Derriford Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people's liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good. This meant people were safe and protected from avoidable harm.

However, managers did not always ensure staff received mandatory training to maintain high-quality care. The service was previously in breach of legal regulation in relation to safe care and treatment. At this assessment the service remained in breach of this regulation.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Trust policies and procedures provided staff with guidance for reporting, managing, investigating, and learning from incidents including deaths.

Managers were responsible for investigating incidents and sharing learning. Review of incident investigation reports showed areas for learning and improvement were identified and action plans written.

Staff received feedback about progress of actions taken via staff huddles, team meetings and newsletters. Learning from incidents was also shared at manager meetings and surgical matrons' safety meetings.

The trust had a Duty of Candour (DoC) and Being Open policy. Staff apologised, gave patients honest information and shared learning in line with legislation and best practise.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Daily site meetings were held to optimise patient flow through the hospital. There was clear guidance for the transfer of patients between departments and wards within the hospital in a safe, effective and timely manner.

Trust discharge policies and processes gave staff guidance about managing patient discharges safely. Staff told us they liaised with system partners and external agencies to ensure patients received continuity of care when discharged. To improve the discharge process for adults with mental health needs a standard operating procedure (SOP) had been devised between the trust and other system partners.

Staff in the discharge lounge told us there could be delays discharging patients due to waiting for medications from pharmacy. The trust was working with partner organisations to improve the process.

Patients told us discharge planning was discussed with them, they had no concerns and knew what to expect.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Safeguarding referrals were sent to the local authority and the trust held monthly meetings with the local council and other stakeholders to track referrals and discuss trends and issues.

Safeguarding training for all staff working with people at risk was aligned to national guidance and monitored via the Trust's performance framework. Surgery care group staff were compliant with levels 1 and 2 safeguarding adults training. However, not all staff had completed their level 3 training.

Staff understood how to make safeguarding referrals and who to inform if they had concerns. They knew how to access support from safeguarding leads.

There were policies to guide staff about the use of restraint and restriction to ensure they were not used inappropriately. The service completed risk assessments when considering the use of restraint.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had access to policies and procedures to assess risk of harm and deterioration of patients' conditions. These followed national guidance and staff understood how to identify and manage risks. Staff in the pre-op assessment unit told us they completed risk assessments for each patient on admission.

The observation policy included screening for sepsis and referenced the national Sepsis 6 Pathway. Staff had clear guidance about actions to take in the event of suspected sepsis and there was good oversight of the management of suspected sepsis.

Staff used the National Early Warning Score (NEWS2) (a nationally recognised tool to identify deteriorating patients and escalated them appropriately). Staff carried out vital observations before, during and after surgery.

The service used the nationally recognised World Health Organisation (WHO) 5 Steps to Safer Surgery checklist. The trust had improved since the last assessment and was now compliant with the WHO checklist. We observed the WHO checklist was embedded into practice.

The service was previously in breach of the legal regulation in relation to safe care and treatment, in particular for patients receiving, and staff documenting risk assessments for venous thromboembolism (VTE). Improvements were found at this assessment and the service was no longer in breach of this regulation.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care.

Staff told us premises and equipment were mostly suitable for providing safe care and treatment and there was enough well maintained equipment. Electrical equipment in each ward area was safety checked. Medicine trolleys were digitally locked and sharps boxes were dated and signed. However, we found an unlocked cupboard where airways equipment was stored. This was raised with staff to rectify at the time.

Surgical wards appeared clean and tidy. We observed appropriate Personal Protective Equipment (PPE) was available and saw evidence of good waste management processes. Sterile procedures were followed.

In the theatres we found sufficient supplies of PPE available for staff, hand wash basins and sharps bins. We observed appropriate use of PPE and hand washing in theatres. Staff followed processes to mitigate against health and safety issues including gas, electric and fire safety.

The newly purpose-built urology unit was designed to be dementia friendly. A quiet room was available for patients and relatives.

The service monitored the environment and made improvements where required, for example in the storage of products deemed hazardous to health.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people's individual needs. However, staff mandatory training did not always meet the trust target for completion.

