Derriford Hospital

Updated 8 March 2023

Pages 1 and 2 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 Derriford Hospital.

We inspected the maternity service at this 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.

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.

University Hospitals Plymouth NHS Trust manages the maternity services at Derriford Hospital. The maternity unit comprises of a central delivery suite, combined ante- and postnatal ward, day assessment unit and maternity triage unit, as well as midwife and consultant-led clinics, fetal medicine and scanning services. The hospital also provides community midwifery services.

From 1 September 2021 to 31 August 2022 there were 3,692 babies born at the hospital.

This focused inspection reviewed the domains of safe and well led using CQC’s established key lines of enquiry (KLOES).

How we carried out the inspection

The inspection was carried out using a post-inspection data submission and an on-site inspection where we observed the environment, observed care, conducted interviews with patients and staff, a review of hospital policies, and review of care records and documentation. Following the site visit we conducted interviews with senior leaders and reviewed patient feedback about the trust made directly to CQC via our routine enquiries process.

We visited the clinical areas of the labour ward, triage, maternity day assessment unit, clinics, fetal medicine/scanning and the ante- and postnatal ward.

We spoke to 20 staff, and to senior leaders and specialists to better understand what it was like working in the service. We spoke to midwives, obstetric staff, support workers, practice development midwives, and the patient safety team.

We interviewed leaders to gain insight into the trusts group leadership model and governance of the service.

We attended ward handovers, safety huddle meetings, and a situation and risk meeting.

We spoke to 5 women and families who were currently being cared for by the trust to gain insight into their experience of care. We also received in excess of 100 online enquiries from women and families who had received care at Plymouth Hospitals’ NHS Trust in the previous few months.

We reviewed 5 sets of maternity records and 8 prescription charts.

We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments, recently reported incidents and audit results.

After the inspection we requested further documentary evidence to support our judgements including policies and procedures, staffing rotas and quality improvement initiatives.

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

Updated 21 December 2022

Updated 25 November 2016

We have rated the safety of services for children and young people as good because:

• There were processes to report incidents with details of full investigations having been completed where appropriate. Learning points were shared with staff. Staff were confident in reporting incidents and always received feedback on progress of the investigations. Staff described being open and honest with patients and their relatives when anything went wrong.
• Standards of hygiene were monitored by staff with specific roles in infection control and areas we visited were visibly clean. Where incidences of infection were found, appropriate action was taken to control it.
• Medicine storage, prescribing and administration was managed to ensure children and young people received the correct medicines at the correct time. Pharmacy staff worked with staff on the paediatric wards to ensure staff were aware of safe protocols and any errors were highlighted as soon as possible.
• Children’s weights were available in most cases for staff to prescribe appropriately.
• Safety audits were viewed by the management team to identify areas where practice needed to be improved with actions for monitoring progress.
• Records were kept securely to maintain confidentiality for the patient but were available for staff to view when required.
• Staff were aware of safeguarding processes and knew how and when to ask for supervision or support.
• Risks to patient safety were identified and reported to senior managers and actions were taken where possible. The last inspection had highlighted concerns over observations of oncology patients following cancer treatment procedures. Delivery of care to these patients had been reorganised and observations were now happening. Risks for children and young people who may harm themselves had been assessed and reduced by adapting the facilities and environment. For example, a room had been identified that was safe for young people to stay in and calm down and ligature risks had been removed. This room also protected children from witnessing disturbing behaviour.
• Emergency equipment appropriate for all ages of children and young people was available for use.
• Numbers of appropriately qualified staff on the ward areas we visited met the levels set out in national guidance. Managers achieved this by using staff flexibly across the paediatric areas. Staffing levels were monitored using a tool to assess how many staff were required to provide care for the number of patients and the level of care they needed.
• Medical staff ensured there were enough senior staff to provide expertise and advice for paediatric care. Medical staff were also providing specialist safeguarding clinics five days a week.
• The community paediatrics team provided a safe multidisciplinary and multiagency service for children and young people who required assessment, support and intervention to ensure their wellbeing and development.
• Services were provided in a child friendly environment by a highly skilled workforce at the Child Development Centre and by the children’s community nursing service. When clinically required, a visit was carried out at a child’s home, nursery, school or other locality setting. This minimised the need for multiple appointments, and duplication of history-taking and documentation.
• Following the last inspection there were concerns with regard to the insufficient number of child assessments and care plans that had been completed in the children’s community nursing team. During this follow up inspection we found the issues had been resolved and patient records were maintained and monitored.

