Source · CQC inspection

Derriford Hospital

Provider University Hospitals Plymouth NHS Trust Type NHS Healthcare Organisation Region South West Last inspected 27 Feb 2026

Overall rating: Requires Improvement View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Good

Caring

Good

Responsive

Requires Improvement

Well-led

Requires Improvement

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Requires Improvement Assessed 27 February 2026

The service is not performing as well as it should and we have told the service how it must improve.

Date of assessment from 15 to 16 October 2025. We carried out this assessment to determine if improvements had been made following our previous inspection in March 2024. We assessed 34 quality statements for the 5 key questions: safe, effective, caring, responsive and well-led.Derriford Hospital provides a range of NHS hospital services. This assessment looked at urgent and emergency care services only which was rated requires improvement at our last assessment. At this assessment the rating remains requires improvement. The rating from urgent and emergency care services has been combined …

Ratings by service

Urgent and emergency services

Requires Improvement

Aug 2025

Surgery

Good

Feb 2025

Urgent and emergency services

Requires Improvement

Jun 2024

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Breaches identified (6)

Breach Overall

At this assessment the rating remains requires improvement as we identified some continued and new breaches of regulations.

· 27 Feb 2026

Breach Safe

Although the service had made significant improvements since our last visit (some breaches had been addressed), they were still failing to provide safe care and treatment.

Regulation: Regulation 12 (Safe care and treatment) · 27 Feb 2026

Breach Caring

We identified breaches in regulation relating to safe care and treatment, dignity and respect and good governance.

Regulation: Regulation 10 (Dignity and respect) · 27 Feb 2026

Breach Overall

However, the service remained in breach of 1 regulation and we found 1 new breach of regulation.

· 14 Aug 2025

Breach Overall

We rated the key questions and the service overall as requires improvement as we identified breaches of regulations.

· 29 Oct 2024

Breach Overall

We rated the key questions and the service overall as requires improvement as we identified breaches of regulations.

· 22 Oct 2024

Earlier inspection findings

pre-2024 framework · 8 must-do 4 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8

Must do

Safe

The service must ensure that adequate mitigation of all risks has taken place to cover the immediate period before the completed of implementation of a new end to end maternity IT system.

Regulation: Regulation 12

⚠ The service used paper-based record systems and out-of-license IT systems that did not always support staff to maintain contemporaneous care records, identified as a significant risk on the risk register.

Must-do action 2 of 8

Must do

Safe

The service must ensure training is completed and compliant against national and trust targets, including but not limited to emergency evacuation of the birth pool, patient group directive medicine, human factors training, safeguarding, and interpretation of CTG monitoring. Any staff who have not received appropriate training must have adequate mitigation in place.

Regulation: Regulation 12

⚠ Mandatory training compliance was below trust targets for key skills including emergency evacuation of the birth pool, PGD medicines, safeguarding, and CTG monitoring. Human factors training was not provided, which is not in line with national guidelines.

Must-do action 3 of 8

Must do

Safe

The trust must ensure safe staffing levels are in place, consider skill mix of the workforce and monitor maternity staffing ‘red flags’.

Regulation: Regulation 18

⚠ The service did not have enough maternity staff (midwifery and medical) with the right qualifications, skills, training, and experience to keep women safe, leading to high vacancy and sickness rates. This resulted in delays in induction of labour, lack of one-to-one care, and senior staff working excessive hours. Maternity staffing …

Must-do action 4 of 8

Must do

Safe

The service must ensure that appropriate risk assessment takes place when women and birthing people are admitted to the service, or when attending triage.

Regulation: Regulation 12

⚠ There was no formalised, standardised, evidence-based method of risk assessment used in maternity triage or labour ward. Staff did not always complete or update risk assessments for women during booking, antenatal care, or when attending triage or admission to labour ward, which was not in line with national guidance.

Must-do action 5 of 8

Must do

Safe

The service must review processes within maternity triage and ensure that care, reviews and waiting times for women are appropriate, risk-based and monitored for efficacy and safety.

Regulation: Regulation 12

⚠ The maternity triage service did not have an evidence-based, standardised system to prioritise and review women attending for urgent maternity care, and no process to support staff in prioritising care for those most in need. The service was not always able to monitor, assess, and review women in a timely …

Must-do action 6 of 8

Must do

Safe

The service must ensure adequate standards of documentation is maintained, including but not limited to: CTG monitoring, patient observations, medicine charts and handover of care. The service must ensure that patient records are stored securely at all times.

Regulation: Regulation 17(2)

⚠ Records were not always clear, up-to-date, or stored securely. Documentation for CTG monitoring, patient observations, medicine charts, and handover of care was inconsistent or incomplete. Patient records were sometimes left in unattended open trolleys in corridors, which is not compliant with data protection laws.

Must-do action 7 of 8

Must do

Safe

The service must ensure that incidents are raised, processed in a timely manner and categorised and risk rated appropriately in order to learn and improve.

Regulation: Regulation 12

⚠ The service did not always manage safety incidents well; incidents were not always categorised appropriately for future learning, and lessons learned were not consistently shared. There were 130 open incidents, with at least 61 over 60 days old, and data provided did not demonstrate accurate oversight of incidents awaiting management.

Must-do action 8 of 8

Must do

Safe

The service must ensure equipment is in-date.

Regulation: Regulation 12

⚠ The service had out-of-date equipment on the labour ward, including adult ECG leads, ECG pads, and manual resuscitation equipment, with no clear record of replacement completion.

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4

Should do

Safe

The service should ensure that audits against the Saving Babies’ Lives Care Bundle v2 are continued and that areas of non-compliance are identified and acted on appropriately in order to improve care.

Should-do action 2 of 4

Should do

Well-led

The service should review ways in which learning is shared and disseminated in order to reach more staff and improve safety culture.

Should-do action 3 of 4

Should do

Safe

The service should review processes for induction of labour, identify ways to alleviate delays and ensure the escalation pathway is used effectively.

Should-do action 4 of 4

Should do

Effective

The service should consider reviewing guidelines more frequently in order to maintain contemporaneous with best evidence-based practice.