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Provider: University Hospitals Plymouth NHS Trust Requires improvement

Reports


Inspection carried out on 20 Aug to 19 Sep 2019

During a routine inspection

Our rating of the trust 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 outstanding.
  • Medical care remained the same and was rated as requires improvement. Safe, effective and responsive all remained the same and were rated as requires improvement. Well-led went down one rating and was rated as requires improvement. Caring stayed the same and was rated as good.
  • Surgery went down one rating to requires improvement. Safe, effective and well-led went down one rating to requires improvement. Responsive stayed the same and was rated requires improvement. Caring stayed the same and was rated as good.
  • Maternity went up one rating to good. Safe and well-led went up one rating to good. Effective and responsive stayed the same and were rated as good. Caring went up one rating and was rated outstanding.
  • Diagnostic imaging went up one rating to requires improvement. Responsive and well-led went up one rating to requires improvement. Safe stayed the same and was rated as requires improvement. Caring stayed the same and was rated as good. Effective was not rated.
  • The remaining core services were not inspected at this inspection and their previous ratings are therefore unchanged.


CQC inspections of services

Inspection carried out on 17 April 2018

During a routine inspection

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

Safe, effective, responsive and well-led were requires improvement, and caring was outstanding. Safe and responsive remained as requires improvement, but effective and well-led dropped by one rating to requires improvement. Caring remain outstanding.

Our inspection of the core services covered only Derriford Hospital.

  • Urgent and emergency care stayed as requires improvement overall. The question of safety remained requires improvement. Effective dropped by one rating to requires improvement. Caring stayed as good. Responsive remained requires improvement. Well-led remained good. The department was too small to accommodate safely the number of patients it saw. There was frequent crowding as a result and patients being held in the corridor, and insufficient equipment to care for patients being held here. The resuscitation area was too small for a major trauma centre. The department was not always safely staffed. Not all patients were monitored for deterioration or pain in good time, and not all patients with suspected sepsis received antibiotics within 60 minutes. Privacy, dignity and confidentiality for patients was not always respected due to issues with space. The department had failed to meet the national standard for A&E waiting times for at least four years. However, we found the department visibly clean, most staff had updated their mandatory training, and there was good access to diagnostic imaging. There was excellent multidisciplinary teamworking, staff did their best to care for patients with compassion, and the department consistently scored above the national average for patients recommending it to their family and friends. Work was ongoing to reduce the number of patients attending the emergency department following the opening of the acute assessment unit on site. Governance processes had been strengthened and risks were well understood.
  • Medical care dropped one rating from good to requires improvement overall. The question of safety remained as requires improvement. Effective and responsive both dropped one rating from good to requires improvement. Caring and well-led remained as good. There were not enough beds to meet the demand of medical admissions to the hospital. The systems to promote patient flow were effective, but the increasing demand outweighed the available beds. Wider community systems reduced the ability of the hospital to discharge patients. This increased the length of stay for patients. Risk assessments and the management of sepsis were not always carried out well, creating a risk for some patients. Systems for managing patients with mental health needs were not consistent across all wards and so care varied. There were vacancies for medical and nursing staff across the medical wards so staffing was not always at safe levels. Mortality statistics were not always recognised when they gave rise to concerns. Although we recognised there were many avenues open to staff to raise concerns, there were some staff who still did not feel able to safely do so.
  • Surgery services remained rated as good. The questions of safety, effective, caring and well-led remained rated as good. Responsive remained rated as requires improvement. Following the last inspection an action plan had been implemented to work towards meeting identified recommendations. The service provided safe and effective care. Patients had good outcomes from their care and treatment. However, despite providing a good quality care, staffing levels were sometimes below the planned safe levels. People could not always access the service when they needed it and targets, included cancer waiting times were not always met. In response to times of hospital pressure, cancelled operations numbers were higher than the England average, and how operating theatres were used was not always efficient. During times when the hospital was over its capacity, facilities and premises used were not always appropriate for surgical patients. There were therefore times when patients’ privacy and dignity could not always be maintained.
  • Maternity services were rated as requires improvement. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings. There were issues with cleanliness and equipment not being checked as required. Some medicines and patient records were not stored securely. The process to monitor risk and oversee the service quality did not provide sufficient assurance, and this resulted in a lack of oversight of the performance of the service. However, there was excellent multidisciplinary working. Staff were caring and compassionate, and the mental health of patients was cared for.
  • Outpatient services were rated as good. We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings. 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 worked collaboratively with other services and utilised clinics well to meet patient’s needs. However, responsiveness required improvement due to waiting time delays, including for cancer services.
  • Diagnostic services were inspected as a core service for the first time at this hospital. They were rated as inadequate. Safe was rated as requires improvement. Effective was not rated. Although we inspected the effective domain, there is a lack of national data available to the CQC. Caring was good. Both responsive and well-led were rated as inadequate. Patients were unable to access services within the targets and standards required. There were unacceptable delays with imaging and the reporting of results. The governance did not provide assurance that the service was safe, effective or meeting patients’ needs. There were risks from ageing equipment and some of the environment did not always respect patients’ privacy and dignity. Most of the staff team we met were demoralised and described themselves in terms including overwhelmed and exhausted. Staff felt they were not able to provide the service they wanted to deliver. However, patients were positive about the way staff treated them, and we observed a caring group of staff.
  • On this inspection we did not inspect critical care, end of life care, or services for children and young people. The ratings we gave to these services on the previous inspections in June 2015 and November 2016 are part of the overall rating awarded to the trust this time.
  • Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Inspection carried out on 19, 20, 21 and 29 July and 12 August 2016

