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Derriford Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 August 2018

Our inspection of the trust covered only this hospital. What we found is summarised above under the sub-heading Overall trust.

Inspection areas

Safe

Requires improvement

Updated 15 August 2018

Effective

Requires improvement

Updated 15 August 2018

Caring

Outstanding

Updated 15 August 2018

Responsive

Requires improvement

Updated 15 August 2018

Well-led

Good

Updated 15 August 2018

Checks on specific services

Maternity

Requires improvement

Updated 15 August 2018

We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. We rated it as requires improvement because:

  • Not all staff had completed mandatory training including emergency procedures, which is designed to give staff the knowledge and skills to keep people safe.
  • Throughout maternity services, we found equipment which had not been cleaned, checked or maintained to ensure it was safe to use; this included equipment used in an emergency.
  • We could not be assured that medicines were managed properly to ensure secure storage, or integrity of the product.
  • Patient Group Directions (PGD’s) were not managed in accordance with National Institute for Health and Care Excellence (NICE) Medicine Practice Guideline for PGD’s issued in August 2013.
  • Records were not always stored securely or filed appropriately to produce a complete account of a woman’s maternity care.
  • Risk management processes did not capture threats to the service and were not always measured appropriately. This resulted in a lack of oversight for those responsible for the performance of the service.
  • Governance processes, involving the timely review of clinical documents and their control, were not robust enough to ensure the latest evidence based practice was integrated into policies and procedures.
  • New roles and practices, for example obstetric nurses were not assessed or evaluated to understand the potential risks to patient safety and how these may be managed.
  • We were not assured midwives working in the High Dependency Unit had been assessed as competent in the skills required to care for a seriously unwell woman.

However:

  • There was evidence of exemplar multidisciplinary relationships between all staff groups across the maternity service. Teams worked effectively together to create a supportive and open culture which included colleagues employed by other services. All staff told us they felt valued and respected.
  • Patient outcomes were monitored to identify areas for improvement.
  • Staff at all levels had a caring and compassionate approach to patients who spoke highly of the care they received.
  • The trust planned services to meet the needs of the population it served. They were in the process of re-evaluating provision to see how this could be improved.
  • Women had access to the maternity services 24 hours a day, seven days a week.
  • Mental health and wellbeing was continuously assessed and support was accessible when needed.
  • Staff offered sensitive and compassionate support to bereaved women and their families.
  • The medical rota provided onsite obstetricians 24 hours a day and avoided the use of temporary staffing.
  • We found examples of continuous improvement for effective discharge and bereavement support.
  • Staff could suggest ideas for improvement and make changes.

Outpatients

Good

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.

Medical care (including older people’s care)

Requires improvement

Updated 15 August 2018

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

  • Areas used for escalation at times of high operational pressures where not always suitable and safe for patients and staff overnight.
  • Risk assessments for venous thromboembolism (VTE) were not always completed in a timely manner. This was not in accordance with national guidance.
  • The sepsis protocol and care bundle was not used consistently across inpatient wards. Not all staff could remember if they had received training on sepsis. However, staff were aware of signs and symptoms of sepsis.
  • Intravenous fluids given to patients receiving haemodialysis were not always prescribed before they were administered. Patients’ blood pressure may drop during haemodialysis for which intravenous fluids are given. These fluids were given via the dialysis machine and not always prescribed and given in accordance with national guidance.
  • Nursing staffing levels did not always meet the acuity and dependency of patients on inpatient wards. The medical care group has seen an 8% increase in patients admitted to hospital but the planned staffing levels had not been increased in line with the increased activity.
  • Medical staff did not always meet required staffing levels. There were vacancies at all levels including consultant vacancies.
  • Training compliance for medical staff in mental capacity act and deprivation of safeguards liberty was 59.5% against a trust target of 95%. Mental capacity assessment forms were not always correctly completed, which meant mental capacity assessments were not always fully completed.
  • Deprivation of liberty safeguards (DoLS) were not always completed. This was not in accordance with the Cheshire West Supreme Ruling (2015).
  • Some clinical guidelines on the trust intranet had exceeded their review date, which meant staff could not be assured they reflected current and most up-to-date guidance.
  • There were not enough medical beds to meet the demand of medical admissions to the trust. The systems to promote patient flow were effective, but the increasing demand outweighed the capacity available within the trust.
  • Processes to ensure discharge from hospital for those patients medically fit to leave were not always effective. There was a high number of patients medically fit for discharge who were unable to leave hospital.
  • There was a high number of patients who were remained in hospital for more than seven days. These patients are known as ‘stranded patients’. These patients occupied between 41% - 44% of the total number of beds in the hospital at the time of our inspection.
  • There was not sufficient scrutiny and challenge of mortality figures to provide assurance of adequate overview of mortality within the medical care group.
  • Not all staff felt able to raise concerns without the fear of retribution.

