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 based on meeting the needs of people who used services and wider communities. We checked 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 remains requires improvement. This meant the service did not always have effective governance to deliver consistent safe and high-quality, person-centred care.

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.

Staff and leaders demonstrated a positive and compassionate culture with a focus on learning and improvement. We heard many staff describe the culture as "all one team”.

In response to our previous inspection, the service developed a plan designed to improve patient safety and the experience patients had while in their care. The plan focussed on speeding up access to get people to the right service in a timely way. The service engaged with staff to drive the plan which was focussed on patient safety and staff were participating. We observed progress had been made with flow and streaming through the department and across the hospital. However, further work was required to meet the needs of the number of patients attending the service.

Funding to improve the waiting room area (building works were about to commence) would improve staff’s visibility of patients for safe monitoring. However, the current environment was not fit for purpose and crowding affected staff’s ability to deliver safe care. The long-term new build was understood to provide solutions to problems identified during our inspection.

Ambulance parking was being reviewed within the long-term building plans to improve access for ambulances and cease blocking one other in the drop off area.

The service worked to decrease ambulance handover delays and addressed the issue as a trust, rather than a service responsibility. This resulted in a significant decrease to the average ambulance handover time.

There were plans for a GP car during the winter, to attend patients in nursing homes to reduce the impact on emergency department attendance and reduce the spread of covid, flu and other viruses.

Staff told us they felt much more involved in service strategy, vision and values. The children’s paediatric nursing team had a good culture, staff felt supported by their matron and had brought about positive change.

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.

Nursing and medical staff across the department understood the key risks to patients. Most staff told us managers were supportive, visible, approachable, understood the challenges of their roles and took action to relieve pressures so staff could work effectively. Most staff felt they were listened to and were not afraid to share their opinions. Managers engaged with them regularly and staff felt confident their concerns were listened to. Staff told us they had not experienced any instances of unfair treatment, discrimination or harassment. Staff talked of a “great team culture” with no hierarchy.

Staff understood the reporting structures and leaders understood their key roles and responsibilities. Leaders also fully understood the key risks and challenges faced by the department. They were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they collaborated with partners such as the local ambulance trust. They told us they worked well together and there was regular engagement to review performance and identify improvements to services.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. Managers said they were confident in their roles and felt supported. We observed open and honest conversations between staff and managers.

Leaders had effective support and opportunities to develop and maintain their credibility and skills. All staff had opportunities to develop including for future leadership roles. There was inclusive recruitment and succession planning. The trust had effective recruitment processes and ongoing checks to ensure all staff met the legal requirements to work in the trust.

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

The service fostered a positive culture where most people felt they could speak up and their voice would be heard regarding themselves or issues which could compromise the quality of patient care. There was 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 guardian’s office (NGO) guidance. An online anonymous reporting platform was also available.

The FTSU team told us all levels of staff including senior leadership engaged with FTSU guardians. Leaders met with the FTSU team twice weekly. The team reported on numbers and themes up to trust board level. Leaders had requested FTSU to carry out a staff survey and the emergency department was organising an event to look at recent feedback from staff. Leads for each area would participate. Last year’s survey showed 88% of staff (trust-wide) would speak up again.

A one-month wellbeing survey was planned across the hospital led by the FTSU team including bullying, sexual safety, burnout and stress. At the same time the hospital would hold listening events with matrons.

Staff told us if they had concerns or feedback they would escalate to the nurse in charge or manager first or approach a FTSU guardian. Staff were aware of who the FTSU guardians were and how to contact them. The guardians’ role was to support workers to speak up when they felt they were unable to in other ways. Most staff we met said they would not be anxious to speak up if they needed to and they felt they would be listened to. However, some staff felt nothing changed after speaking up and some told us concerns raised with management were not always addressed.

Patients, relatives and carers had opportunities to give feedback on the service they received by visiting the trust’s patient advice and liaison service (PALS) or through the trust’s website, telephone, form or email. We observed posters in the department asking patients for feedback which contained QR codes for easy access. Friends and family test feedback forms were also offered for visitors. Feedback was taken seriously and used to improve care and treatment when possible. The length of wait in accessing the department has been responded to including the building of the urgent treatment centre.

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

The trust’s equality, diversity and inclusion (EDI) policy set out their 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 quality and equality impact assessment policy was circulated across the trust. The equality, diversity and inclusion improvement plan (at board and executive team level) included objectives to improve the diversity of senior leadership teams and widen recruitment opportunities within local communities.

Leaders said the service had worked to recruit and retain staff. However, there were still some vacancies across the department. The trust was undergoing an organisational structure review which included standardisation of some staff roles.

