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 reviewed the learning culture, safe systems, involving people to manage risks, safe environments, safe and effective staffing and infection prevention and control (IPC), quality statements for the safe key question. Treatment and care was not always provided in a safe way. Patients did not have timely access to assessment or treatment. There were long waits for patients in ambulances and within the department. Patient risks were not always monitored safely or effectively following triage. The service could not move patients promptly to medical and surgical wards. Patients experienced delayed discharges. However, staff were doing their best to mitigate risk at a time of very high occupancy in the department.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients continued to experience long waits and delays to triage and treatment. A patient’s relative was told there may be a 48 hour wait for patient to be admitted to hospital. However, they were well looked after and the relative was kept informed.

There were improved relationships internally between the department’s team and the medical and surgical teams. The trust was working with a national NHS improvement team that had supported the service to review patient flow and safety. However, there remained significant issues regarding the flow of patients through the hospital and out into the community, which caused delays to emergency department patients. Managers told us new executives were in post and staff said they listened. There was better support and focus across the trust which meant that departments were able to work together. There were processes to share feedback with staff. However, not all staff received feedback/learning from senior staff when incidents had been raised, which led to a culture of staff being less inclined to report incidents. The pathway for patients with mental health needs had improved with a dedicated nurse being appointed to support patients through the pathway. However, not all staff were aware of the hours the nurse was available and said they were not very quick to respond to calls for assistance in the department. Staff were building relationships internally and externally with local stakeholders, ambulance services and GPs. Weekly meetings with the ambulance service had helped to jointly manage the high numbers of patients arriving by ambulance.

The provider had processes and policies to foster a learning culture. Senior staff met quarterly, and evidence showed staff feedback was documented and taken forward with teams for learning. However, not all staff were engaged in this process. The service had arrangements related to infection prevention and control (IPC), which included screening, monitoring of expected standards and shared learning. There was roll out of continuous improvement planned, which included building work and expansion.

Some patients told us they experienced long waits accessing care while waiting on ambulances or in the waiting room. One patient said she had been there for 24 hours, had been assessed in the emergency department, and was now waiting to be admitted. However, some patients told us they were seen relatively quickly.

Staff told us a treatment area was providing ward-based care due to delays transferring patients to wards. Patients were in the area for long periods, putting increased pressure on staff and delaying patients who were waiting to be seen for treatment. Some patients were admitted overnight on the Same Day Emergency Care (SDEC) unit and they were unsafe due to inadequate staffing and lack of facilities. The unit was supported by the acute care team. This was not in line with the NHS England (NHSE) SAMEDAY strategy 7 priorities. However, teams continued to adapt to meet patient needs. Some patients who initially arrived by ambulance were seen, treated and discharged from the department but could not always go home until transport was available, sometimes resulting in patients returning to wait on ambulances. Data showed that patient transport services were available between 7am to midnight, 365 days of the year. However, this was subject to eligibility rules. Out of hours there was access to taxis including wheelchair accessible taxis.

Members of the NHS ambulance service at the Hospital Ambulance Liaison Officer (HALO) reception desk, said they work closely with hospital staff and regular meetings were held. Crews continued to experience long waits to admit patients which created delays for patients waiting in the community.

The provider had processes and escalation plans to manage increased pressures on the service. There was a Secondary Transfer Policy for Major Trauma to improve the patient pathway and ensure patients were transferred to a point of care as quickly and safely as possible. However, the service still faced challenges with access and flow which meant they could not always ensure patients received timely assessment or treatment. Performance data showed delays for patients waiting to be seen. On the day of our on-site visit 297 people attended the department and of those, 77 waited over 12 hours to be seen, treated and/or admitted. There was ineffective streaming of walk-in patients on arrival at reception which contributed to high numbers of patients in the department. However, children attending the department were immediately directed to the children’s emergency entrance. There was a procedure for reviewing patients on ambulances by a doctor or nurse. However, we observed long waits and sometimes crews chasing staff for patients to be reviewed. Evidence showed that following triage there were guidelines to refer patients to specialty services. However, there were transfer delays due to lack of beds on required wards. Some patients were returned to ambulances to wait with the support of medical staff from speciality areas. Patients were reviewed and prescribed treatment or investigations while waiting. There was a Rapid Assessment and Triage (RAT) protocol for patients arriving by ambulance for immediate safe clinical triage and stabilisation, handover to the emergency care staff and release of ambulances. However, there was only 1 RAT room and we observed patients being returned to ambulances following triage, with treatment started where possible, until a space became available in the department. Some patients waited on ambulances for up to 24 hours.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

Some people attending the department said they experienced long waits (9 out of 13 people to whom we spoke). Patients were at risk of clinical deterioration.

Staff were focussed on patient care and had insight into patient safety risks against which they were trying to mitigate. They told us there was a strong focus on ambulance waits but the biggest risk was the waiting room area and triage. Despite improvements, this was an ongoing concern including weekly incidents due to crowding. Not all staff received feedback/learning from senior staff when incidents had been raised, which led to a culture of staff being less inclined to report incidents. However, there were processes to share feedback with staff. Falls risk assessments were completed at triage for people with dementia. Nurses and Health Care Assistants (HCAs) were trained to assist people with dementia. Patients were also identified if they were not allowed any food or drink or if they were waiting a long time. Staff said there were many delays obtaining medicines from pharmacy when discharging patients, contributing to the risks associated with poor patient flow through the hospital.

