Royal Derby Hospital

Updated 29 November 2023

Pages 1 to 3 of this report relate to the hospital and the ratings of that location, from page 4 the ratings and information relate to maternity services based at Royal Derby Hospital.

We inspected the maternity service at Royal Derby Hospital as part of our national maternity services inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

The Royal Derby Hospital provides maternity services to the population of Derby and the surrounding areas.

Maternity services at Royal Derby Hospital include antenatal, intrapartum (care during labour and delivery) and postnatal maternity care.

The maternity unit includes an obstetric consultant-led delivery suite, maternity pregnancy assessment unit, and a ward for antenatal and postnatal care. The alongside midwifery-led birth centre provides intrapartum care for women and birthing people who meet the criteria and are assessed to have lower risk pregnancies. The birth centre has four birthing rooms, one of which has a birthing pool. In the year January to December 2022 there were 5850 births at Royal Derby Hospital.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

We will publish a report of our overall findings when we have completed the national inspection programme.

Our rating of this hospital went down. We rated it as Requires Improvement because:

• Our rating of Inadequate for maternity services changed the rating for the hospital overall. We rated safe as Requires Improvement and well-led as Requires Improvement.

We also inspected 1 other maternity service run by University Hospitals of Derby and Burton NHS Foundation Trust. Our reports are here:

• Queens Hospital - https://www.cqc.org.uk/location/RTGX1

How we carried out the inspection

We provided the service 2 working days’ notice of our focused inspection of the maternity service, looking only at the safe and well-led key questions.

We visited antenatal clinics, pregnancy assessment unit (triage), labour ward, the midwifery-led birth centre alongside the labour ward, obstetric theatres, and ward 314 antenatal and postnatal ward.

During the inspection, we spoke with 36 staff including the clinical director of obstetrics, head of midwifery, obstetricians, doctors and midwives.

We reviewed 10 patient records including observation charts and medicines records.

We spoke with 3 women, birthing people and families. We received 568 'give feedback on care' forms through our website of which 277 were positive, and 291 raised concerns about the service. Where women and birthing people raised concerns, themes included: postnatal care, delays to induction of labour and pain management.

Following our onsite inspection, we spoke with senior leaders within the service; we also looked at a wide range of documents including standard operating procedures, guidelines, meeting minutes, risk assessments, recent reported incidents as well as audits and action plans. We then used this information to form our judgements.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 22 October 2020

Our overall rating of this service stayed the same.

• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients and acted on them. The service controlled infection risk and managed safety incidents well.
• Staff provided good care and treatment Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information.
• The service took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.
• Staff were focused on the needs of patients receiving care and were clear about their roles and accountabilities.

However:

• Governance processes were inconsistent and not all staff received updates and information, and lessons learned from incidents were not always shared.
• Not all staff had received training in key skills in line with the trust’s target.
• Some patient records were not always up-to-date with the rationale not always documented.

Updated 31 March 2015

Staff on the children’s wards and the neonatal unit worked hard to provide safe care. There were arrangements in place to monitor incidents, and staff were clear on their responsibilities. Staffing levels were appropriate at the time of our visit, although we were aware there were pressure points in some areas.

Children were treated according to national guidance. We observed many examples of compassion and kindness shown by staff across all the departments and ward areas.

Services were planned and delivered to take into account local need. The capacity of the neonatal unit was stretched at times but there were plans in place to introduce more cots in early 2015. Services for children and young people were well-led. There were clear governance arrangements in place.

Updated 31 March 2015

There were safe levels of medical and nursing staff, and staff were supported to develop and maintain clinical expertise.

Competent medical, nursing and other professionals worked effectively together to ensure safety. There was one never event in the week prior to our visit which was fully investigated, procedures were amended and information cascaded to staff to reduce future risk.

All patients and relatives we spoke with told us that staff were supportive, efficient and caring. The service provided follow-up arrangements for patients who had been cared for in intensive care to reduce emotional and psychological distress after their experience. There was effective clinical leadership and managers worked closely to support improved patient care. Clear plans, protocols and procedures meant that the staff were aware of their responsibilities.