In the most recent NHS national staff survey (2024) the majority of responses had improved. Most staff said there were enough staff to do their job properly and staff were able to access the right learning and development opportunities when required. There was a large increase in the number of staff who considered the organisation acted on concerns raised by patients. However, there was also an increase in the number of staff who had experienced physical violence from patients, relatives or members of the public, and some staff we spoke with confirmed this. There were 22 violence and aggression incidents against staff in July 2025. The department displayed information explaining violence and aggression would not be tolerated.

The service did not have good governance to assess and improve the quality of service. They did not act on the best information about risk, performance and outcomes.

The service's governance processes did not ensure people were assessed and treated in line with standards of care. This included people experiencing long waits for medical review.

Processes to identify concerns were not always effective in improving performance. Mandatory training did not always meet the trust's target for completion. There was continued poor compliance in most areas including, medicines, infection prevention and control, resuscitation and safeguarding training modules.

Governance processes did not always escalate and mitigate risks. Staff had identified patients experiencing long waits for medical reviews which affected the flow of patients through the emergency department. Leaders said there had been discussions to manage risks for people waiting for medical reviews. However, sufficient actions to mitigate risks relating to medical reviews in the department had not been taken.

The service did not always have complete audit programmes to manage safety and quality. During our assessment we did not find concerns in the completion of records or consent. However, the service did not have a process to monitor the standards of record keeping or that consent was obtained correctly. This meant the service could not be assured that actual practice was in line with best practice.

The service had a leadership structure supported by governance processes. The emergency care group senior leadership team oversaw the department with clear responsibilities. There was a governance structure with lines of accountability from the care group to the overall trust board. Some leaders described the governance structure as robust and felt listened to regarding improvements.

The service held a variety of meetings to discuss the management of patient flow, performance and safety within the department. Records of governance meetings demonstrated the quality and safety of the service was monitored and reviewed. These multi-disciplinary meetings ensured everyone was aligned regarding the department's current status and prioritised actions to improve patient care and reduce waiting times. Challenges were discussed and any backlog and impacts on flow across the hospital.

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

The service was working with external system partners to improve admission avoidance and timely discharge which relied on the availability of community services for people to use instead of attending hospital.

Directorate leaders engaged with external stakeholders and patient feedback was shared with the trust.

Commissioners were supportive of the trust’s improvement work to strengthen performance, the implementation of the timely ambulances handover process and were working together around measures to improve hospital discharge processes. They said they worked closely with the trust and were also aware of the trust’s work regarding organisational restructuring which would strengthen the senior clinical leadership and improvement in staff culture.

Senior leadership said they had an engaging relationship with the local NHS ambulance service. There were regular meetings with the service area lead to discuss incidents, expectations for the timely handover process (THP) and to utilise patient pathways.

Representatives from the local NHS ambulance service said they had a good working relationship with the emergency department leadership team and trust in general. They had been working closely and in partnership with the trust to support improvements in flow. They said engagement with the department related to handovers and delays could be challenging at times. However, over the past 6 months they had seen a consistent positive change in approach at the trust. Ambulance leaders said this had been positive for patients in the community but also for their day to day working relationships with trust’s staff. They recognised there was still significant improvement in flow required and they would continue to work in partnership with the trust.

To help contain the spread of Covid-19, flu and norovirus, the service partnered with GPs to visit care homes when patients were suspected to have these viruses.

The service had seen an increase in needing police intervention. The service worked proactively with the police to inform investigations. However, there were ongoing concerns police did not work cooperatively to support individuals with mental health needs. There was an identified consultant who liaised with the police and the community. Staff told us the partnership was improving.

As part of efforts to support the trust’s improvement plan, they had developed partnerships with system partners and councils to support the drive to redirect patients to community hospitals.

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

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. We saw the department had empowered staff to make changes. Staff were asked to participate in working parties regarding the new future emergency care building.

There was an ethos of improving services and a lot of work had been achieved through the improvement plan. We saw examples of improvements made by the service regarding waiting times, flow and streaming. However, leaders recognised there was further work to be done.

Feedback, complaints and incidents were discussed at department clinical governance meetings. Learning and improvements were reviewed.

The service had strong external relationships which supported improvement and innovation. Staff and leaders engaged with external work, including research, and embedded evidence-based practice in the organisation. Current research projects included optimising patient risk management in urgent primary care services.

The service provided a list of quality improvement projects currently being undertaken or had been completed. These ranged from social support such as a free library for the waiting room, to supporting evidence-based care (for example pain relief in the emergency department). The paediatric department was to benefit from the donation of two buzzy devices, a bee-shaped tool using vibration and cold to distract children and reduce needle pain, helping to make medical procedures less distressing for young patients.

The trust was in the process of implementing an electronic patient records system replacing existing disparate 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 other trusts across Devon.

The trust had commenced work on building a new purpose-built emergency care building, with an anticipated four-year build programme.