However:

  • The medical care group had a good safety record. Staff were aware of, and adhered to infection prevention and control measures.
  • Medicines were stored safely. Medicine fridge temperatures were monitored daily and medicines waste was managed well.
  • There was a good incident reporting culture. Incidents were investigated and actions for learning were identified and shared with staff.
  • Patient outcome data was similar to the national average. The medical care group submitted data to national patient outcome audits which demonstrated performance was similar to the national average.
  • Staff assessed patients’ nutritional and hydration needs in line with national guidance. There were different diets to meet patients’ nutritional needs.
  • There was effective multidisciplinary team working across all wards and departments.
  • Staff cared for patients with compassion and took time to interact and listen to patients and their relatives.
  • Staff sought feedback from patient and gave examples of changes made in response to feedback.
  • Staff assessed patients’ individual needs. Staff made reasonable adjustments to ensure all patient needs were met.
  • Leaders and ward managers had the skills, knowledge, experience and integrity to lead teams effectively. The trust had recently introduced a leadership and talent strategy.
  • Most staff felt supported, respected and valued. All ward managers and matrons stated they were proud of their staff, their hard work and commitment to provide high quality care to patients.
  • There were processes and systems of accountability to support the delivery of good quality and sustainable services. There was a formal governance structure within the medical care group, which helped to ensure effective governance.
  • There were arrangements for identifying and managing risks. We spoke with ward/department managers and leaders and found that personal concerns about risks were aligned with those risks added to the risk register.

Diagnostic imaging

Inadequate

Updated 15 August 2018

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

  • Patients were frequently and consistently unable to access services in a timely way. There were substantial waiting lists and inpatient scans were frequently delayed.
  • There were unacceptable waits for some patients for imaging and reporting. This included patients suspected of having cancer.
  • Leaders did not have the necessary capacity to lead effectively. This included both with service management and team leadership.
  • There was no credible statement of vision.
  • There was detailed oversight of risks, but limited capacity to plan and act upon risks. This led to ineffective risk management and the increase for potential risks to become an actual incident.
  • The governance arrangements and their purpose were unclear and there was a lack of clarity about how decisions were made and how individuals were held to account.
  • There were low levels of staff satisfaction and high levels of work overload. Staff did not feel valued, supported, or appreciated by the rest of the trust.
  • Some equipment in the diagnostic imaging department was several years beyond its ‘end of life’ date which increased mechanical risks in the department.
  • There were shortfalls in how the needs of patients were addressed in some areas. Particularly computed tomography (CT) and plain film X-ray.
  • Staff treated patients with dignity as best they could. However, the design of the imaging department did not always protect people fully.
  • Outcomes for patients had varied results for the MRI hip fracture audit, the trauma audit and stroke audit.