During an inspection looking at part of the service

We inspected Plymouth Hospitals NHS Trust in July 2016 as a follow up to the comprehensive inspection that was carried out in April 2015. The follow up inspection was announced, and took place on 19, 20, 21 July and 12 August 2016. Further unannounced visits were carried out on 29 July 2016.

During the previous inspection we rated the trust as requires improvement overall. The follow up inspection therefore focussed on those areas rated previously as requires improvement and inadequate. We also inspected well led at trust level.

During our inspection we inspected the following locations:

  • Derriford Hospital
  • Mount Gould Hospital

We inspected the following core services against the following domains:

  • Urgent & emergency services (safe, responsive and well led)
  • Medical care (including older people’s care), (safe and responsive)
  • Surgery (safe, responsive and well led)
  • Critical care (responsive)
  • Maternity and Gynaecology (safe)
  • Services for children and young people (safe)
  • End of life care (effective)
  • Outpatients & Diagnostic Imaging at both sites (safe, effective – not rated, responsive and well led).

We rated the trust as requires improvement  for safe and responsive. Effective and well led were rated as good.  Caring was not inspected as part of this follow up inspection, but was rated as outstanding overall at the previous inspection in April 2015. We have aggregated the ratings from the previous inspection and given overall ratings for each core service.

There had been progress in many of the areas where improvements had been required at the previous inspection.

Derriford Hospital the safe domain improved from requires improvement to good for, surgery,  maternity, services for children and young people, outpatients and diagnostics. The responsive domain has been rated as requires improvement which is again an improvement on the previous inspection where outpatients and diagnostics and urgent and emergency care were rated as inadequate in 2015.

We rated Mount Gould Hospital as requires improvement overall, safe was rated as good but improvements needed in the responsive and well led domains rated as requires improvement.

Our key findings were as follows:

Safe:

  • At Derriford Hospital surgery, maternity and gynaecology, children and young people and outpatients and diagnostic imaging were rated as good. Medical care and urgent and emergency care was rated as requires improvement.
  • There was a positive incident reporting culture with evidence of full investigations taking place and learning being identified and shared with staff to improve safety. Staff were confident in reporting incidents although in some areas, incidents were not graded appropriately.
  • At Mount Gould, the systems and arrangements for reporting and responding to governance and performance management data had improved but still did not effectively monitor and record risks and incidents. There was no centralised monitoring of safety issues in remote clinics, although leaders visibility and engagement had improved on a local level.
  • Staff were open and honest with patients and their relatives when anything went wrong. We saw evidence of people receiving a sincere and timely apology and being informed about actions taken to prevent future occurrences.
  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse. All staff we spoke with had a good awareness of safeguarding legislation and many had been given prompt cards to assist them in the identification of abuse. Staff knew what to do when they suspected abuse.
  • Standards of hygiene were monitored by staff with specific roles in infection control and clinical areas were visibly clean, hygienic and well organised. Staff followed trust policies regarding infection control and routinely used protective personal equipment (PPE), hand gel and regularly washed their hands. Although in some areas, sharps waste was not always disposed of promptly, and chemicals were stored in ward areas which patients had access to. Where incidences of infection were found, appropriate action was taken to control it.
  • At Mount Gould, patients were cared for in a clean and hygienic environment, and there were systems in place to reduce the risk and spread of hospital acquired infections, however, results of audits were not shared with all staff.
  • Controlled drugs were stored and checked appropriately, and allergies were clearly recorded on medicine charts. Pharmacy staff worked with staff on the wards to ensure they were aware of safe protocols and any errors were highlighted as soon as possible. Following concerns raised at our last inspection in relation to insulin prescribing the trust had set up a working group to review their policies and procedures. However, intravenous fluids were not always being stored securely and medicines were not always secured on wards where patients were able to self-administer their medicines.
  • At Mount Gould, there were improved practices in respect of the management of prescription forms and the trust’s policy for the custody of the medicines keys which kept patients safe.
  • Staffing levels and skill mix were planned and implemented to keep people safe at all times and staff shortages were monitored and acted on. Managers deployed staff flexibly to cover shortfalls where possible, however in some areas, large numbers of nursing vacancies meant wards were not always staffed to the agreed level. Some gaps were identified in medical rotas and the trust was taking action to minimise the risk, for example, the introduction of doctors’ assistants had reduced the burden on junior doctors.
  • The trust had set the target for mandatory training to 100%. In many areas this was being met, although in other areas, the figures ranged between 80% to 90%. Most staff we spoke with were aware of how and when to update their training, but in some areas, for example in maternity, clearer processes are required to identify the training needs of staff and compliance with those needs. Related to this, we found staff training was urgently required for emergency procedures using the birthing pool.
  • Risk assessments, care plans, triage processes and the use of adult early warning scores kept people safe from the risk of harm, however, the use of a paediatric early warning score was inconsistent and did not ensure children at risk of deterioration were recognised and monitored accordingly. 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.
  • In the majority of areas, care records were clear, contemporaneous, complete and signed. However in some areas, they were inconsistently completed, and for example in diagnostic imaging, not all images requiring documented evaluations had them recorded.
  • Records were kept securely to maintain confidentiality and prevent tampering and were available for staff to view when required in most areas. In oncology outpatients however, we found that records were kept in unlocked trolleys in unlocked rooms overnight and on the paediatric ward, patient details were displayed on an electronic board which visitors could view, potentially compromising a child’s confidentiality. In the emergency department, computers were not always logged out to prevent unauthorised access to patient identifiable information.
  • Equipment for use in an emergency was regularly checked and prepared for use in all areas. We saw in some areas that faulty equipment had been replaced; however, a number of items had not been serviced within the recommended timescales.
  • Improvements had been made to the environment in the clinical decisions unit; a new helipad had opened to provide safer and direct access for patients being transported by helicopter. Some ward areas had been refurbished to meet the needs of patients who lived with dementia, and delivery suite had been partially refurbished following concerns raised during the last inspection. However, there were no plans in place to complete the refurbishments on delivery suite. The emergency department remained cramped in a lot of areas and the paediatric unit was not secure.

