Derriford Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good. Leaders and the culture they created assured the delivery of high-quality care. However, not all actions were taken in a timely way to address some risks.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust had developed a 5-year research and development strategy. By embedding research and innovation into clinical practice, patient outcomes would be enhanced. Development included their strategy for how they delivered services closer to home for people and provide timely access to services. People would be involved in the design.

The Medication Safety Committee met 10 times a year to continuously improve the safe use of medicines and provided oversight and senior clinical leadership on medication safety, learning from mediation incidents and continuous improvement.

During this assessment leaders and staff told us there was a friendly and open culture focussed on teamwork and providing quality care. They spoke positively about the support they received from managers.

Theatres staff reported a positive culture with many happy staff who had often worked in the department for many years.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff were unanimous their line managers were supportive, understood the challenges of their roles and took action to relieve pressures so staff could work effectively. Staff felt they were listened to and were not afraid to provide their opinions.

Managers said they were confident in their roles and felt supported. We observed open and honest conversations between staff and managers.

Staff told us managers engaged with them regularly and felt confident their concerns were listed to. Staff we spoke with told us they had not experienced any instances of unfair treatment, discrimination or harassment.

Some matrons, nurses, doctors and managers told us they had concerns about the impending financial cuts and potential job reductions, and the impact of the recovery programme.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The trust had a Freedom to Speak Up (FTSU) policy which gave staff guidance about how to speak up and raise concerns for the benefit of patient care or if the issue affected their working life. This was in line with the National Guardians Office (NGO) guidance.

Staff we spoke with knew about the FTSU process. They said they were encouraged to speak up and were not afraid to do so. Some staff said they would raise concerns directly with their managers who would support them. A staff survey showed 88% of staff said they would speak up again. This exceeded the national figure of 82.8%.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust had an Equality, Diversity and Inclusion policy setting out the trust's commitment to diversity and inclusion in their services for patients, visitors, and staff, following legislation including the Equality Act 2010. The trust monitored and reported annually on gender, ethnicity and disability pay gaps. The trust followed national reporting requirements. The Equality, Diversity & Inclusion (EDI) Improvement Plan included objectives to improve the diversity of senior leadership teams and widen recruitment opportunities within local communities. The EDI Strategy 2024-2028 was around education, relationships and fair processes.

At the service group level, practical and pastoral support as well as clinical support was provided to international staff. Internationally educated nurses spoke positively about the support they received. Staff reported improvements had been made.

International staff on wards and in theatres told us all staff were treated the same and managers engaged with them regularly. They felt welcomed and the hospital helped them with accommodation for their families. They had good inductions.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff did not always act on the best information about risk, performance and outcomes or share this securely with others when appropriate.

The service had a leadership structure supported by governance processes. The surgery care group senior leadership team oversaw specific surgery specialisms with clear responsibilities. There was a governance structure with lines of accountability from wards and through the surgery care group to the overall trust's board.

There were robust meeting structures for assurance, performance and finance purposes. Records of governance meetings demonstrated the quality and safety of the service was monitored and reviewed. This included review and learning from incidents, risks, staff views, patient experience, service performance, safeguarding and training compliance.

Some leaders described the governance structure as robust and felt listened to regarding improvements.

There was a governance structure for escalation of any potential risk and had mitigations to manage risks. The service had identified gaps in mandatory training modules. However, the risk to patient privacy and dignity had not been addressed and resolved until we identified it.

The service was previously in breach of the legal regulation in relation to the security of paper patient records. Improvements were found at this assessment and the service was no longer in breach of this regulation. The trust ensured paper patient records were held securely and only accessed by authorised personnel.

The trust participated in relevant national clinical audits. Outcomes for people were mainly positive.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. Staff share information and learning with partners and collaborate for improvement.

The service provided examples of collaboration with partners to support and improve the healthcare experience of patients.

The trust was in the process of implementing an electronic patient records system replacing existing unlinked clinical systems and enhancing clinical decision-making, operational efficiency and patient safety. They were liaising with other local trusts on what they described as the largest digital transformation in decades. This would help the trust align with trusts across Devon.

The service partnered with a local NHS trust to review best practice in theatres and improve performance for people.

Collaborative working with partners included a plan to introduce a quality check of complaint responses with patient council and patient safety partners in the summer of 2025.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for people. Staff actively contribute to safe, effective practice and research.

There was an ethos of improving services across wards and departments. We saw examples of improvements made by the service. Some were focussed on increasing theatre time and reducing waiting lists.

The trust was in the process of implementing an electronic patient records system. They were liaising with other local trusts on what they described as the largest digital transformation in decades.

The Perioperative Medical Programme Report April 2025 planned for the implementation of a Quality Improvement project to realise the benefits of early screening and optimisation to support people manage their health to be in the best condition for planned surgery.