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Derriford Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 18 December 2019

Our rating of services stayed the same. We rated it them as requires improvement.

A summary of our findings can be found in the ‘Overall trust’ section of the report.

Inspection areas

Safe

Requires improvement

Updated 18 December 2019

Effective

Requires improvement

Updated 18 December 2019

Caring

Outstanding

Updated 18 December 2019

Responsive

Requires improvement

Updated 18 December 2019

Well-led

Requires improvement

Updated 18 December 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 18 December 2019

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

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

  • Regulations were not met in relation to consent, safe care and treatment, premises and equipment, governance and staffing.

  • Systems and processes were not always reliable or appropriate to keep people safe. There was an increased risk that people are harmed due to poor communication of patient risks when patients moved between wards. Record keeping needed to improve and staff did not always receive feedback on incidents and incident investigations were not always completed in a timely way.

  • Consent was not always recorded in line with relevant guidance and legislation. There was a lack of consistency in how people’s mental capacity was assessed and not all decision-making was recorded in line with guidance and legislation.

  • Governance and risk management processes did always support the delivery of high-quality person-centred care.

However:

  • People are supported, treated with dignity and respect, and are involved as partners in their care.

Services for children & young people

Good

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.

Critical care

Good

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.

End of life care

Good

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.

Surgery

Requires improvement

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.

Urgent and emergency services

Requires improvement

Updated 31 May 2019

Diagnostic imaging

Requires improvement

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.

Maternity

Good

Updated 18 December 2019

Our rating of this service improved. We rated it as good because:

  • Safe, effective, responsive and well-led were rated good. Caring was rated outstanding.

  • Safe care was being provided across the maternity service. Staff received appropriate training and were clear about the systems and processes they used to assess and respond to patient risk. Patient safety incidents were reported and investigated to ensure learning and change.
  • Staff provided effective care within the maternity service. The service provided care and treatment based on national guidance and evidence-based practice. The effectiveness of care and treatment was monitored, and findings used to make improvements. Staff were competent for their roles. Staff supported women to make informed decisions about their care and treatment and provide consent.
  • We identified good multidisciplinary team working. There was a presence of the multidisciplinary team within maternity services and a holistic approach to assessing, planning and delivering care.
  • Outstanding elements of care were observed. Staff treated patients with compassion, dignity and respect, took account of their individual needs, and helped them understand their planned care.
  • The service was inclusive and took account of women’s individual needs and preferences, and treated concerns and complaints seriously to investigate and share learning.
  • The service was well led, and the leadership team understood and managed the priorities of the service, and there was a vision and strategy aligned to the pan-Devon vision and plans, and national priorities.
  • Staff felt respected, supported and valued, and there was an evident multi-professional and collaborative culture within the division. There were effective governance processes and management of performance and risk, with further governance improvements planned. Staff were committed to learning and improving services.

However:

  • There were a few areas where safety could be improved to be brought in line with best practice. Carbon monoxide levels were not routinely recorded within patient notes. This meant women might not be offered support to stop smoking.
  • Training compliance for medical staff did not meet trust targets.
  • Appraisal rates did not meet trust targets.
  • Understanding of the Mental Capacity Act and Deprivation of Liberty Safeguards was limited and variable. We were not assured that consent was appropriately managed and vulnerable patients were identified and or supported.
  • Maintenance and layout of the environment did not always meet national guidance. There was not always enough ward view to ensure staff could see all patients.

  • Safety thermometer results were not displayed within the service for staff and visitors to observe, although the service measured performance through the safety thermometer.

Medical care (including older people’s care)

Updated 5 March 2019

This was a focused follow-up inspection. Therefore, we did not rate this service. There was progress in addressing the concerns in the warning notice, although some areas had not been well considered or implemented quickly enough for medicine and pharmacy services.  

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.