The service was previously in breach of the legal regulation in relation to ensuring enough staff to keep patients safe on the wards. Improvements were found and the service was no longer in breach of this regulation.

There were mixed views from staff about whether their areas were well staffed. Senior nurses said there was good team working and doctors said they felt supported. However, others described they experienced challenges ensuring safe staffing for example to cover night shifts. Twenty-four hour meetings were held daily to monitor staffing levels.

Staff said they completed mandatory training appropriate to their roles and received on-going training and appraisals. Staff spoke positively about the opportunities they had for career development.

The service was previously in breach of the legal regulation in relation to staffing, in particular we had found that mandatory training was not completed. At this assessment the service remained in breach of this regulation. Data provided for April 2025, showed some areas were compliant with the trust target of 90%. However, resuscitation training for the service was non-compliant at 78.57% (practical) and 82.66% (theory). Mental Capacity Act training was delivered throughout the year.

Oliver McGowan Mandatory Training on Learning Disability and Autism was a legal requirement. 80% of the surgery care group had completed the tier 1 training and fell short of the 90% target. Tier 2 Oliver McGowan training had started.

The trust set a target of 90% for staff annual appraisals. Improvements were found since the last assessment. Staff told us appraisals were meaningful, and one consultant said they had good cross-departmental appraisals.

People told us staff were attentive and checked on their well-being and comfort regularly and staff were suitably qualified to look after them. One patient said they were "very grateful to staff and all have been brilliant".

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The trust's Infection, Prevention and Management policy guided staff to minimise the risk of infection to patients, staff and visitors. The Decontamination policy directed staff regarding the decontamination of medical devices and other equipment in accordance with national standards and guidance (NICE 125 surgical site infections: prevention and treatment).

The surgical wards we visited appeared clean and tidy, and "I am clean" stickers were in use. The surgical areas cleanliness audit for April 2025 showed monthly compliance in line with the National Standards of Healthcare Cleanliness.

Hand hygiene audits monitored staff compliance with national guidance and trust policy for handwashing. The January 2025 audit showed monthly totals of 99 and 100% compliance. On wards we observed staff washing their hands between patient interactions. Hand sanitiser was available and used by staff.

The service monitored compliance against NICE 125 Surgical Site Infections: Prevention and Treatment and data showed low rates of surgical site infections for hip replacement surgery.

We saw good practice on wards with sharps boxes and waste. Staff followed the NHS England Uniforms and Workwear Guidance. All wards had appropriate PPE available and IPC signage.

In theatres we found there were sufficient supplies of PPE, hand washing basins and sharps bins. We observed staff appropriately using PPE and following The National Safety Standards for Invasive Procedures (NatSSIPs) when preparing for surgery. We saw evidence of good waste management and sterile procedures were followed.

Patients said the wards were clean and one patient described cleanliness of the ward as "second to none". Another said, "there is always someone cleaning" and spillages were cleaned quickly.

The service did not always make sure medicines and treatments were safe and met people's needs, capacities and preferences.

The trust had invested in pharmacy and a Pharmacy Workforce Plan to increase staffing in pharmacy. However, surgical wards did not have the same level of pharmacy support as other areas of the trust.

There was a Safe Administration of Medicines policy and a Self-Administration policy. Assessment forms required completion prior to patients' self-administering medicines. However, during our assessment staff were not always following these processes and addressed this during our visit.

The trust had implemented an electronic application to support the management of emergency medicines. However, staff were not clear about the process for checking emergency medicines to ensure they were available and in date.

We found medicines in most emergency trolleys were in date.

The Trust had a process to monitor patients' medicines. However, due to pharmacy staff shortages this was not always achieved. To mitigate the risk associated with this, pharmacy had implemented a prioritisation tool to ensure those patients who were in most need of pharmacy review were seen.

The service had systems to ensure staff knew about safety alerts and incidents. The Patient Safety Incident Response Group (PSIRG) evidenced actions had been taken to tackle medicines errors.

There was a Safe Storage of Refrigerated Medicines procedure. However, there was no ambient temperature monitoring of areas where medicines were stored and this was being addressed. In theatres we observed medication appropriately stored in fridges and items were in date.