we found that there were concerns with aspects of 14 discharges to other registered providers. For example, information about discharges was not recorded in one place on the wards meaning that the discharging nurse on the day of discharge could not always be sure that they had fully completed all the tasks required. We found there was no theme running through the concerns reported to us about discharges; the issues were that although there were comprehensive records available to ward staff, information about a patients' discharge was recorded by different health professionals in different places meaning that there was a risk that important discharge information could be missed by the discharging nurse.

We fed back our findings to the trust on 13 March 2014. They immediately brought forward a roll out trust wide of new discharge recording tools such as a discharge checklist and care plan. We saw this had already been planned for shortly after our inspection and had been discussed within the trust as items for delivery in March 2014 within meetings, for example in December 2013. We saw there were discharge audits carried out and feedback processes in place with scheduled discussions to ensure ongoing improvement that addressed the above issues.

We found the trust to be compliant with Outcome 6, Co-operating with other providers in relation to patient discharges. We were unable to check whether compliance with this outcome is sustained as the new discharge processes needed time to embed within the ward settings. However, we saw clear evidence that the trust had an audit process scheduled within a reasonable time frame.

12, 13 August and 3 September 2013

During an inspection looking at part of the service

This inspection was carried out to follow up on compliance actions made at the previous inspection in November 2012. These related to consent to care and treatment, assessing and monitoring the quality of service provision and records. The compliance actions were focussed around safe theatre practice and 'do not resuscitate' decision making processes therefore we did not speak to inpatients directly about these topics. Three inspectors visited the acute hospital site on 12 and 13 August 2013. An inspector also visited wards to speak with two relatives and two patients on 3 September 2013. We met with staff including the Chief Executive, Head of Governance, Chief Nurse/Executive Director of Service Delivery, Acting Assistant Director of Nursing for Specialised Services, Assistant Director of Nursing, a consultant, three senior house officers, a registrar and nine matrons/sisters. We spent time in general operating theatres and on nine wards including acute medicine, orthopaedics, elderly care, stroke rehabilitation and drug and alcohol specialities. In general operating theatres we met with three registered nurses, two operating department practitioners, a theatre sister, two anaesthetists, two surgeons and a healthcare assistant.

We also looked at 25 patient records in depth, looking specifically at records relating to 'do not resuscitate' decision making processes and records in general operating theatres relating to safe theatre checks. An acting assistant director of nursing also accompanied us to look at some of these records on one ward.

At our last inspection we found that some of the patient records we looked at did not show that the trust always acted in accordance with legal requirements in relation to 'do not resuscitate' orders. Following the inspection the trust sent us an action plan explaining the changes they were going to make. At this inspection we found that the trust were following their own action plan and a range of measures had been put in place to ensure on-going improvement. This included measures to ensure that the 'do not resuscitate' decision making process was more formally recorded to show that legal requirements were followed. We received further information following this inspection from the Resuscitation Lead and Senior Resuscitation Officer and found that this work was on going. Overall we saw that improvements were happening trust wide, for example audits were in place to monitor recording of capacity assessments and that where short falls in record keeping were found, action was being taken.

At our last inspection we found that records did not clearly show that all surgical checks had been performed in the operating theatres. Following the inspection the trust sent us an action plan explaining the changes they were going to make. At this inspection we found these improvements and changes had taken place or that action towards improvement was in progress.

At this inspection we visited five theatres including general theatres and ophthalmology theatres. We watched eight theatre safety checks take place. All were clear and followed the trust policy.

6, 7, 9 November 2012

During a routine inspection

We visited the Wonford acute hospital site on 6 and 7 November 2012. Four inspectors were accompanied by a specialist pharmacy inspector. We met with staff including anaesthetists, health care assistants, ward clerks, physiotherapists, chief pharmacist, specialist nurses including the new post of Consultant Nurse for older people, educational leads, operating department practitioners, registered nurses, surgeons, consultants, matrons, Head of Governance and the Chief Executive and team. We spoke with patients, staff and relatives in the accident and emergency department, pharmacy, medical admission unit, general operating theatres and maternity theatre and nine wards in a range of specialities. We also spent time observing the care in depth of 12 patients who lacked capacity on two wards and looking at records.

Overall, patients experienced care, treatment and support that met their needs and protected their rights. Patients understood the care and treatment choices available and were shown respect. Patients were asked for their consent prior to treatment and the trust acted in accordance with their wishes.

21, 23 March 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

10 November 2011

During a routine inspection

The inspection team was led by two CQC inspectors. The inspection team also included an 'expert by experience' ' a person who has experience of using services (either first hand or as a carer) and who can provide the patient perspective and we were also joined by a CQC methodology developer.