However:

• Safeguarding update training for staff was at 91% which was not compliant with the 100% trust target. There were plans to enable staff to attend this training.
• Mandatory training for staff in one subject area was 80% which was below the trust target level of 100% compliance, although staff we spoke with were aware of when and how to update their training.
• Two pieces of equipment we saw indicated they had not been serviced within recommended timescales.
• In one area we visited there was an out of date Children’s British National Formulary alongside the current version creating a risk of staff using outdated prescribing information.
• Patient details were displayed on an electronic board where visitors could view it which could compromise a child’s privacy.
• Children and young people needing more intensive support from child and adolescent mental health services were cared for on the ward until a bed became available.
• An oxygen cylinder for emergency use in a community setting was not easily portable.

Updated 25 November 2016

We have rated the responsiveness of the critical care service as good because:

• The services were planned and delivered to meet people’s needs and co-existing conditions. The services met with local clinical commissioning groups to plan, evolve and improve their services.
• There were arrangements for relatives to stay close to the hospital in purpose-provided accommodation. They had access to facilities, including food and drink, and extensive information in bedside folders about all services within the hospital and the wider community.
• In accordance with specialist guidance, a consultant reviewed patients in both the critical care units within 12 hours of their admission.
• A productive and efficient working relationship had been established between the general/neurosurgical critical care team and the bed management team. This had brought the issues affecting critical care more to the fore and improved access and flow for patients. Cardiac services had been reconfigured to improve delays, access and flow.
• The general/neurosurgical unit had made good progress to reducing the number of patients discharged at night. This was continuing to improve.
• There had been significant progress in reducing the delays in discharging patients from the general/neurosurgical unit. The results showed the unit was now below (better than) the average for similar units for delayed discharges.
• There had been productive consultations between medical teams, and improvements and adaptations to operating theatre lists to help with access and flow in the general/neurosurgical unit. This had led to new efficiencies and reduced the number of operations cancelled due to lack of a critical care bed. There had also been work undertaken to adapt clinical pathways in cardiac services, and find alternatives to admission to critical care.
• There were almost no patients transferred to another hospital due to lack of a critical care bed. There had been a high level of flexibility and response from the critical care teams to enable almost all patients to be admitted to the units when they needed urgent and emergency care.
• The individual needs of patients were taken into account and patients were well supported. Care was tailored to the needs of patients, and their preferences and circumstances were understood and acknowledged.
• Complaints were listened and responded to, and used to improve patient care and support.
• Patients and their relatives were included in feedback and investigations of complaints, and told when practice had changed because of their input.

However:

• The critical care services had yet to establish the dedicated psychology service, although had made good progress with commissioners, and already obtained partial funding for the new services.
• The cardiac critical care unit had yet to contribute to the Intensive Care National Audit and Research Centre in order to obtain and learn from valuable benchmarking against other similar units. This had been recognised, and work towards producing data was underway.

Updated 18 December 2019

• Safe, responsive and well-led were rated as requires improvement. Caring was rated good. Effective was not rated.

• Compliance with mandatory training did not meet trust targets. Staff did not always follow trust policies and national guidance for the prevention and control of infections. There was still ageing equipment past their end of life which broke down and meant there were delays or cancellations of diagnostic imaging procedures. There were not enough staff to meet the demands of the service.

