Derriford Hospital

We inspected Plymouth Hospitals NHS Trust in July 2016 as a follow up to the comprehensive inspection that was carried out in April 2015. The follow up inspection was announced, and took place on 19, 20, 21 July and 12 August 2016. Further unannounced visits were carried out on 29 July 2016.

During the previous inspection we rated the trust as requires improvement overall. The follow up inspection therefore focussed on those areas rated previously as requires improvement and inadequate.

During our inspection we inspected the following locations:

• Derriford Hospital
• Mount Gould Hospital

We inspected the following core services against the following domains:

• Urgent & emergency services (safe, responsive and well led)
• Medical care (including older people’s care), (safe and responsive)
• Surgery (safe, responsive and well led)
• Critical care (responsive)
• Maternity and Gynaecology (safe)
• Services for children and young people (safe)
• End of life care (effective)
• Outpatients & Diagnostic Imaging (safe, effective – not rated, responsive and well led).

We rated Derriford hospital as requires improvement overall taking into account the domains we inspected this time and the domains we inspected in 2015. There had been progress in many of the areas where improvements had been required at the previous inspection. The safe domain improved from requires improvement to good for, surgery, maternity, services for children and young people, in outpatients and diagnostic imaging the safe domain had improved from inadequate to good. The responsive domain has been rated as requires improvement overall which is again an improvement on the previous inspection where outpatients and diagnostics and urgent and emergency care were rated as inadequate in 2015. Outpatients and diagnostic imaging had improved from inadequate overall to good overall. Caring was not rated as part of this follow up inspection, but was rated as outstanding overall at the previous inspection in April 2015.

Our key findings were as follows:

Safe:

• There was a positive incident reporting culture with evidence of full investigations taking place and learning being identified and shared with staff to improve safety. Staff were confident in reporting incidents although in some areas, incidents were not graded appropriately.
• Staff were open and honest with patients and their relatives when anything went wrong. We saw evidence of people receiving a sincere and timely apology and being informed about actions taken to prevent future occurrences.
• There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. All staff we spoke with had a good awareness of safeguarding legislation and many had been given prompt cards to assist them in the identification of abuse. Staff knew what to do when they suspected abuse.
• Standards of hygiene were monitored by staff with specific roles in infection control and clinical areas were visibly clean, hygienic and well organised. Staff followed trust policies regarding infection control and routinely used protective personal equipment (PPE), hand gel and regularly washed their hands. Although in some areas, sharps waste was not always disposed of promptly, and chemicals were stored in ward areas which patients had access to. Where incidences of infection were found, appropriate action was taken to control it.
• Controlled drugs were stored and checked appropriately, and allergies were clearly recorded on medicine charts. Pharmacy staff worked with staff on the wards to ensure they were aware of safe protocols and any errors were highlighted as soon as possible. Following concerns raised at our last inspection in relation to insulin prescribing the trust had set up a working group to review their policies and procedures. However, intravenous fluids were not always being stored securely and medicines were not always secured on wards where patients were able to self-administer their medicines.
• Staffing levels and skill mix were planned and implemented to keep people safe at all times and staff shortages were monitored and acted on. Managers deployed staff flexibly to cover shortfalls where possible, however in some areas, large numbers of nursing vacancies meant wards were not always staffed to the agreed level. Some gaps were identified in medical rotas and the trust was taking action to minimise the risk, for example, the introduction of doctors’ assistants had reduced the burden on junior doctors.
• The trust had set the target for mandatory training to 100%. In many areas this was being met, although in other areas, the figures ranged between 80% to 90%. Most staff we spoke with were aware of how and when to update their training, but in some areas, for example in maternity, clearer processes are required to identify the training needs of staff and compliance with those needs. Related to this, we found staff training was urgently required for emergency procedures using the birthing pool.
• Risk assessments, care plans, triage processes and the use of adult early warning scores kept people safe from the risk of harm, however, the use of a paediatric early warning score was inconsistent and did not ensure children at risk of deterioration were recognised and monitored accordingly. 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.
• In the majority of areas, care records were clear, contemporaneous, complete and signed. However in some areas, they were inconsistently completed, and for example in diagnostic imaging, not all images requiring documented evaluations had them recorded.
• Records were kept securely to maintain confidentiality and prevent tampering and were available for staff to view when required in most areas. In oncology outpatients however, we found that records were kept in unlocked trolleys in unlocked rooms overnight and on the paediatric ward, patient details were displayed on an electronic board which visitors could view, potentially compromising a child’s confidentiality. In the emergency department, computers were not always logged out to prevent unauthorised access to patient identifiable information.
• Equipment for use in an emergency was regularly checked and prepared for use in all areas. We saw in some areas that faulty equipment had been replaced; however, a number of items had not been serviced within the recommended timescales.
• Improvements had been made to the environment in the clinical decisions unit; a new helipad had opened to provide safer and direct access for patients being transported by helicopter. Some ward areas had been refurbished to meet the needs of patients who lived with dementia, and delivery suite had been partially refurbished following concerns raised during the last inspection. However, there were no plans in place to complete the refurbishments on delivery suite. The emergency department remained cramped in a lot of areas and the paediatric unit was not secure.