However:

  • Feedback from patients and those close to them was positive about the way staff treated patients. Patients told us they were treated with dignity, respect and kindness.
  • There were many examples of staff speaking compassionately with patients and supporting their needs, despite recognising the busy working environment.
  • Openness and transparency about safety was encouraged, particularly around the learning following a never event.
  • Risks to patients who use services were mostly assessed, monitored and managed well on a day-to-day basis.
  • Most staff had received up-to-date training in all safety systems, processes and practices.
  • All staff had the skills, experience, and qualifications needed to effectively perform their role.
  • People’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
  • Patient outcomes within the ultrasound service were positive.

Urgent and emergency services (A&E)

Requires improvement

Updated 15 August 2018

  • The department was not designed to safely manage the numbers of patients that regularly attended. There was frequent crowding and the use of the corridor area prevented fast and easy movement through the department. There was insufficient equipment available to monitor the number of patients in the department, visibility of patients in the corridor was poor, and there was a risk to deteriorating patients being missed as a result.
  • The resuscitation area was too small to enable the required equipment and staff to easily work, especially in the event of major trauma, and to accommodate the numbers of patients requiring resuscitation facilities. The four-bedded resuscitation area was frequently full, and patients were moved out of resuscitation before staff felt this was clinically appropriate because the space was needed for other patients who were more unwell.
  • The paediatric department doors were not secured, meaning unauthorised persons could gain access or children could leave without being challenged. There were also unprotected electrical sockets within reach of children.
  • While staff understood their responsibilities to report incidents, there was often limited time to do so and longstanding issues were often not reported because staff didn’t believe action would be taken.
  • Patients waiting for X-rays were unattended, unobserved, and left with no means of calling for help. We found a patient with dementia in a distressed state and trying to pull out a needle in the back of their hand, which a family member of another patient had to stop.
  • Staffing in the department was not sufficient to safely manage the numbers of patients at all times. This was particularly evident during the regular periods of crowding.
  • Receptionists were not trained to recognise seriously unwell patients and were not provided with any guidance to help them recognise ‘red flag’ signs and symptoms.
  • The department was not using an early warning score system for adult patients and observations were not being recorded regularly. Staff used their discretion to determine how often observations should be completed, but we found significant gaps in the records we reviewed.
  • Patients suspected of having sepsis were not always treated with antibiotics within 60 minutes.
  • Pain relief in majors was not always provided in a timely way, and pain scoring was not consistently completed in observation charts.
  • There was mixed performance for treating patients against national standards, for example in the case of asthma and sepsis some standards were worse when compared nationally, while other standards such as vital signs in children and procedural sedation were either better or in line with national standards.
  • Yearly appraisals were not completed in line with the trust’s target for any of the staffing groups working in the emergency department.
  • It was not possible to easily recognise the roles of each team member during a trauma call because staff did not always wear the correct tabards.
  • Capacity assessments and consent was not always clearly recorded in patients’ notes.
  • There were times when patients’ privacy and dignity was not maintained, usually due to the high workload staff were managing and the design of the department.
  • The privacy of patients arriving by ambulance was not maintained because there was nowhere private for the handover of confidential information to take place.
  • There was no protection from the weather for patients arriving by ambulance or being dropped off by car outside the department.
  • Patients with mental health conditions were required to wait with other patients in the busy department because there were not any dedicated facilities, apart from an assessment room.
  • Flow through the department was slow and patients often waited long periods of time before they were admitted, transferred or discharged. The department had failed to meet the four-hour standard during the previous 12 months and was consistently performing below the national average.
  • Escalation processes in response to high demand and crowding were slow to provide additional support and often had little impact.
  • Team meeting minutes generally lacked detail and only captured brief notes about the areas of discussion. These meetings did not have action trackers so there was no central oversight of progress against required actions.
  • Control measures for several risks did not appear to be having the intended outcome and as a result these risks remained a significant concern.
  • Confidential patient information was not always given the care it required. For example, we found a list of patient names and hospital numbers alongside their pregnancy test results in an unattended, unobserved room in a public corridor.
  • There were limited means of public engagement and feedback from the public was not actively sought.