Effective:

  • At this inspection we rated the effective domain in end of life care only.  Although we inspected the effective domain in outpatients  and diagnostic imaging services we did not rate them due to the lack of national data available to the CQC.
  • Patient needs were assessed and treated in line with evidenced based guidance. In outpatients and diagnostic imaging, we saw evidence of audit to ensure that practice was monitored ensuring consistency.
  • 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, but these changes had not yet been started.
  • End of life outcomes were monitored against national standards. Local audits were delayed in being completed in some areas. Outcomes from previous audits had been used to make changes to patients care.
  • Ward staff had sufficient training and the ongoing support and help for the Specialist Palliative Care Team to deliver effective care and treatment.
  • The multi-disciplinary working between the Specialist Palliative Care Team and the wider hospital and local community were outstanding. The integrated working supported continuity of care and avoidable admissions to hospital.
  • When people in outpatients and diagnostic imaging received care from a range of different staff, teams or services, this was coordinated well ensuring that all relevant teams were involved in the planning and delivery of peoples care and treatment. Staff discussed with inspectors how important it was to work collaboratively to meet the needs of the patient and could give us multiple examples where this was taking place.
  • 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.
  • In outpatients and diagnostic imaging, although most staff could access the information they needed to assess, plan and deliver care to people in a timely way there were still improvements to be made. Although the number had reduced significantly since our last inspection, there were still 2000 temporary notes in circulation meaning that treatment decisions were being made without all relevant clinical information. In diagnostic imaging although it had reduced significantly, there were still 2000 images requiring reporting on a backlog. These were being managed in a proactive way and work was still being done to reduce this.

Caring:

  • At this inspection, the caring domain was not inspected because during the last inspection in April 2015 the trust was rated outstanding overall for caring.

Responsive:

  • We rated responsive at Derriford hospital as requires improvement. Urgent and emergency care, surgery, outpatients and diagnostic imaging were all rated as requires improvement and medical care and critical care were rated good.
  • There was a consistent failure to meet the four-hour performance standard in the emergency department, and frequent crowding was becoming “normalised”, although the department had called a risk summit with relevant senior managers and hospital executives to raise their concerns and seek trust-wide solutions to the impact of crowding.
  • The trust breached the 18-week referral to treatment target operational standard across all surgical specialties, apart from plastic surgery, from March 2015 to June 2015, when the target was abolished by the government (the operational standard is still used by the majority of trusts to monitor their performance). By February 2016, only one surgical speciality was meeting the abolished operational standard and that was plastic surgery. Performance had deteriorated to under 50% for neurosurgery. Over the entire period, all specialties except for plastic surgery performed below the England average.
  • Since our last inspection in April 2015 the number of cancelled operations had risen. The percentage of patients not treated within 28 days of a cancelled operation had also risen. Due to pressure for their beds and the demand for their services, some patients had to use facilities and premises not appropriate for the services being provided. The theatre booking system had been reviewed and changes implemented, although staff told us there were ongoing issues with the theatre lists not always being finalised at 3pm the day before surgery.
  • The trust had a number of initiatives to reduce the number of cancelled operations. For example, the ‘golden bed’ identified patients who could be discharged earlier to free up beds for elective operations.
  • The trust had 67 patients waiting over 52 weeks for their operations, and of these 37 had not been given a date. However, the trust was working hard to reduce these and had action plans in place.
  • There were long waiting times and delays for an outpatient appointment. Although significant improvement had been made some people were not able to access the services for assessment, diagnosis or treatment when they needed to due to the management of the backlog in appointments required and high levels of over referral to services. There were a total of 30,862 patients requiring follow up but a majority of these had an appointment date at the time of the inspection. However, we found there was a proactive and innovative approach to how clinic utilisation and capacity was managed. Particularly in rheumatology, psychology and breast imaging.
  • At Mount Gould, for some patients, access to new and follow-up appointments were delayed by an ongoing recognised backlog of appointments and typing of clinic letters; however this had reduced since the last inspection. However, the systems and data used to monitor reasons for the short notice cancellation of clinics were not accurate or robust.
  • The numbers of medical outliers had reduced since our last inspection as the trust had provided additional medical beds. This meant that patients received a responsive service and their access to medical staff had improved.
  • The acute stroke pathway was responsive to the needs of patients and staff provided a proactive service to ensure patients were assessed and treated promptly on arrival at the hospital.
  • There was not a clear pathway for patients attending the hospital for care and treatment from the cardiac catheter laboratories. The medical care group were in the process of increasing the services available to patients by the provision of a third mobile cardiac catheter laboratory.
  • Information technology systems were not integrated and delayed access to some services, particularly computerised tomography within the emergency department.
  • The critical care services had yet to establish the dedicated psychology service in accordance with the guidelines of the Faculty of Intensive Care Medicine core standards and NICE guidance, 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 supplying data was underway.
  • Complaints were managed well within the outpatients and diagnostic imaging and critical care services and people we spoke with knew how to make a complaint. The service listened to complaints, responded to them, and used them to improve patient care and support. Lessons were learnt from complaints and were disseminated well to different teams. We saw that outcomes to complaints were explained to the complainant and always offered an apology. Patients and their relatives were included in feedback and investigations of complaints, and told when practice had changed because of their input. However, in the emergency department, complaint responses were not completed in a timely manner.
  • The individual needs of patients were taken into account when planning and delivering services and patients with complex needs and learning or other disabilities were well supported. However in the emergency department, patients’ needs were not always being met, particularly in respect of mental health patients and those patients being held in the central ‘corridor’ area.
  • Care was tailored to the needs of patients, and their preferences and circumstances were understood and acknowledged. This was particularly evident with the reasonable adjustments made for patients living with dementia and learning disabilities. Relatives of patients in critical care were able stay close to the hospital in purpose-provided accommodation.
  • The numbers of patients experiencing multiple moves between wards had reduced since our last inspection. Patients did not experience moves late at night as frequently as at our last inspection. There had been significant improvements in the general/neurosurgical unit, which was discharging fewer patients at night, and this was continuing to improve. There were almost no patients transferred to another hospital due to lack of a critical care bed. There was a high level of flexibility and response from the teams, and patients were admitted to the units when they needed urgent and emergency care.

Well led:

  • We rated well led at the trust as good overall.
  • There was a clear statement of vision and values, driven by quality and safety. Staff were aware of the trust’s vision, values and strategy in surgery and the emergency department. However, they were not translated into a credible strategy for outpatients with limited defined objectives that were regularly reviewed and relevant. In the service line strategies we looked at, outpatients was rarely mentioned and some strategies had not been updated since 2012.
  • The leadership, governance and culture promoted the delivery of high-quality person-centred care. Staff felt that senior managers were visible, approachable and accessible; they told us they felt respected and valued and spoke about an open culture.
  • Governance structures and processes were being used to monitor and improve safety and quality, although in the emergency department the recording of meetings was historically inconsistent with limited information being captured, but this had improved in recent months.
  • There were good governance structures, processes and systems in place throughout outpatients and diagnostic imaging to ensure accountability, the management of risk, the management of performance, and regular review to gain oversight of how the services were performing. This was particularly highlighted through the oversight and challenge of the management of the outpatients follow up backlog.
  • Staff were kept informed and updated about relevant risks and the actions being taken to mitigate them, and were encouraged to share their experiences of what went well and what could be done better, although some staff felt disengaged because they were unable to stay updated or check and respond to emails while at work due to time pressures. Some innovation and improvement projects had been completed and were delivering improved services in the emergency department.
  • Within the interventional radiology department, staff told us there were issues with working relationships as the roles and responsibilities of the nursing and radiology staff were not clearly defined. Not all staff within interventional radiology felt their ideas were being listened to and acted upon in relation to developing the department.
  • The thoughts and ideas from staff on how the surgical care group could be improved were being listened to and the culture around incident reporting and learning outcomes had changed positively.
  • Patients had various forums in which they could raise concerns and ideas including ‘tea with matron’ sessions.

