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Response to CQC Report into Unannounced Inspection of Diagnostic Imaging and the Emergency Department

Chief Executive Ann James said:

“Today sees the publication of our CQC report. Inspectors from the CQC visited to carry out an unannounced inspection of Diagnostic Imaging and the Emergency Department on 8 March 2021.

I am delighted to say the improvements we have made in Diagnostic Imaging were recognised by the CQC inspectors. They found good levels of patient care and good management of patient safety. They were satisfied that the service had a vision for the future and a strategy to get there, led by a capable leadership and that staff reported feeling supported and valued.

  • Staff monitored the effectiveness of care and used the findings to make improvements and achieved good outcomes for patients.
  • Leaders were visible and approachable in the service for patients and staff.
  • Staff felt respected, supported and valued. They were focused on the needs of patients receiving care.
  • Staff were positive about their work, their managers, and the support they received.
  • The service collected reliable data and analysed it. Information was easily available for staff to have oversight of their own department. All staff were committed to continually learning and improving services. Staff had a good understanding of quality improvement methods and the skills to use them.

This is a superb turnaround from when the department was issued with a warning notice in 2019 and testament to the efforts of so many staff in Team Imaging, not least the leadership team who have worked diligently to lead these improvements. We are one of the trusts whose diagnostic waits have recovered more quickly following the pandemic, which demonstrates how these improvements are well and truly embedded.

Team Imaging provide an example of the successful improvement culture we have at University Hospitals Plymouth NHS Trust. This is called our People First programme. We will now demonstrate how we are applying that same improvement approach to our emergency care services.

The CQC have applied a warning notice to emergency care at Derriford Hospital, because of their concerns over safety, particularly crowding and delays to patients being seen. We are disappointed to receive this notice. Our staff have worked hard during the global pandemic to meet the needs of patients attending as emergencies, both with and without COVID-19 and it is important to recognise we are working to meet the needs of patients right across the peninsula in our role as a Major Trauma and specialist centre. It is good to see the inspectors recognised that “Staff were focused on the needs of patients receiving care.”

We have provided the CQC with evidence of the immediate actions we have already taken to address their concerns and ensure patients attending the department are safely cared for. We have a comprehensive Urgent and Emergency Care improvement programme and some of the key themes about what we are doing are captured in the table below.

We have a good record of being able to turn things around. We also have a bright future to look forward to with plans for a new Urgent and Emergency Care Centre. The creation of this centre will also help reduce crowding and create a better care environment. Watch this video to find out more about our plans (16 mins 12s length).

I hope patients and their families will take comfort from the fact that 90% of patients visiting the Emergency Department rated their experience as very good or good, understand we have already made changes and we have big improvements planned in the shape of our new Urgent and Emergency Care Centre.

We are committed to making the improvements necessary to support patients moving more quickly and safely through our Emergency Department. We cannot do this alone. This is a system challenge and we continue to work with our partners in the community and SWAST to make improvements in the hospital and across our health and care system.”

Darryn Allcorn, Chief Nursing Officer for NHS Devon Clinical Commissioning Group, added:

“We acknowledge the findings of the Quality Commission (CQC) report on Urgent and Emergency Care and Diagnostic Imaging services. We welcome the improvements found in Diagnostic Imaging services and recognise everyone at University Hospitals Plymouth (UHP) NHS Trust is working hard to build on the progress made to date.

“We share the trust’s disappointment at the outcome in relation to Urgent and Emergency Care and we know the Emergency Department team works incredibly hard to provide high quality care for people, not just from Plymouth, but from across the region.

“The safety of patients is paramount, and the report shows improvements are needed. UHP have given us an assurance that the necessary changes are being made to address the issues highlighted within the report. As the Integrated Care System for Devon, we are working with other local health and care partners on a range of measures to support Derriford Hospital, which include expanding the Community Crisis Response Team, improving the process for ambulance handovers, promoting the Think 111 message, helping people get home from a hospital stay as quickly and safely as possible, and widening the use of alternative services, such as the Urgent Treatment Centre at the Cumberland Centre.”

