Plymouth's Derriford says action has been taken - after inspectors demanded immediate changes
The trust was issued with a warning notice after an unannounced inspection in March
Last updated 8th Nov 2024
Inspectors at Plymouth's Derriford Hospital have taken action which they was 'to protect people using urgent and emergency services'.
The Care Quality Commission says it acted on concerns about access to the emergency department during an unannounced in inspection in March.
The trust was issued with a warning notice 'to make rapid and widespread improvements to keep people safe and improve access and overcrowding in the emergency department'.
The overall rating for the trust and the hospital remain as 'requires improvement'.
Inspectors found that 'not all staff received feedback from leaders when incidents had been raised' - adding: "This led to a culture of staff being less inclined to report incidents."
They also concluded: "The layout of the waiting room made it difficult for staff to safely observe or hear people call out for assistance. The waiting room was not large enough to safely accommodate the high volume of people 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 with some areas being standing room only."
What did the inspector say?
Catherine Campbell, CQC deputy director of operations in the south, said: “On previous inspections we had highlighted the pressures at Derriford Hospital being mainly due to limited availability of social care beds and community care, which impacted on the number of medically fit people able to be discharged. That hindered flow throughout the hospital, causing people to experience long delays.
“During this inspection we found people were still experiencing long waits in ambulances and the emergency department waiting room was still overcrowded. This included people experiencing long waits to be triaged, treated or discharged. One person’s relative was told there may be a 48 hour wait for their loved one to be admitted to hospital.
“However, some told us they had been assessed and treated relatively quickly. People gave positive feedback about staff, describing them as brilliant and lovely. This doesn’t alter the fact that in October 2021, we highlighted the same problems to the trust’s leadership and local stakeholders.
“There is a new leadership team in place at the trust and we are aware that emergency department delays in treatment is one of the areas that has been prioritised to improve care. But, continued focus is required on what the trust can do to improve the safety, quality and experience of care for people through the emergency department, by making the improvements required in the warning notice will focus attention on the areas we want to see significant and widespread improvement particularly regarding overcrowding in the emergency department.
“This includes focusing attention on the areas we want to see significant and widespread improvement particularly regarding overcrowding in the emergency department.
“The new leadership team 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 people arriving by ambulance.
“We will continue to monitor the trust, including through future inspections, to ensure the necessary improvements are made so people can receive safe and appropriate care.”
What has the NHS trust said in response?
Chief Executive Mark Hackett said: “At the time, we know the quality and speed of care we were able to offer patients coming for Urgent and Emergency Care was not what we aspire it to be when the CQC inspected our services back in early March. They arrived during an internal Critical Incident and what they saw was fairly reflected in their report, but that was eight months ago now and we have made good progress in improving our performance since then. Our staff are doing all they can to ensure the safety of patients at all times – we know there is still work to do but it is important to reflect the improvements we have made since the inspection, which are many. We have made significant improvements since March, but we are striving for better and there is more to do.”
Has anything changed?
The hospital trust say there has been a relentless focus on improvement through the One Plan for UEC, including creating new pathways away from the Emergency Department, initiatives to treat people in the community to avoid hospital conveyance and investing in more Same Day Emergency Care.
We have started to reduce waits for patients, improving performance against the 4-hour target from 54% in March 2024 to 66.3% by the end of October 2024. We have also reduced ambulance handover delays significantly. At the time of the visit in March, we were recording 9,326 hours lost to ambulance handover delays, we have brought that figure down to around 3,700 in October.
There is more work to do to further improve, and this istaking place right now. There is considerable work andongoing investment to make this an organisation that offers high quality care.
The inspectors recognised there was ongoing improvement to staffing levels in the Emergency Department. Staffing levels for nursing has improved, including the introduction of a Nurse Manager to provide the helicopter view of the department was noted by the inspectors. The number of vacancies that have been filled in the Emergency Department has been exceeding our target this year and we are investing in new consultants for Urgent and Emergency Care.
Our One Plan - We have a single plan for improvement which ensures that patients who attend as emergencies are seen in the right place, at the right time by the right staff. This plan is about three key things: admission avoidance, flow through the hospital, and timely discharge to get people to the comfort of their own homes more quickly. We are already seeing improvements as a result of the OnePlan since its introduction earlier in the year, such as an improving 4-hour performance and a decrease in ambulance delays.
