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.

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.

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.