Arrangements for the management of level 2 patients in the high dependency units did not meet national standards. There was daily review by medical consultants but there was no routine involvement or support from intensive care consultants. Nursing staff were working to competency frameworks relevant to their specialty but few had critical care qualifications. Audits of performance, and outcomes for patients, in the high dependency areas were not compared against similar care units nationally.

Updated 6 June 2019

Our rating of this service improved. We rated it as good because:

• The leadership, governance and culture were used to drive and improve the delivery of high quality person-centred care.
• Senior managers and managers at all levels had the appropriate skills and capabilities to provide a good sustainable service for end of life and palliative care patients. Managers felt supported by the executive team and their own management team.
• Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. Staff throughout the trust, spoke with passion about their work and were proud of what they did. There was a culture of openness flexibility and willingness among all the staff we met.
• There was a patient centred culture throughout the service. Patient stories were used in team meetings, so staff could reflect on what could be improved or share good practice. Staff said using patient stories helped them to focus on why they do job and ensure the patient was at the heart of everything they did.
• Continuous learning, improvement and innovation was important to leaders and staff; patient stories were heard at board level, efforts were made to create a non-clinical environment for patients in their last hours of life and feedback from relatives was obtained and used to shape the future of the service.
• The Nightingale Macmillan Unit had achieved MacMillan Quality Environment Award (MQEM) accreditation in 2017 with a maximum score of five out of five. MQEM is a detailed quality framework used for assessing whether cancer care environments meet the standards required by people living with cancer. It is the first assessment tool of its kind in the UK.
• The bereavement office was committed to the needs of the local people both the deceased and the living. For example, they were made aware last year of a 95-year war veteran who had died in the hospital without any family or friends. The Bereavement office contacted the local regimental group, to see if any relatives could be found. After an appeal was put out by the regimental group, over 200 people attended the war veteran’s funeral, where the service was conducted with full military honours. The local paper reporting “There was standing room only at the funeral service”.
• Staff who provided end of life care said they had received training in safeguarding children and vulnerable adults. Safeguarding training was part of the trust’s mandatory training programme.
• We saw infection prevention and control (IPC) policies and procedures in place that were readily available to staff on the hospital intranet. Infection prevention and control was included in the trust’s mandatory training programme.
• We saw comprehensive risk assessments completed in the medical and nursing notes. These were commenced on admission and there was evidence that risk assessments continued throughout the patients stay in hospital. Examples of this included skin assessments for pressure ulcer risk and updated care plans for patients with mouth care needs.
• The trust used the AMBER care bundle system. This is a model which provides a systematic approach to management and care of hospital patients who are facing an uncertain recovery and who are at risk of dying in the next one to two months. We saw care nursing care records where the AMBER care bundle was used to assist in the planning and delivery of patient care.
• The trust had good multidisciplinary working relationships with the local hospice to provide support for patients at the end of their lives and advice for the trust staff out of hours, with representatives from local hospices took part in the end of life care steering group meetings.
• The end of life care medical documentation contained detailed discussion and decision making with the patient and/or family and outlined the professionals involved in the care. The document also provided guidance and flowcharts for clinicians on symptom control such as management of pain, nausea, agitation and breathlessness.

However:

• The trust recognised they were not providing a HPCT seven days a week. However, they told us there were plans for this to commence, however, with the acquisition by merger of a neighbouring trust only recently undertaken, the trust was unable to advise the date this would commence.
• During our inspection, we looked at 15 ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders across the hospital and found there were inconsistencies in how these were completed. We found that out of 15 DNACPR orders we looked at, ten that were completed correctly, (65%) were on The Macmillan Nursing Unit. Five were not completed correctly (33 %) and these were on the wards throughout the hospital
• The trust took an average of 45 working days to investigate and close two of the complaints. This is not in line with their complaints policy, which states complaints should be resolved within 25 working days. The one complaint still open at the time of reporting had been open for 38 working days. This was also not in line with the policy statement that complaints should be resolved within 25 working days

Updated 29 November 2023

Updated 31 March 2015

There were reliable systems, processes and practices in place to protect patients from avoidable harm and abuse. Risks to patients using the services were assessed and appropriately managed.