The trust has also given an update on work in different departments
As part of the One Plan, we have created new pathways for patients within Derriford Hospital. For example, people with issues in early pregnancy go straight through to our Early Pregnancy Service and patients who have gynaecological problems go straight to that specialist unit.
Our Urology team have been amongst the first in the country to introduce a Urology Same Day Emergency care model and to help patients with urological problems attending as emergencies.
Work has also taken place between the Children’s Assessment Unit and the Paediatric Emergency Department to stream children up to Level 12, our children’s unit, faster.
We have also seen sustained improvement in the percentage of fractured Neck of Femur (NOF) patients undergoing surgery within 36 hours, down from 59 hours. NOF patients are also spending less time in the Emergency Department, coming down from 497 minutes to 306 minutes
More space to see and treat patients on the same day; 57% of the patients we see and treat on the same day (Same Day Emergency Care) are streamed from the Emergency Department -historically these patients would have been admitted into the hospital
More rapid assessment spaces in the Emergency Department A new Medical Receiving Unit – this supports the movement of medical patients out the Emergency Department prior to admission to a ward and is making a difference in ambulance handover times
More hot clinics – these have been put in place so patients who attend the Emergency Department, but who are well enough to return to a specialist clinic the next day or soon after,
Community initiatives - our teams, in conjunction with partner organisationLivewell Southwest, have started to rollout community initiatives that are supporting patients to receive treatment and recover in the community, whether that is at home or in another care setting.
Community Frailty Virtual Wards – 21 virtual beds for six areas in Plymouth. This looks at all patients care needs and medicines, allowing frailty teams to devise and coordinate care with specialist input in the community. This is in addition to the Virtual Wards already in place at UHP
Our new X-Ray Car Pilot Service– the car is out and about in the community attending frail and vulnerable patients who have had a fall, releasing 3-5 ambulances into the community every day. The project may prevent over 70 conveyances to the Emergency Department per month, with a monthly reduction of 1000 inpatient beds across the hospital.
Our Supportive and Palliative Care Service, which is major component of our Urgent and Emergency Care One Plan programme, is well into mobilisation. The service enhances our end of life offer for our patients and their families by utilising End of Life beds at Mount Gould hospital, expanding our End of Life team in the Emergency Department, and partnering with Marie Curie to ensure a partnership approach to the provision of palliative care expertise and capacity.
Outpatient Head Injury Support Service supporting older patients access to imaging after head injury. The service allows patients to remain in their current setting and attend a scheduled CT scan either on the same day, or the next, avoiding ambulance conveyance into the Emergency Department
CQC inspectors noted at the time, the current Emergency Department physical environment is unfit for purpose and this adds to a poor patient experience. We are addressing this through the opening of our on-site Urgent Treatment Centre (UTC), named the Dartmoor Building, in early 2025. A new facility for our Fracture Clinic will also be relocated from the main hospital site to the Dartmoor Building. This space will offer a multidisciplinary team of experts to diagnose, treat and support patients in their recovery of fractures in a larger, modern purpose-built healthcare environment.
Our plans to build a new Urgent and Emergency Care Centre through the New Hospital Programme are underway. Enabling works have commenced for the new 17,000m2 Urgent and Emergency Care Centre at the front of Derriford Hospital. This new facility will consist of four floors of emergency care facilities; one devoted to same day emergency care, a new paediatric emergency department, emergency surgery theatres, imaging facilities, interventional radiology facilities, training facilities, staff rest and welfare facilities, and all the support accommodation associated with our emergency care pathway.
What does the local MP say?
Commenting on the Care Quality Commission's new report on University Hospitals Plymouth, Luke Pollard MP, Member of Parliament for Plymouth Sutton and Devonport, said:
"I welcome the improvements being made at Derriford, but this report also shows that the significant concerns I raised about the NHS being pushed to breaking point under the last government were correct.
"I praise Derriford's work in getting things to a better place. But for the sake of patients and staff, there is still much work for us to do to give Plymouth the hospital and emergency department that our city deserves."