• The needs of local people were not always met. Some patients had to wait longer than intended to receive diagnostic imaging procedures. The service did not meet its internal two-week cancer target performance, but there was improvement across all modalities. The service did not meet the six-week national standard for diagnostic tests, although there was some improvement. There were not enough consultants to report on images to meet demand.

• There were unfilled vacancies in middle management positions and there was no clinical lead at the time of our inspection. There was a lack of experienced leaders in some modalities to lead teams efficiently. Leaders were not given non-clinical time to support junior staff and service improvement initiatives. There was no overall vision and strategy for the development of diagnostic services although, there was a clear equipment and workforce strategy to help improve the service. Senior leaders did not feel the service was valued and supported by the trust. Some staff felt they were not valued for the roles they carried out. However, the culture within the service was improving and staff worked well together as teams.

  However:

• Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved good outcomes for patients. The service made sure staff were competent for their roles and managers appraised staff’s work performance. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

• Staff treated patients with compassion and kindness and took account of their individual needs. Staff provided emotional support to patients, families and carers to minimise their distress.

Updated 25 November 2016

We have rated the service as good for effective because:

• Patient needs were assessed and treated in line with evidenced based guidance. Pain management and the management of nutrition and hydration was assessed, managed and recorded to ensure patients at the end of life were comfortable.
• Following the previous inspection a local quality improvements in environment project had been undertaken. Areas of improvement were planned, for example single rooms available for privacy for patients at the end of life. The timescale for completion was two years.
• End of life outcomes were monitored against national standards. Outcomes from previous audits had been used to make changes to patients care.
• Ward staff had sufficient training and the ongoing support and help from the Specialist Palliative care Team to deliver effective care and treatment. Access to the specialist palliative care team had increased to seven days a week.
• The multi-disciplinary working between the Specialist Palliative Care Team and the wider hospital and local community were outstanding. The integrated working supported a continuity of care and the prevention of avoidable admissions.
• Improvements were seen in the completion of the Treatment Escalation Plans (TEP) but auditing of improvements was not yet fully completed. The management of Deprivation of Liberty safeguards ensured the safety of patients.

Updated 8 March 2023

Updated 15 August 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. We rated it as good because:

• There were well established links with the onsite mental health liaison team to help protect vulnerable patients.
• Risks to patients were assessed monitored and managed in line with national legislation and guidance.
• Most environments and equipment in the outpatient department kept people safe from harm and were visibly clean.
• Techniques used to ensure cleanliness were in line with national quality standards.
• Medicines were managed in line with national guidance and legal requirements, and we saw improvements made as a result of audits.
• There was a good incident reporting culture and openness and transparency was encouraged.
• Staff understood their responsibilities to raise concerns and report incidents, and we saw evidence of action taken when as a result.
• Patients’ care and treatment was planned and delivered in line with current evidence based guidance, and audits were carried out to ensure practice was monitored.
• Staff were suitably qualified and had the skills to carry out their roles effectively, and the learning needs of staff were identified through appraisals.
• When people received care from a range of different staff, teams or services, this was coordinated well, ensuring all relevant teams were involved.
• Staff understood how important it was to work collaboratively to meet the needs of the patient.
• Patients’ privacy and dignity was respected in all aspects of care throughout the outpatient department.
• Staff took the time to interact with patients and their relatives or carers, and were kind and helpful.
• Staff understood the impact of the treatment/diagnosis on patients’ emotional wellbeing and actively supported patients.
• Staff could signpost patients to relevant support services and groups.
• Staff communicated with patients so they understood the treatment they received and what was going to happen next.
• Services used a proactive and innovative approach to how clinic utilisation and capacity was to be planned in the future.
• The needs of different people were considered with the reasonable adjustments made for patients living with dementia and learning disabilities.
• The environment was equipped to manage the specific needs of patients and training had been rolled out to all staff.
• Complaints were managed well within the outpatient service and most people we spoke with knew how to make a complaint. Lessons were learnt from complaints and were discussed within governance meetings and with staff.
• Patients could make appointments through a system which offered choice and convenience.
• There was a clear strategy for outpatients with defined objectives that were regularly reviewed and relevant to the current and future challenges services faced.
• There were good governance structures, processes and systems throughout outpatient departments to ensure accountability, the management of risk, the management of performance, and regular review to gain oversight of how the services were performing.
• The leadership team in the outpatient department were supportive of their staff and had the knowledge, skills, experience, and time to manage their services.
• Leadership had good oversight of the quality of care. We saw the positive impact audits had on individual outpatient areas.
• Staff and patients continued to be engaged in how care was delivered, and felt they were active contributors. Patients had various forums in which they could raise concerns and bring ideas.
• Leaders and staff strived for continuous learning, improvement and innovation.