Effective:

• At this inspection we rated the effective domain in end of life care only which was rated previously as requires improvement.  Although we inspected the effective domain in outpatient and diagnostic imaging service we did not rate them due to the lack of national data available to the CQC.
• Patient needs were assessed and treated in line with evidenced based guidance. In outpatients and diagnostics, we saw evidence of audit to ensure that practice was monitored ensuring consistency.
• 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, there was a timescale of five two years for the plan to be completed.
• End of life outcomes were monitored against national standards.  Outcomes from previous audits had been used to make changes to patients care. There were some improvements seen from the 2016 National Care of the Dying Audit and an action plan put in place to focus on the areas which required further work.
• Ward staff had sufficient training and the ongoing support and help from the Specialist Palliative Care Team to deliver effective care and treatment. There had been an increase to seven day access to the Specialist Palliative Care Team.
• The multi-disciplinary working between the Specialist Palliative Care Team and the wider hospital and local community were outstanding. The integrated working supported continuity of care and prevented avoidable admissions to hospital.
• When people in outpatients and diagnostic imaging received care from a range of different staff, teams or services, this was coordinated well ensuring that all relevant teams were involved in the planning and delivery of peoples care and treatment. Staff discussed with inspectors how important it was to work collaboratively to meet the needs of the patient and could give us multiple examples where this was taking place.
• 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.
• In outpatients and diagnostic imaging, although most staff could access the information they needed to assess, plan and deliver care to people in a timely way there were still improvements to be made. Although the number had reduced significantly since our last inspection, there were still 2000 temporary notes in circulation meaning that treatment decisions were being made without all relevant clinical information. In diagnostic imaging although it had reduced significantly, there were still 2000 images requiring reporting on a backlog. These were being managed in a proactive way and work was still being done to reduce this.

Caring:

• At this inspection, the caring domain was not inspected because during the last inspection in April 2015, the trust was outstanding overall for caring.

Responsive:

• Urgent and emergency care, surgery, outpatients and diagnostic imaging were all rated as requires improvement and medical care and critical care were rated good.
• There was a consistent failure to meet the four-hour performance standard in the emergency department, and frequent crowding was becoming “normalised”, although the department had called a risk summit with relevant senior managers and hospital executives to raise their concerns and seek trust-wide solutions to the impact of crowding.
• The trust breached the 18-week referral to treatment target operational standard across all surgical specialties, apart from plastic surgery, from March 2015 to June 2015, when the target was abolished by the government (the operational standard is still used by the majority of trusts to monitor their performance). By February 2016, only one surgical speciality was meeting the abolished operational standard and that was plastic surgery. Performance had deteriorated to under 50% for neurosurgery. Over the entire period, all specialties except for plastic surgery performed below the England average.
• Since our last inspection in April 2015 the number of cancelled operations had risen. The percentage of patients not treated within 28 days of a cancelled operation had also risen. Due to pressure for their beds and the demand for their services, some patients had to use facilities and premises not appropriate for the services being provided. The theatre booking system had been reviewed and changes implemented, although staff told us there were ongoing issues with the theatre lists not always being finalised at 3pm the day before surgery.
• The trust had a number of initiatives to reduce the number of cancelled operations. For example, the ‘golden bed’ identified patients who could be discharged earlier to free up beds for elective operations.
• The trust had 67 patients waiting over 52 weeks for their operations, and of these 37 had not been given a date. However, the trust was working hard to reduce these and had action plans in place.
• There were long waiting times and delays for an outpatient appointment. Although significant improvement had been made some people were not able to access the services for assessment, diagnosis or treatment when they needed to due to the management of the backlog in appointments required and high levels of over referral to services. There were a total of 30,862 patients requiring follow up but a majority of these had an appointment date at the time of the inspection. However, we found there was a proactive and innovative approach to how clinic utilisation and capacity was managed. Particularly in rheumatology, psychology and breast imaging.
• The numbers of medical outliers had reduced since our last inspection as the trust had provided additional medical beds. This meant that patients received a responsive service and their access to medical staff had improved.
• The acute stroke pathway was responsive to the needs of patients and staff provided a proactive service to ensure patients were assessed and treated promptly on arrival at the hospital.
• There was not a clear pathway for patients attending the hospital for care and treatment from the cardiac catheter laboratories. The medical care group were in the process of increasing the services available to patients by the provision of a third mobile cardiac catheter laboratory.
• Information technology systems were not integrated and delayed access to some services, particularly computerised tomography within the emergency department.
• The critical care services had yet to establish the dedicated psychology service in accordance with the guidelines of the Faculty of Intensive Care Medicine core standards and NICE guidance, 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 supplying data was underway.
• Complaints were managed well within the outpatients and diagnostic imaging and critical care services and people we spoke with knew how to make a complaint. The service listened to complaints, responded to them, and used them to improve patient care and support. Lessons were learnt from complaints and were disseminated well to different teams. We saw that outcomes to complaints were explained to the complainant and always offered an apology. Patients and their relatives were included in feedback and investigations of complaints, and told when practice had changed because of their input. However, in the emergency department, complaint responses were not completed in a timely manner.
• The individual needs of patients were taken into account when planning and delivering services and patients with complex needs and learning or other disabilities were well supported. However in the emergency department, patients’ needs were not always being met, particularly in respect of mental health patients and those patients being held in the central ‘corridor’ area.
• Care was tailored to the needs of patients, and their preferences and circumstances were understood and acknowledged. This was particularly evident with the reasonable adjustments made for patients living with dementia and learning disabilities. Relatives of patients in critical care were able stay close to the hospital in purpose-provided accommodation.
• The numbers of patients experiencing multiple moves between wards had reduced since our last inspection. Patients did not experience moves late at night as frequently as at our last inspection. There had been significant improvements in the general/neurosurgical unit, which was discharging fewer patients at night, and this was continuing to improve. There were almost no patients transferred to another hospital due to lack of a critical care bed. There was a high level of flexibility and response from the teams, and patients were admitted to the units when they needed urgent and emergency care.

