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Mount Gould Hospital Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 25 November 2016

We inspected Plymouth Hospitals NHS Trust as part of our programme of comprehensive inspections of all acute NHS trusts between 19 and 21 July 2016.

This inspection was a follow up to the comprehensive inspection covering the domains of safe, effective, responsive and well led.

During our inspection we inspected the following locations:

  • Derriford Hospital
  • Mount Gould Hospital

We rated Mount Gould Hospital as requires improvement overall, with improvements needed in the responsive and well led domain. Caring was not rated as part of this follow up inspection, but was rated as good on the previous inspection in April 2015 and has been included in the overall rating.

Our key findings were as follows:

  • The systems and arrangements for reporting and responding to governance and performance management data had improved but still did not effectively monitor and record risks and incidents.
  • The trust’s target of 100% for compliance with mandatory training for safeguarding of children was met, and staff were able to confidently describe their responsibilities in respect of the Mental Capacity Act 2005.
  • For some patients, access to new and follow-up appointments were delayed by an ongoing recognised backlog of appointments; however this had reduced since the last inspection. Also, a typing backlog of clinic letters was causing further delays for patients.
  • There was no centralised monitoring of safety issues in remote clinics, although leaders visibility and engagement had improved on a local level.
  • Patients were cared for in a clean and hygienic environment, and there were systems in place to reduce the risk and spread of hospital acquired infections, however, results of audits were not shared with all staff.
  • There were improved practices in respect of the management of prescription forms and the trust’s policy for the custody of the medicines keys which kept patients safe.
  • The systems and data used to monitor reasons for the short notice cancellation of clinics were not accurate or robust.

We saw several areas of outstanding practice including:

  • The results from programmes of audit in some specialities were being used to develop and improve services for patients.
  • Strengthened working relationships in both clinical and administrative teams had led to further improvements in the delivery of outpatient services across the trust.

However, there were also areas of poor practice where the trust must;

  • Reduce the number of clinics cancelled and capture the reasons why.
  • Reduce the numbers of patients waiting past their to be seen date.

In addition, the trust should consider:

  • Reviewing and sharing cleaning audits carried out by external companies.

  • Reviewing its systems and process which give assurance that services delivered by external companies are carried out in a way that keeps people safe.
  • Reviewing secretarial staff numbers to help clear the typing backlog of Mount Gould clinic letters and ensure the digital dictation system is fully implemented.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas



Updated 25 November 2016


Insufficient evidence to rate

Updated 25 November 2016



Updated 25 November 2016


Requires improvement

Updated 25 November 2016


Requires improvement

Updated 25 November 2016

Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 25 November 2016

  • Some staff were still not receiving feedback from incidents.

  • Staff incident reporting was the only safety indicator used by some senior managers.

  • Cleaning audits carried out by Livewell were not shared with staff.

  • Some diagnostic imaging protocols were out of date and referred to out of date practice.

  • Staff were unsure how information about patients additional needs was gathered.

  • A backlog of typing in some specialties was having a knock on effect to other specialties.

  • The pain management service sometimes had more patients booked than it had capacity.

  • Some specialties still had DNA rates above the England average.


  • Senior staff provided guidance and support to junior staff to help them report safety incidents.

  • Regular hand hygiene audits in pain management fed results directly back to monthly governance meetings.

  • The number of temporary notes had reduced, and audits were being carried out.

  • A new system of monitoring FP10 had been introduced.

  • A pharmacy review of medicines had removed unused medicines from the pain management outpatients, and regular pharmacy visits had increased their visibility to staff and strengthened relationships.

  • Diagnostic reference levels had been implemented.

  • Patient outcome audit results had been presented nationally, and a senior nurse sat on the NICE board.

  • External organisations had been approached to help develop new policy documents.

  • Pain management planned some of its treatment to suit the needs of the patients.

  • Large notice boards displayed patient centered information.

  • A new reporting structure in the bookings team had helped develop a live clinic booking system, and work was being done to maximise the clinic use through overbookings.

  • Overall, the DNA rate in outpatients and pain management had improved, and less than 1% of diagnostic imaging patients DNA.

  • Pain management and ENT collected friends and family test data to continually improve services for patients.

  • There was strong leadership in the pain management service and good working relationships in the bookings team.

  • Staff fed and understood how audits fed into the overall governance framework.

  • One central equipment register in diagnostic imaging helped plan the future capital replacement program.