However:

• Not all medical staff in outpatients were up to date with their required mandatory training, including safeguarding training.
• The environment and space within some clinics and their waiting areas remained an issue and some areas did not have sufficient seating.
• We found unattended records in an unlocked room in the Royal Eye Infirmary.
• Most services were not available seven days a week, mostly due to staffing and capacity issues, however this was a key target of the newly developed outpatient strategy.
• There were long waiting times and delays for some outpatient appointments. Although improvements were being made, some patients were not able to access services for assessment, diagnosis or treatment when they needed to.
• The outpatient department was not meeting the national target for cancer waiting times for two-week-wait urgent patients or for 62-day pathway patients, although improvement plans had been developed.

Updated 18 December 2019

Our rating of this service went down. We rated it as requires improvement because:

• We rated safe, effective, responsive and well-led as requires improvement. We rated caring as good.

• The trust’s target for updating key skills through completion of mandatory training was not met by all staff groups. Risk assessments for venous thromboembolism were not always carried out. The service did not always have enough nursing and support staff with the correct skill mix to keep patients safe from avoidable harm and to provide the right care and treatment. The staffing tool used to determine staffing levels was not appropriate for all patients. Records were not always stored securely. Not all specialities were achieving the trust’s target for compliance with the World Health Organisation’s surgical safety checklist.
• The service was performing worse than comparable trusts and/or failing to meet national standards against many of the measures in national clinical audits. The trust’s appraisal target was not met by all staffing groups.
• Premises did not always meet the needs of patients. People could not always access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were mostly above (worse than) national standards. The percentage of operations cancelled as well as the percentage of operations cancelled and not rebooked within 28 days was consistently above the England average.
• Governance processes were not always effective, and staff were not always clear about their roles and accountabilities. The service did not always collect reliable data and analyse it. Data or notifications were not always consistently submitted to external organisations as required. There was not always effective participation in and learning from internal and external reviews. Operational pressures adversely affected staff well-being and development. Morbidity and mortality review minutes were not standardised across the service, thereby limiting the ability to use these minutes to share learning across the care group.

However:

• Staff knew how to identify adults at risk of actual or potential abuse and how to report it. The service used systems to identify and prevent surgical site infections. Staff were clear about the processes they should follow to risk assess patients and respond to those who may deteriorate. The environment and equipment mostly kept people safe. The service managed patient safety incidents well and staff were clear on how to report incidents.
• There was effective care within surgical services. The service provided care and treatment based on national guidance and evidence-based practice. Doctors, nurses and other healthcare professionals worked together as a team to benefit patients. Staff gave patients practical support and advice to lead healthier lives.
• Care was provided to patients which was compassionate. Staff supported patients to make informed decisions about their care and treatment.
• The service met the needs of individuals. Care was planned to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. Staff felt respected, supported and valued. Leaders operated effective governance processes and managed risk, issues and performance well. Leaders and staff actively engaged with patients, staff, the public and local organisations to manage services. All staff were committed to continually learning and improving services.

Updated 21 December 2022