Well led:

• We rated well led at the trust as good overall, with urgent and emergency care, surgery and outpatients and diagnostic imaging all being rated as good.
• There was a clear statement of vision and values, driven by quality and safety. Staff were aware of the trust’s vision, values and strategy in surgery and the emergency department. However, they were not translated into a credible strategy for outpatients with limited defined objectives that were regularly reviewed and relevant. In the service line strategies we looked at, outpatients was rarely mentioned and some strategies had not been updated since 2012.
• The leadership, governance and culture promoted the delivery of high-quality person-centred care. Staff felt that senior managers were visible, approachable and accessible; they told us they felt respected and valued and spoke about an open culture.
• Governance structures and processes were being used to monitor and improve safety and quality, although in the emergency department the recording of meetings was historically inconsistent with limited information being captured, but this had improved in recent months.
• There were good governance structures, processes and systems in place throughout outpatients and diagnostic imaging to ensure accountability, the management of risk, the management of performance, and regular review to gain oversight of how the services were performing. This was particularly highlighted through the oversight and challenge of the management of the outpatients follow up backlog.
• Staff were kept informed and updated about relevant risks and the actions being taken to mitigate them, and were encouraged to share their experiences of what went well and what could be done better, although some staff felt disengaged because they were unable to stay updated or check and respond to emails while at work due to time pressures. Some innovation and improvement projects had been completed and were delivering improved services in the emergency department.
• Within the interventional radiology department, staff told us there were issues with working relationships as the roles and responsibilities of the nursing and radiology staff were not clearly defined. Not all staff within interventional radiology felt their ideas were being listened to and acted upon in relation to developing the department.
• The thoughts and ideas from staff on how the surgical care group could be improved were being listened to and the culture around incident reporting and learning outcomes had changed positively.
• Patients had various forums in which they could raise concerns and ideas including ‘tea with matron’ sessions.

We saw several areas of outstanding practice including:

• A new role had been developed within the acute medical units and the short stay ward to enable medicines for patients discharges to be prepared more efficiently. A pharmacy technician was seen to work proactively and support ward staff with monitoring the prescribing, preparation and delivery of medicines for patients being discharged.
• The access for patients to receive care and treatment on the stroke pathway had improved since our last inspection. The staff team were proactive and consistently reviewed their practice to speed up the time from patient arrival to treatment. We saw evidence of where patients had been taken straight to specific treatment areas and were in receipt of treatment in very short timescales. The staff team reviewed patient treatment pathways with a view to looking at where time could be saved and where any marginal gains could improve patient outcome.
• There had been an outstanding response from the critical care teams and the hospital trust to those areas of concern raised in our previous report. The areas we said the trust must or should improve had all been addressed. Not all were fully completed, particularly where funding was an element of the project, but there had been significant improvement in all areas to patient care, treatment and support.
• The multi-disciplinary working between the hospital and the community services providing end of life care was outstanding. There were processes in place to enable ongoing monitoring of patients in the community and where possible prevent avoidable admissions to hospital.
• The multi-disciplinary working between the hospital staff and the chaplaincy enabled the ongoing parochial and spiritual support of patients and their families at the end of life. Staff felt supported by the chaplaincy and the support provided to patients, whilst not always recorded, was creative in its endeavour to meet the needs of patients at the end of life.
• The use of prompt cards in outpatient areas to give staff easy access to phone numbers and processes involving safeguarding and the management of patients with complex needs.
• The training provided to vascular surgeon trainees by the radiologists to ensure a good understanding of the risks associated with the use of radiation.
• The use of radiologists on the critical care unit to ensure instant information to the clinicians on the unit and to have quick reporting times and added opportunities for learning.
• The use of a mobile phone application in the psychology service to assist in patient initiated contact clinics. This reduced the demand for the clinics and encouraged patients to manage their own care.
• Utilising a patient liaison radiographer to facilitate ‘first day chats’ in radiotherapy giving more time to patients and to allow the treatment radiographers to have a lessened workload and to ensure the smooth running of the radiotherapy machines.
• The audit processes used (through the fundamentals of care audit and the departmental nursing assessment and assurance framework) to gain oversight and assurance of individual outpatient clinics and diagnostic imaging areas adherence with the regulations in the health and social care act 2010.
• The pathway for patients requiring live-donor kidney transplantation in diagnostic imaging. This ensured that all pre-operative procedures (including a nuclear medicine scan, a chest X-ray, an ultrasound scan and blood tests) completed on one day.
• The diagnostic imaging department achieving Imaging Services Accreditation Scheme accreditation and having ISO accreditation recertified.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Formalise the recordings of meetings in the emergency department to ensure adequate assurance that the relevant persons are attending and discussions are held to identify learning points. Also ensure actions are recorded and allocated to a person who can progress the actions and progress is monitored.
• Review performance data in the emergency department to ensure it is accurately captured and reported, allowing adequate monitoring and scrutiny.
• Ensure safeguarding training for staff in the emergency department and across all areas is completed to ensure trust compliance targets are met.
• Ensure the paediatric early warning score is implemented fully and used consistently to ensure children are safely assessed and managed.
• Continue to work with commissioners and the local mental health service provider to ensure mental health patients arriving at the emergency department receive the care they require in a timely manner.
• Continue to ensure the emergency department’s four-hour performance improves, with an ultimate aim to achieve the 95% standard.
• Review the storage of intravenous fluids in the emergency department to prevent tampering.
• Ensure that equipment stored on wards and in corridors does not obstruct or impede the access to and through fire exits.
• Ensure all equipment in all areas, and specifically the emergency department, is maintained in accordance with the trust’s service schedule. Provide a system to adequately monitor and report on this.
• Review the available storage to patients who self-medicate and retain their own medicines on the wards.
• Make sure that medical records are stored securely overnight in the oncology outpatients department.
• Ensure audit programmes associated with end of life care carried out in line with the plan and that actions and improvements are reviewed.