There were processes for patients to be signed in at reception and wait for triage. However, patient risks were not always identified in a timely manner in the waiting room and the monitoring of risks was not always effective. Crowding and the layout of the waiting room made it difficult for staff to safely observe patients, hear patients call out or be able to move patients in wheelchairs or on trolleys if required. Risk scoring was used in deciding the priority of patients to be seen. We saw evidence of monthly Risk Monitoring Registers and actions taken. Incidents were investigated in line with policy guidance and reported monthly as part of governance processes.

Although patients experienced long waits in ambulances and waiting rooms, some patients told us they were well looked after by staff. Due to the waiting and treatment areas being full, one patient said their assessment was conducted in the middle of the waiting area, in front of a nursing station, which they found undignified. Another patient was moved out of a side room and relocated in front of a desk.

Staff understood the challenges of the demands on the service and utilised different areas to make patients as safe as possible. Due to length of wait to be seen, staff told us sometimes patients waited overnight in the waiting room; some patients slept on the floor.

The waiting room was not large enough to safely accommodate the high volume of patients and visitors in the area. We saw all areas of the department were very busy and the waiting room was crowded with people in very close proximity to each other. There was outside seating with heaters being used as the waiting room capacity had been exceeded. The layout of the waiting room made it difficult for staff to safely observe patients or hear patients call out for assistance. A written sign in the waiting room directed patients to check a screen for wait times, however, this was not switched on. Staff told us the screen was often disconnected. There were very long waits for patients to be triaged. There were not enough chairs to accommodate patients and accompanying visitors. Many people were standing. There continued to be high numbers of ambulances with patients on board waiting to be seen. We observed patients experiencing very long waits in ambulances due to significant issues regarding the flow of patients through the department. Patients waited on trolleys with ambulance staff to be triaged. The main treatment area was full, with beds very close together. We observed a lack of dignity for patients in the crowded environment and delays responding to call bells. However, staff interaction with patients was friendly and polite. Equipment for staff was well stocked and organised.

Evidence showed matrons conducted and completed monthly audits. For example: cleanliness of environment, safe disposal of implements, alcohol gel availability, oxygen checks, call bells answered and storage of medicines. Audit results varied but were mainly 50 – 100% compliant.

Patients attending the department said staff kept them informed while others said communication was poor. Patients described nurses as “lovely” and “doing their best”.

Staff knew how to escalate concerns if patients deteriorated and required urgent assistance. However, the layout of the waiting room, together with crowding, made it difficult for staff to observe patients. Staff told us they were not always able to give the care they wanted to provide to their patients, and this was a concern for them. They reported positive teamwork and felt support by their leaders. Nurses and Health Care Assistants (HCAs) were trained to assist people with dementia. Staff told us end-of-life patients were supported by palliative staff as 85% of palliative patients attended the department. The end-of-life team had a good record of transferring patients to the right place, therefore seeing a reduction in deaths in the department. Leaders told us there was funding to increase the number of nurses with a strong focus on retention as well as recruitment.

We observed staff were extremely busy.

Mandatory training was required of all staff and was monitored. However, figures showed that some staff had not completed training within required timeframes. Regular simulation training (true-to-life learning environments) sessions were available to staff. There was evidence of leadership development and training for staff. Staff appraisals were not always completed. Rates fell short of the 100% target. For example, 30 out of 103 nursing staff appraisals had not been completed due to pressures on staffing and the continued increase in the number of patients attending the department.

A cleaning frequency poster was displayed in the waiting area, visible to staff and patients. We observed areas to be crowded but tidy and cleaning was in progress. A patient commented (in a trust survey) that it would have been nice if the cubicle was clean, and that the floor and the bed were dirty.

Staff received mandatory infection prevention and control (IPC) training during induction, as well as annual updates. Audits were completed to check compliance with standards. Over a recent 6 month period, 590 hand hygiene audits showed an overall compliance score of 92% out of 100%.

Cleaning was undertaken in the department by dedicated cleaning and housekeeping teams. There was easy access to equipment to do their jobs. Staff wore uniforms correctly and adhered to bare below the elbow policy. Equipment was not labelled to confirm it had been cleaned, although we did not identify any dirty items. There was a good stock of personal protective equipment (PPE) and we observed staff using these where required. There were adequate clinical and general waste bins in all areas. There were handwashing facilities available for staff and we observed staff using them.

Staff understood processes for suspected infectious patients. However, staff did not always have capacity to follow protocols to keep people safe from risk of infection. Long waits for triage delayed identifying infection. Risk of contamination from waiting room chairs. There were daily checklists for cleaning and re-stocking equipment trolleys. However, it was not always documented they had been completed. The department’s training team included IPC in all training and staff competencies were checked. Safe IPC practice was included in all clinical skills training. Mandatory training data for March 2024 showed ED staff as 97% compliant for IPC Level 1 (completed every 3 years) but only 74% for IPC Level 2 (completed annually). The expectation was 100% compliance. Staff also received training in food safety. There were hygiene audits and these were regularly completed. The audits showed staff followed the hand washing process.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.