However:

  • Although mandatory training compliance was below the trust’s target of 95%, most staff were up-to-date with mandatory training.
  • Staff understood their safeguarding responsibilities and most were up-to-date with the appropriate level of safeguarding training. There were clear processes for staff to follow and staff felt comfortable using these.
  • Despite being cluttered in some areas due to a lack of space, the department mostly appeared to be tidy and was visibly clean. Staff generally followed good infection prevention and control processes, although there were several occasions where patients in the corridor were treated by staff who had not cleaned their hands.
  • Patients with a mental health condition were referred promptly following triage to the psychiatric liaison service, provided by a local community provider.
  • The department had a variety of risk assessments available for patients, including for falls, pressure ulcers, and the need for bed rails. We found these were completed appropriately in most patient records.
  • Guidelines were in place to support staff to provide effective treatment, and these were up-to-date with national guidance and standards and regularly reviewed and audited.
  • Patients in minors had their pain assessed at triage and were offered appropriate pain relief in a timely manner.
  • Staff were competent to carry out their roles and were provided with training opportunities to develop their skills, including simulated scenarios.
  • There was excellent multidisciplinary team working both within the department and with teams outside the department, including external partners.
  • Despite challenges caused by the environment, demand and crowding, staff did their best to provide compassionate care to all patients.
  • The department consistently scored above the national average in the NHS Friends and Family Test.
  • Patients and their relatives were provided with appropriate emotional support where required, and staff took the time to ensure this took place.
  • Most patients felt they were involved in decisions about their care, and felt staff listened to them during discussions about their care.
  • Staff could support the needs of most patients, through access to appropriate specialist teams and services. These included, for example, learning disabilities, dementia, frailty and translation services.
  • Work was ongoing to reduce attendances at the emergency department by using the acute assessment unit for appropriately referred patients.
  • There was a generally supportive and respectful culture, although there were some groups of staff who felt this was not the case.
  • Staff wellbeing had a high priority and a wellbeing committee had been established to deliver projects to improve staff wellbeing, including a week-long wellbeing festival.
  • Governance processes had been strengthened. Governance meetings were well-attended and included representatives from management, medical and nursing staff groups. Minutes of governance meetings were well-maintained and actions were recorded and tracked.
  • Risks in the department were well-understood and documented. The risk register aligned with the concerns staff and leaders told us about, and was regularly reviewed and updated.
  • Staff responded quickly and efficiently in response to a fire alarm in the department requiring a full evacuation. It was clear staff had received appropriate training to manage such a risk.
  • There were effective arrangements to ensure the information used to monitor, manage and report on quality and performance was accurate, valid, reliable, timely and relevant.

Surgery

Good

Updated 15 August 2018

Our rating of this service stayed the same. We rated it as good because:

  • The service managed patient safety incidents well and learned from them. Incidents were recorded investigated and acted on.
  • Staff kept appropriate records of patients’ care and treatment. Records we viewed were legible, accurate and informative.
  • People’s care and treatment was planned delivered and monitored in line with current evidence-based guidance.
  • People had comprehensive assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.
  • Staff spoke of good teamwork and enjoyed their work. Managers and senior leaders were proud of the workforce. Staff at all levels were clear about their roles and understood for what they were accountable.
  • The surgical care group leads and other levels of governance in the organisation functioned effectively and interacted with each other appropriately. Leaders were knowledgeable about issues and priorities for the quality and sustainability of their services.
  • People had comprehensive assessments of their needs, which included pain relief, mental health, physical health and wellbeing, and nutrition and hydration needs.

However:

  • Staffing levels did not always meet the need of the patients to ensure safe care and treatment.
  • People could not always access the service when they needed it. The division was not achieving targets for patients receiving treatment within the targeted timeframe, this included cancer waiting times.
  • During times of escalation and bed pressures, facilities and premises used were not always appropriate for surgical patients and patient’s dignity and respect could not always be maintained.
  • Cancelled Operations as a percentage of elective admissions were consistently higher than the England average. Theatre utilisation was worse than the national average.