• Reduce the number of clinics cancelled and capture the reasons why.

In addition Action the hospital SHOULD take to improve includes:

• Translate the vision and values of the organisation and service lines into clear, credible, and well defined objectives for outpatients which are regularly reviewed and remain relevant and achievable.
• Review governance processes within the emergency department to ensure full integration between the medical and nursing teams.
• Strengthen the nursing oversight of the whole emergency department, including majors, minors, resuscitation and the clinical decisions unit for each shift.
• Ensure incidents reported in the emergency department are correctly graded in the severity field.
• Encourage staff to report mixed-sex breaches.
• Use clearer processes in order to be able to identify and evidence, at all times, the percentage of staff across the trust who were compliant with mandatory and role specific training. This would also provide greater safety assurance at service line, care group and trust levels that governance information was reliable and valid.
• Ensure that all wards and departments are adequately staffed.

• Review why surgery has the most complaints

• Consider staffing allocation to allow for management and supervision from senior staff in all paediatric areas.

• Review the arrangements for speech and language accessibility over the weekend to ensure that patients do not remain nil by mouth as a result of waiting for a swallowing assessment.
• Plan to risk assess the impact of the location of the proposed cardiac catheter laboratory, reflecting on the patient journey and pathway.
• Review the environment regarding the safety of patients admitted to wards and departments living with mental illness and especially with the risk of self-harming.
• Continue with the action plan to reduce their referral to treatment times in all surgical specialities.
• Continue to look at ways of reducing the number of cancelled operations and the numbers not re-booked within the 28-day time scale.
• Continue to look at ways of reducing the number of patients who have been waiting for operations longer than 52 weeks.
• Ensure that theatre lists are finalised at 3pm the day before the operations are due to take place.
• Continue to make improvements on the follow up backlog waiting list to meet people’s needs and minimise risk and harm caused to patients through excessive waits on follow up of outpatient appointments and excessive waits on the reporting of images.
• Put process in place that ensure all diagnostic imagines that required documented evaluations have one.
• Review the paediatric unit in the emergency department to ensure it is adequately secure to keep children safe.
• Ensure patients in the minors’ waiting area in the emergency department are observed so any deterioration can be quickly responded to.
• Ensure all patients awaiting X-ray in the emergency department who are not escorted have access to the portable call bell in accordance with the department’s standard operating procedure.
• Ensure patients arriving at the emergency department by ambulance are protected from the elements as best as possible.
• Review the transfer team in the emergency department to ensure that when patients are transferred to a ward a clinically safe handover is completed in all cases.
• Review the hospital’s procedure for crowding in the emergency department to include the actions required by the wider hospital in order to support safe patient care.
• Review plans to increase the space in the emergency department to consider how crowding can be reduced and patient flow improved within current financial constraints.
• Progress the work to install an adequate area for the preparation of medicines in the resuscitation area of the emergency department.
• Ensure wasted controlled drugs in the emergency department are disposed of in accordance with trust policy.
• Ensure that medicine trolleys are not left unattended when unlocked and that medicines are secured at all times.
• Ensure height and weight measurements of children are readily available for staff prescribing medications.
• Ensure only current medicine guidance is available in all paediatric areas.