Minor injuries units opening times


Think NHS 111

We are also asking for the public to play their part and #HelpUsHelpYou by Thinking NHS 111 first.

If you need urgent medical advice, there’s just one telephone number to remember – 111. By contacting 111 first, either online or by phone, people will get quicker and safer access to NHS services when they need urgent care.

Those contacting 111 who need emergency medical care from a hospital Emergency Department (also known as A&E) will be given direct access to the department.

If the issue would be better dealt with in a Minor Injury Unit, GP surgery or other urgent care site, patients will be booked in directly. This will ensure that people get to the right place for treatment quickly and should reduce waiting times.

By contacting 111 first, people will not only be treated more quickly, but the number of unnecessary visits to some of the region’s busiest healthcare facilities will be reduced – taking pressure off local services and ensuring social distancing measures are applied.


Concerns raised and what we are doing to address them

These changes have resulted in a significant improvement in ambulance handover times and initial time to treatment for patients.

Concerns raised and what we are doing to address them

CQC Findings of concern

Actions taken to address

Crowding with the Emergency Department and environment

We have created separate entrances for patients arriving by ambulance and those arriving on foot, directed by NHS 111 for example. We are moving patients through the Department as quickly as possible by a relentless focus on flow: getting patients to the right place as quickly as possible, including those ready to be discharged home.  These changes have already resulted in a significant improvement in ambulance handover times and initial time to treatment for patients.


Operational management presence has been strengthened in ED from 08:00-20:00 each day to work closely with the Patient Flow Co-ordinator and ED Sister to track capacity


Direct admission pathways to the Surgical Assessment and Medical Assessment Units have been improved to support identification of patients who can go straight to the most appropriate area and bypass the full ED pathway

We have strengthened the process for transfer of patients to the Acute Assessment Unit and Frailty Unit


K Bay on the Medical Assessment Unit has been repurposed to provide a GP expects/admissions area – this re-routes patients and prevents unnecessary ED attendances

Lapses in practice around infection prevention and control

Due to the need to respond to COVID safely and do everything we can to maintain social distancing, throughout the pandemic we have used two Emergency Departments: one for patients with possible COVID and the other for patients without symptoms indicative of COVID

We have clearly defined socially distanced areas for patients waiting to be triaged. All patients are now offered a clinical face mask upon entry to the Emergency Department

Patients were not being seen in priority based on their clinical need and not sufficient oversight

The ambulance handover sign off process has been strengthened and is supported by standard processes for the HALO Corridor and Delayed Ambulance Handovers, jointly agreed with UHP and South Western Ambulance Service.

We have senior staff assessing patients’ clinical needs when they arrive, to ensure those with the highest clinical need are seen in a timely way

Regular ‘safety huddles’ have been reinstated in START to review patient safety and ensure plans for treatment and early escalation are in place

Patients with mental health needs were not always seen in a timely manner and cared for in an appropriate environment.


We have trialled placement of the Psychiatric Liaison team from Livewell Southwest in the Emergency Department to support care for patients in a timely manner

Staffing levels – nursing and medical

We have completed reviews for both our nursing and medical teams to ensure we have the right numbers of staff

Patient record keeping is inconsistent

Staff have been reminded of the importance of good record keeping and all documents are checked prior to them leaving the Emergency Department

Performance data showed delays in patients both accessing the emergency department and waiting to be seen

We have reduced the waiting time between arrival by ambulance and being brought into the Emergency Department

We improved use of the discharge lounge leading to earlier flow through the hospital resulting in the creation of early capacity.

Supporting new leaders and improving culture

We have an Urgent and Emergency Care programme and part of this is designed to strengthen the culture within the department

Risks and issues and were not always identified or appropriate actions taken to reduce their impact.

We have risk registers at departmental and Care Group level and all risks are reviewed and monitored through the Emergency Department Governance meetings.  Serious risks are monitored through the Medicine Care Group Quality Assurance Group and reported through to the Board via its sub committees.


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