We saw several areas of outstanding practice including:

  • A new role had been developed within the acute medical units and the short stay ward to enable medicines for patients discharges to be prepared more efficiently. A pharmacy technician was seen to work proactively and support ward staff with monitoring the prescribing, preparation and delivery of medicines for patients being discharged.
  • The access for patients to receive care and treatment on the stroke pathway had improved since our last inspection. The staff team were proactive and consistently reviewed their practice to speed up the time from patient arrival to treatment. We saw evidence of where patients had been taken straight to specific treatment areas and were in receipt of treatment in very short timescales. The staff team reviewed patient treatment pathways with a view to looking at where time could be saved and where any marginal gains could improve patient outcome.
  • There had been an outstanding response from the critical care teams and the hospital trust to those areas of concern raised in our previous report. The areas we said the trust must or should improve had all been addressed. Not all were fully completed, particularly where funding was an element of the project, but there had been significant improvement in all areas to patient care, treatment and support.
  • The multi-disciplinary working between the hospital and the community services providing end of life care was outstanding. There were processes in place to enable ongoing monitoring of patients in the community and where possible prevent avoidable admissions to hospital.
  • The multi-disciplinary working between the hospital staff and the chaplaincy enabled the ongoing parochial and spiritual support of patients and their families at the end of life. Staff felt supported by the chaplaincy and the support provided to patients, whilst not always recorded, was creative in its endeavour to meet the needs of patients at the end of life.
  • The use of prompt cards in outpatient areas to give staff easy access to phone numbers and processes involving safeguarding and the management of patients with complex needs.
  • The training provided to vascular surgeon trainees by the radiologists to ensure a good understanding of the risks associated with the use of radiation.
  • The use of radiologists on the critical care unit to ensure instant information to the clinicians on the unit and to have quick reporting times and added opportunities for learning.
  • The use of a mobile phone application in the psychology service to assist in patient initiated contact clinics. This reduced the demand for the clinics and encouraged patients to manage their own care.
  • Utilising a patient liaison radiographer to facilitate ‘first day chats’ in radiotherapy giving more time to patients and to allow the treatment radiographers to have a lessened workload and to ensure the smooth running of the radiotherapy machines.
  • The audit processes used (through the fundamentals of care audit and the departmental nursing assessment and assurance framework) to gain oversight and assurance of individual outpatient clinics and diagnostic imaging areas adherence with the regulations in the health and social care act 2010.
  • The pathway for patients requiring live-donor kidney transplantation in diagnostic imaging. This ensured that all pre-operative procedures (including a nuclear medicine scan, a chest X-ray, an ultrasound scan and blood tests) completed on one day.
  • The diagnostic imaging department achieving Imaging Services Accreditation Scheme accreditation and having ISO accreditation recertified.

  • At Mount Gould, the results from programmes of audit in some specialities were being used to develop and improve services for patients and strengthened working relationships in both clinical and administrative teams had led to further improvements in the delivery of outpatient services across the trust.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • Formalise the recordings of meetings in the emergency department to ensure adequate assurance that the relevant persons are attending and discussions are held to identify learning points. Also ensure actions are recorded and allocated to a person who can progress the actions and progress is monitored.
  • Review performance data in the emergency department to ensure it is accurately captured and reported, allowing adequate monitoring and scrutiny.
  • Ensure safeguarding training for staff in the emergency department and across all areas is completed to ensure trust compliance targets are met.
  • Ensure the paediatric early warning score is implemented fully and used consistently to ensure children are safely assessed and managed.
  • Continue to work with commissioners and the local mental health service provider to ensure mental health patients arriving at the emergency department receive the care they require in a timely manner.
  • Continue to ensure the emergency department’s four-hour performance improves, with an ultimate aim to achieve the 95% standard.
  • Review the storage of intravenous fluids in the emergency department to prevent tampering.
  • The provider must ensure that equipment stored on wards and in corridors does not obstruct or impede the access to and through fire exits.
  • Ensure all equipment in all areas, and specifically the emergency department, is maintained in accordance with the trust’s service schedule. Provide a system to adequately monitor and report on this.

  • The provider must review the available storage to patients who self-medicate and retain their own medicines on the wards.
  • The provider must make sure that medical records are stored securely overnight in the oncology outpatients department.
  • At Mount Gould, the provider must reduce the number of clinics cancelled with less than six weeks notice and reduce the numbers of patients waiting past their to be seen date, capturing the reasons for the delay.
  • Ensure audit programmes associated with end of life care are carried out in line with the plan and within reasonable timescales, and that actions and improvements are reviewed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21 to 24 April 2015 and 30 April, 1 and 5 May 2015

During an inspection looking at part of the service

We inspected Plymouth Hospitals NHS Trust as part of our programme of comprehensive inspections of all acute NHS trusts. We carried out our announced inspection on 22, 23 and 24 April 2015 and unannounced inspections at Derriford Hospital on 30 April, 1 and 5 May 2015.