• Review and upgrade computer systems in the emergency department to allow integration with wider hospital systems.
• Ensure computer records are adequately secured when computers are left unattended to prevent unauthorised access.
• Ensure that patient records are consistently completed and are kept up to date.
• Ensure patient details in children’s and young people’s services are kept confidential and that only authorised personnel are able to access details of care.
• Ensure that where registered nurses were required to countersign the work of health care assistants this is consistently carried out.
• Ensure that all chemicals are secured and not accessible to patients and visitors to wards and departments. Clinical waste including sharps bins should be sealed and dated correctly and removed from the wards promptly.
• Review the layout of wards which had six beds to a bay as in some areas this impeded access to hand washing facilities and clinical waste bins thus potentially compromising the control and prevention of infection.
• The maternity services should ensure the birth pool cleaning policy demonstrates compliance with any manufactures guidelines and recommendations and incorporates any further recommendations from the trusts infection control lead.
• Review the signage for the ambulatory care unit as it was not clear from the main hospital corridors.
• Ensure staff in the emergency department all have name badges which include the role they are in. Consideration should also be given to providing patients with a leaflet that details the different types of uniforms and what they designate.
• Make sure chemicals and substances that are hazardous to health are secured and not accessible to patients and visitors in the Fal unit sluice area.
• Make sure the resuscitation trolley and equipment identified in theatres as needing service in April 2016 is now serviced.
• Make sure the equipment log is up to date with all servicing of equipment.
• The oxygen cylinder for use in emergencies, kept at the Child Development Centre, should be portable and safe for staff to move.
• Make sure that all staff ideas are listened to and reasons given if they cannot be actioned.
• Continue to pursue (with clinical commissioning groups) the development of a dedicated service in line with NICE guidance CG83 to support patients and those close to them in both general/neurosurgical and cardiac critical care with their psychological and psychosocial needs.
• Complete progress to allow the cardiac critical care service to contribute to the Intensive Care National Audit and Research Centre in order to obtain and learn from valuable benchmarking against other similar units.
• Ensure all patients in the cardiac critical care unit are able to see a clock from their bed.
• Improve the trust website so it has helpful and important information about the critical care services at the hospital.
• Should complete all outstanding refurbishments required on the delivery suite. This includes the remaining nine birth rooms, and the bathrooms and toilets which were shared between patients.
• Should clean the windows on the delivery suite.
• Should provide more equipment to promote normalising birth and movement during labour and to aid pain relief.
• Consider how to raise an alert to potential safeguarding issues if parents or their children do not book appointments that have been professionally advised.
• Consider how they manage and mitigate the risk to lone workers.
• Consider in-house provision of physical intervention trainers to ensure appropriate staff in the children and young people’s service are fully trained.
• Ensure that local audits for the ‘Last days of Life Care Plan’ are put in place to provide evidence or any changes needed in practice.
• Ensure the ongoing completion of plans in place to develop rooms for privacy for patients at the end of life and suitable environments for private discussion and the delivery of bad news.
• Ensure improvements identified by the  end of life 'quality improvement in the environment' project have timescales for completion which will enable patients and families to have a better experience

Professor Sir Mike Richards

Chief Inspector of Hospitals