Patient needs were assessed and their care and treatment were delivered in line with local and national guidance for best practice. Consent to care and treatment was obtained in line with legislation and guidance. Staff were suitably qualified and skilled to carry out their roles effectively and in line with best practice. There were good examples of staff working collaboratively to meet patient needs.

Patients spoke positively of staff they came into contact with. Staff were observed to be caring and compassionate in the way they dealt with patients and their families or carers. They were knowledgeable and enthusiastic about the service they provided and this was reflected in how they engaged with people.

Updated 22 October 2020

Our overall rating of this service went down. We rated it as requires improvement because:

• Not all staff had received training in key skills in line with the trust’s target.
• Lessons learned from incidents were not always shared with staff.
• Staff did not always undertake mental capacity assessments in line with the Mental Capacity Act.
• Governance processes were inconsistent and not all staff received updates and information.

However:

• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients and acted on them. The service controlled infection risk and managed safety incidents well.
• Staff provided good care and treatment. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information.
• The service took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services.

Staff were focused on the needs of patients receiving care and were clear about their roles and accountabilities.

Updated 6 June 2019

Our rating of this service stayed the same. We rated it as good because:

• Staff understood safeguarding processes, were trained to stream and triage effectively and could identify and treat sepsis quickly. The service had sufficient nursing and medical staff with the right qualifications to deliver good quality care and treatment. Patients with mental health issues were assessed in a timely manner.
• Time from admission to triaging was consistently lower than the England average. The service provided safe care and treatment based on national guidance, patient’s pain was assessed and they were given appropriate fluid and nutrition.
• Staff were competent in their roles and worked together as a strong cohesive team. Patients had access to 24-hour diagnostic screening, specialist and support services.
• Staff understood their roles and responsibilities concerning the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff took account of patient’s individual needs, caring for patients with compassion and understanding, involving them in decisions about their care and providing emotional support when necessary.
• The trust had systems and processes in place to promote access and flow through the department and any complaints and concerns made were treated seriously, investigated and lessons learned from them.
• Managers at all levels had the skills and abilities to run a service providing high quality and sustainable care. There was a vision for what the service wanted to achieve and workable plans to turn it into action and systems were in place to identify risks with plans to eliminate or reduce them.
• The trust was committed to improving services and promoting training and research. Innovative systems had been put in place for those with a hearing impairment and to empower adult patients to request a review of their pain. A system had been introduced to improve the quality of care in the department which had received a nomination from the National Patient Safety Awards.

However:

• The trust had not achieved its own targets for all mandatory training elements for all members of staff and the adult emergency department (ED) could not access patient’s notes relating to their care in the local mental health trust.
• There were low numbers of hand gel dispensers at entrances to each area in adult ED and at point of care.
• The digital system in adult ED had not been updated to meet the reporting requirements for the 2018 emergency care data set (ECDS). No documented triggers were in place to denote when a patient required additional observations if their NEWS2 score was five or above.
• Two sets of clinical guidance were available on the trust’s intranet, one of which had not been reviewed. However, the trust were aware of this and were taking actions to mitigate any risk.
• The space in the ‘major’s area was inadequate for the number of patients requiring it later in the day and patients complained about their length of stay.
• From December 2017 to November 2018 the trust consistently failed to meet the standard of 95% of patients being admitted, transferred or discharged within four hours. There was no designated space for patients requiring a quiet space due to dementia, learning disability or autism.
• Junior staff did not have the opportunity to attend governance meetings and risks on the risk register dated 14 November 2018 had review dates that were in the past.
• There no specific engagement arrangements in place to receive feedback from patients with mental health and emotional well-being concerns.