We reviewed all the information we hold about this provider and carried out a visit on 9 and 10 November 2011. During our visit we observed how patients were being cared for in 11 areas including specialist wards, general wards, theatres, outpatients and the emergency medical unit. We talked with patients who use services and their relatives, talked with staff, checked the provider's records and looked at records of patients who use services.

We interviewed staff in all areas. This included ward sisters, nurses, care assistants, a learning disability specialist, junior doctors and a consultant. We also spoke the Head of Governance and the Director of Nursing. We spoke in depth to 18 patients who were using the service and spoke briefly to several other people receiving care on the wards.

We asked the trust to provide us with evidence of how they are complying with five outcomes. This included; nursing quality assessment tools, training records for each ward specifically in safeguarding and child protection, personal development reviews for a sample of staff, personal development plans for a random sample of staff and appraisals, Audit Report on Clinical Documentation October 2011, policies on specific requirements and managing violence and the South West Hospital Standards in Dementia Care peer review site visit September 2011. We also looked at information received from the local involvement network (LINks).

All patients who were able to communicate effectively with us said that the staff explained what they would be doing to assist them and asked if it was all right before carrying out care activities. None of the patients who spoke to us had felt embarrassed or uncomfortable during their time on the wards.

All the patients commented that they would feel able to raise a concern and that they would be listened to. Where issues had been raised staff had addressed these. We saw examples of how patients had made their opinions known and that there were clear procedures to ensure that these were addressed or suggestions listened to. We also saw that a regular, comprehensive trust newsletter for staff also includes patient experience topics.

We asked patients to comment on the provision of information including care and treatment options, the risks and benefits of these. Patients spoken to said that they had been given sufficient information.

We asked if there had been any chance to be involved in discussions and if so had the staff listened to their opinions. Patients spoken to said that they had been involved in discussions about their care and that the staff listened to their opinions and information provided.

We heard that people felt well cared for. We saw excellent care delivered by staff in all areas. People were attended to by staff who were thoughtful, attentive and respectful to patients and call bells were responded to in a timely way. Staff spent sufficient time giving care.

We saw that care plans and care delivery for people who were able to communicate their needs were detailed and reflected the information on staff handover notes. Staff were able to tell us about these people's needs, being especially informed on the specialist ward where good relationships had been formed over time. Although the trust have identified that care planning and delivery of care for people who are less able to communicate for themselves requires some improvement, better practice has not yet reached all areas of the hospital which we assessed. However, this improvement is ongoing.

Staff are well supported by the trust with regular appraisals, clear mandatory training expectations and systems that ensure that staff are trained to perform their duties. Staff are particularly well informed about safeguarding issues and child protection and we saw excellent systems in place to identify these and act upon them promptly.

The trust ensures that it has a clear overview of systems and processes by identifying areas which need improvement. They are receptive to recommendations and showed that there is an excellent ethos of good quality assurance. In particular, theatres have launched a 'Better safe than sorry' campaign as part of the launch of the Safe Surgery and Interventional Procedure policy following reflective learning. Not only have staff been trained rigorously but the trust are sharing their findings with other trusts.

14 April 2011

During a themed inspection looking at Dignity and Nutrition

All patients said that the staff explained what they would be doing to assist them and asked if it was all right before carrying out care activities. None of the patients who spoke to us had felt embarrassed or uncomfortable during their time on the wards. However, two patients who are unable to take nutrition by mouth were finding it difficult being in an area where most other patients were eating. One care worker asked a patient who could not eat what they would like and then apologised but the patient told us that this often happened. Both patients said that they would like to be occupied in some way or some thought be given to them at mealtimes to make them feel less distressed during this time.

All the patients commented that they would feel able to raise a concern and that they would be listened to. Where issues had been raised staff had addressed these.

We asked patients to comment on the provision of information including care and treatment options, the risks and benefits of these. Patients spoken to said that they had been given sufficient information.

We asked if there had been any chance to be involved in discussions and if so had the staff listened to their opinions. Patients spoken to said that they had been involved in discussions about their care and that the staff listened to their opinions and information provided.

We asked the patients if the staff had talked to them about what they like to eat and if they required help with their diet. Patients did not have any complaints about the food other than that the menu was on a rolling weekly basis.

We asked the patients to describe mealtimes and received positive responses. We saw staff going around the ward before mealtime to give patients the opportunity to wash their hands prior to eating. Patients said that they were helped to eat if they needed assistance and we saw staff being attentive whilst promoting patients' independence.

Some patients were restricted to pureed or mash able food and they understood the reasons for this. We looked at the range of dishes available on the special diet menus and found them to be well thought out and presented in an appetising way.