The trust has 12 registered locations:

  • Derriford Hospital
  • Launceston General Hospital
  • Liskeard Community Hospital
  • Mount Gould Hospital
  • Cumberland Centre
  • Plymouth Dialysis Unit
  • Plymouth Hospitals NHS Trust HQ
  • Royal Cornwall Hospital
  • South Hams Hospital (Kingsbridge Hospital)
  • Stratton Hospital
  • Tamar Science Park
  • Tavistock Hospital

During our inspection we inspected the following locations:

  • Derriford Hospital
  • Mount Gould Hospital

We rated the trust as requires improvement overall and as requires improvement for safety, responsiveness was rated as inadequate. We rated it as good for effective and well-led key questions. There were three services – maternity, end of life care, and services for children and young people – where caring was judged to be outstanding. All other services were rated as good for caring. At hospital level Derriford and Mount Gould Hospitals were rated as requires improvement for the well-led key question, and also requires improvement overall.

Our key findings were as follows:

  • We saw and heard many examples where staff had demonstrated outstanding support for patients and their families. The patient bereavement survey undertaken between January 2015 and April 2015 covered eight different wards and all comments seen were very positive, confirming that relatives felt that the care provided was excellent. Patients said they felt able to influence decisions made about them, and relatives felt included in treatment decisions.
  • In the maternity service we observed compassionate, dignified and person-centred care. Staff demonstrated a familiarity with how patients preferred to receive their care. Children in both acute and community services were truly respected and valued as individuals and encouraged to self-care and were supported to achieve their full potential within the limitations of their clinical condition. One young person said “I have a whole health team around me who have worked with me and my family over many years. I have always felt involved in my care and the children’s community nurse is excellent and I would like to nominate them for a trust WOW award”.
  • The trust had been experiencing a period of high activity since December 2014, with an increase in attendances at the emergency department. As a result the trust had operated at a position of red or black escalation for a number of weeks, leading to an enhanced focus on patient flow, discharge and liaison with other external organisations to ensure patients were seen, treated and discharged in a timely way. At times this proved challenging. We saw on our inspection that in the emergency department staff were sometimes stretched in being able to care for the numbers of additional patients, who at times were cared for in corridor areas.
  • People were frequently unable to access services in a timely way for initial diagnosis and treatment. People experience unacceptable waits for some surgical services.
  • At the peak of activity there had been up to 100 medical patients being cared for on surgical wards. The increased demands on the trust’s services and beds resulted in a high number of elective operations being cancelled. There was a lack of robust system for booking patients for surgery. The system used was not streamlined and relied upon a number of individuals to populate the theatre lists with no one in overall charge of this process.
  • We were told of plans to introduce new IT software to help this and re-introduce a scheduling team to take over the process. The increased demands on the trust’s services and beds resulted in a high number of elective operations being cancelled. The trust was also not always meeting the national targets for rebooking patients within the 28-day timescale.
  • There was a lack of robust system for booking patients for surgery. The system used was not streamlined and relied upon a number of individuals to populate the theatre lists with no one in overall charge of this process. We were told of plans to introduce new IT software to help this

and re-introduce a scheduling team to take over the process.

  • Concerns were identified with the management of medicines in a number of areas. This related to some practice not being in line with trust policy and a lack of suitable arrangements for storage of medicines.
  • At Mount Gould Hospital the management of FP10 prescriptions (these are prescriptions used for out patients that can be taken to any community pharmacy) was not robust. The trust took immediate action when we brought this to their attention.
  • In diagnostic imaging there was a backlog of radiology reporting with a total of 12,693 unreported diagnostic imaging scans in September 2014. An action plan was implemented consisting of: prioritisation of urgent scans; general practice chest X-ray’s taking ultimate priority; a waiting list initiative to prioritise patients at risk. This was managed by radiologists and radiographers volunteering to report on these scans as well as close monitoring of reporting capacity. As a result, unreported scans dropped to 4,750 in March 2015. However, since then and before the inspection this had increased to approximately 7,000.
  • In April 2015 there was a total of 110,657 patients on a follow-up waiting list with 36,724 (33%) of these patients in breach of their see-by date. A total of 1961 patients had their outcomes missing and no see-by date (meaning that the hospital did not know when a follow up appointment was required). Of the patients in breach of their see-by date, more than 26,000 (71%) did not have appointments.
  • In October 2014 a validation exercise was started to identify and prioritise patients who may be at high risk of harm as a result of long waiting times. There were a total of 4,703 ‘time critical’ patients identified at the time of the inspection. However, progress with the validation exercise varied between service lines, as not all of them had begun the validation exercise and there remained a risk to those patients who had yet to be identified as urgent or at risk of harm from a delay in their being seen or treated.
  • At Mount Gould Hospital we found there was a lack of leadership and senior engagement with the service. This meant the systems for governance and performance were not operated effectively to ensure optimum oversight of risks.
  • The hospitals were predominantly seen to be clean and well maintained, although the maternity delivery suite required improvement in the fabric of the building as it was difficult to clean and not all hand wash basins met the required standard.
  • Levels of staffing were raised as a concern in several areas. This had an impact on patients, particularly in diagnostics in addressing the diagnostic reporting backlog. In wards and departments bank and agency staff were frequently used. While this enabled some shifts to be adequately staffed, at times there were fewer staff on duty than was required. We heard of difficulties in recruitment and retention, and how the trust was working on a targeted approach to attract staff to the area.
  • Access to the Children’s and Adolescent Mental Health Services (CAMHS) at weekends was not always timely. There were internal issues around the security team – although they were present, they were not able to provide practical assistance because they had not been trained in dealing with young people. The practice educator had begun a programme of training for paediatric ward based staff in the use of restraint and conflict de-escalation.
  • Patients were at the centre of the critical care service and good results were achieved for patients who were critically ill with complex problems and multiple needs. The mortality rates within units showed that more people than would have been expected survived their illness due to the care provided.
  • Care pathways complied with National Institute for Health and Care Excellence (NICE) guidelines and the Royal College standards. Outcomes demonstrated that the majority of services provided care, treatment and support that achieved good outcomes, promoted a good quality of life and were based on the best available evidence.
  • There was good multidisciplinary working within the units and wards to make sure that patient care was coordinated, and staff in charge of patients’ care were aware of their progress. We saw physiotherapists and occupational therapists assessing and working with patients on the wards, then liaising with and updating the nursing and medical staff.

We saw several areas of outstanding practice including:

  • The care and support provided to patients at the end of their lives was outstanding. Patients and relatives told us that they felt included and involved in decisions about care and treatment, and that they had been treated as individuals, with their choices listened to and respected. Feedback from all patients and relatives was extremely complimentary about the care they had received and the staff who had delivered the care.
  • The involvement with community services in patient care was integral. As a result discharges were seen to be managed quickly to meet patients’ needs. We heard and saw instances of how the specialist palliative care team (SPCT) within the hospital worked with the local hospice and Hospice at Home team within the community to improve patient support.
  • The acute care team within critical care providing an outstanding service in terms of outreach and responding to deteriorating patients in the hospital. This was recognised by other staff, in particular the surgical and medical wards. We were told the team were quick to respond, were highly experienced and knowledgeable, and staff could ask their advice and support on any matter. Staff said the acute care team had encouraged and enabled them to ask for advice or a review of any patient where, although the patient might not be triggering a risk level, the nurse or doctor had doubts or, as was described by one of the staff, “something that didn’t feel quite right, or a gut instinct.”
  • The consultant intensivist clinical lead provided an outstanding example of compassion and support to a past patient who came to the unit during our inspection. This patient had effectively become “lost within the healthcare system” for a number of reasons linked to other events in their life. The patient was not judged for perceived or accepted failings in their life so far, but was offered compassion, advice, support, understanding and encouragement to move forward.
  • Staff on the delivery suite, Argyll ward (maternity) and Norfolk ward (gynaecology) provided outstanding care to patients. The culture was focused and embedded on the provision of person-centred care and treatment to meet individual patient needs. Patient feedback was overwhelmingly positive, which was also reflected in monthly Friends and Family tests. Patients said that the reassurance and care given had increased their own confidence. Staff of all professions and grades demonstrated kindness, compassion, dignity and respect. Patients were fully involved with their care and treatment and were actively encouraged to ask questions. Specialist professional counselling was available from midwives and a clinical psychologist supported women with difficult or complex decisions, care or treatment.
  • The neonatal intensive care unit (NICU) clinical director was an advanced neonatal nurse practitioner (ANNP).NICU benefitted from a neonatal technician service which staff found invaluable. The clinical educator for general paediatrics offered bespoke training and had performed a comprehensive training needs analysis to ensure staff were able to access training to meet their needs.
  • The paediatric services benefitted from dedicated pain assessment services and dedicated pain nursing staff.
  • We found staff to be very caring and supportive of the children, young people and their families that the paediatric services looked after both in the acute and community settings. We heard many positive comments about staff going beyond the call of duty to provide care and support. Children were truly respected and valued as individuals and encouraged to self-care and were supported to achieve their full potential within the limitations of their clinical condition. Feedback from children who used the paediatric community services, parents and stakeholders was continually positive about the way staff treated people. Parents said staff went the extra mile and the care they received exceeded their expectations.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must ensure:

  • All staff are aware of their role in incident reporting and there are systems and process in place to monitor not only individual incidents but trends and themes.
  • Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed to provide adequate levels of nursing and medical staff to ensure the safety of patients at all times. This applies to the emergency department, children’s services, outpatients and diagnostics, maternity services and medical services.
  • Patients in the emergency department that are awaiting x-rays in the corridor and the reception area away from staff vision are suitably monitored.
  • The safety and security of staff and patients in the CDU by providing a means of calling for assistance in an emergency.
  • Systems for booking theatre slots are robust and coordinated across the trust so that theatre time is utilised to provide a timely and consistent service.
  • Ensure there are systems in place so that the impact of system escalation does not delay patients who are cancelled at short notice and that they are re booked for their surgery within the 28 day requirement. The reception and waiting area in the emergency department complies with the Disability Discrimination Act.
  • Staff are administering medicines in line with the NMC standards for medicines management.
  • The checking systems for ensuring medication is fit for use, is consistently followed by staff. Intravenous fluids should be stored securely so that they are not accessible by patients and visitors to wards and departments.
  • Medicines and controlled drugs are kept in locked cabinets in the obstetric theatre and anaesthetic rooms when not in use.
  • Medications are managed appropriately in the outpatients departments and trust processes and policies are followed.
  • Patients receive appropriate and ongoing risk assessments such as mental health risk assessments and complexity scoring, to determine the appropriate place for them to be cared for and monitored.
  • All staff have sufficient knowledge of and implement the Mental Capacity Act so that patients’ mental capacity is confirmed and to identify patients who lack capacity to make decisions, so that patients’ best interests were being served.
  • Patients are protected from risk through improvement of systems and performance in relation to the time patients spend in the emergency department.
  • Treatment Escalation Plans (TEPS) are fully completed to ensure patients’ choices and preferences and ceilings of care are identified.
  • It improves the premises for patients who are using Interventional Radiology, to make sure there is a suitable environment for patients to recover post procedure.
  • Patients’ records are stored securely at all times to prevent unauthorised access to them.
  • It improves the experience of patients by addressing the high numbers of elective operations that have been cancelled.
  • Systems for booking theatre slots are robust and coordinated across the trust so that theatre time is utilised to provide a timely and consistent service.
  • The critical care service improves the experience of patients by addressing the significantly high levels of discharge from the unit that are either delayed for more than four hours or happen at night.
  • It provides a suitable environment for patients awaiting x-ray that will provide privacy and the ability to call for assistance if required.
  • The environment and equipment on the delivery suite is fit for purpose and is able to be effectively cleaned and decontaminated to prevent the risk of cross infection. The delivery suite did not comply with the Health and Social Care Act 2008 Code of Practice on the prevention and control of infections and related guidance.
  • Care and treatment is provided in a safe way for patients by ensuring premises are safe to use for their intended purpose, that is cleaning materials and sharps materials are stored securely in areas that are not accessible to patients or visitors.
  • There are sufficient resources to ensure the cleaning of blood and body fluid spillages does not pose a risk that clinical staff are unable to meet the clinical needs of patients in preference to cleaning
  • The ratio of supervisor of midwives to midwives is at the recommended level of 1:15 (Midwifery Rules and Standards, rule 12, Nursing and Midwifery Council, 2014).
  • Staff working in gynaecology are supported to have annual appraisals.
  • Rooms used for recovery of children following intrathecal chemotherapy on the children’s Outpatients Department meets laid down recommendations.
  • The safety of adolescents with mental health issues when using any of the paediatric services at all times.
  • All children using the acute or community paediatric services have a care plan in place that is updated at regular intervals or when changes occur to the child or young person.
  • Systems and process are in place to manage the backlog of follow-up appointments and the backlog of imaging reporting, to mitigate the risks to patients of delayed diagnosis and treatment.
  • Action plans are realistic and focused on the areas of concern in relation to the backlog of unreported scans in diagnostic imaging.
  • Staff have the competence, skill and experience to deliver patient care and treatment and meet patients’ needs. This includes the management and leadership roles at Mount Gould Hospital
  • Systems, processes and standard operating procedures are reliable and appropriate to keep people safe, and monitor whether safety systems are implemented at Mount Gould Hospital
  • At Mount Gould Hospital the consistent application of medicines optimisation across the services, in particular: safe storage and management of stocks of FP10 and outpatient prescription forms, safe disposal of surplus or wasted medicines, and safe custody of medicines keys, so that prescription forms and medicines are only accessible to staff with suitable authority.
  • They review the managerial and governance arrangements in outpatients, so that risks systems and processes to minimise likelihood of risk in relation to access to services and a standard booking process for appointments across all departments are fully implemented.
  • All staff understand and work within the requirements of the Mental Capacity Act 2005 where they work with people who may lack the mental capacity to make decisions.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.