Chesterfield Royal Hospital NHS Foundation Trust

Chesterfield Royal Hospital was built in the 1980s and became a foundation trust in 2005. The hospital serves five local districts with a population of approximately 441,000. There is a small ethnic minority population, with over 96% of the population belonging to a white ethnic group. Life expectancy for both men and women in two districts (Chesterfield and Bolsover) is worse than the England average.

The hospital provides 682 inpatient beds and employs over 3,500 staff. In the year 2013-14, there were more than 71,000 inpatient admissions and 257,000 outpatient attendances; over 67,000 patients attended the accident and emergency department.

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it was an example of a low risk trust according to our new intelligent monitoring model. Our inspection was carried out in two parts: the announced visit, which took place on the 21,22,23 and 24th April 2015; and the unannounced visit which took place during the evening of the 2 May 2015.

Our key findings were as follows:

• All of the services we inspected were found to be caring. Staff were kind and caring towards patients, and treated patients with dignity and respect. Most patients and visitors we spoke with were complimentary about the care they were receiving.

• Overall we observed the hospital and clinic environments were visibly clean, hygienic and well-maintained. Improvements were needed in relation to the storage of clinical waste in the Eye Centre, within the Outpatients service. Patients told us they were impressed with the standards of cleanliness. There had been 30 cases of C difficile (a bacteria which causes diarrhoea) infection in the year up to February 2015 which was worse than the England average. Fifteen of the 23 (65%) confirmed patients with C difficile had one or more lapses in the quality of care identified as part of the investigation process. There had been two cases of Methicillin Resistant Staphylococcus Aureus (MRSA) reported between April 2013 to Nov 2014, both occurring in 2013. The trust had 17 cases of Methicillin-Susceptible Staphylococcus Aureus (MSSA) throughout the same period but this was similar to the England average. MRSA and MSSA are types of bacteria that can cause infections. We found there were systems in place to deal with infection prevention, and control and we observed staff to be following the trust guidelines.

• Nursing staffing levels had been reviewed and there had been an increase in nursing and midwifery staff. We found the day time staffing levels were in line with national guidance and generally, both the day and night time staffing was in line with the numbers of staff the trust had identified they needed. There was an escalation process in place so that staff could flag if they were concerned about the staffing levels on each shift. In some areas, particularly within medicine, staff didn’t feel there were always enough staff on duty overnight. Some of the staff told us they didn’t report their concerns about the night staffing levels through the incident reporting system. We raised this with the trust and they took action straight away to review their staffing levels at night. There was a reliance on bank and agency nursing staff in some areas and like many trusts, they faced difficulties recruiting nurses.

• There had been an increase in the number of midwives, and although the trust was not meeting national recommendations for birth to midwife ratios, staffing was comparable with other maternity services across the region. The trust was not able to provide a band six registered children’s nurse to be on duty at all times. This was due to difficulties in recruiting suitably experienced children’s nurses.

• Medical staffing was at safe levels in most of the services we inspected; however in some areas there were vacant posts and reliance on locum medical staff.

• Patients were provided with the assistance they needed to eat and drink and the risk of malnutrition or dehydration was assessed. Speech and language therapists provided support to ward areas to carry out swallowing assessments, and dieticians provided nutritional advice.

• Patients’ pain was assessed and generally well managed. There were no specialised tools in place to assess pain in those with a cognitive impairment such as a learning disability or those living with dementia. Women in labour were given a choice of pain relief and provided with non-pharmacological options such as aromatherapy and the use of a birthing pool. Epidural pain relief was available on request, and the waiting time for this was within an acceptable 30 minute timeframe.

• Monitoring by the Care Quality Commission had not identified any areas where medical care would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital-level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected. Information about patients’ outcomes was monitored. The trust participated in all of the national audits it was eligible for. Where improvements were identified, the trust was responding and was making progress implementing its action plans in order to improve the quality of care they were providing.

• Like many trusts in England, the hospital was busy and the trust had faced challenges in access and flow, especially during the winter months. Bed occupancy in the hospital had been consistently over 90% which was above the England average of 88%. In the medical division, bed occupancy was 95.5% in February 2015. It is generally accepted that when bed occupancy goes over 85% it can start to affect the quality of care provided to patients and the running of the hospital. Due to issues with patient flow, medical patients were transferred or admitted to beds that were designated for other specialities.

• The trust had a clear vision and a set of values which the vast majority of staff understood. This had been developed alongside staff and other stakeholders. There were a number of strategies in place and these all had clear goals which were measurable. All actions from the working strategies were being monitored. This allowed performance to be closely monitored.

• The trust worked on a divisional structure which was clinically led, the chief executive described how this empowered clinical staff. There was recognition however, that this was more developed in some areas than in others, and more time was needed for this structure to become embedded.

• The senior leaders in the trust had been working to increase the level of staff engagement. This was work in progress and we found evidence to suggest this was improving, but the staff survey results had been disappointing for the trust. Many staff told us they felt the organisation had changed over the past two years and was now one which had a real focus on the quality of care for patients.

We saw several areas of outstanding practice including:

• Staff in the x-ray department were able to view the electronic patient information screen held in the emergency department. This meant they knew when patients were awaiting x-ray and responded promptly, usually within 20 minutes of the request being entered into the system.

• Staff working for the local mental health trust which provides care for people with mental health problems, were able to view the electronic information screen held in the emergency department. This meant they knew when patients were awaiting review and responded promptly, usually within 60 minutes.

• Locum doctors working in the emergency department received quarterly reviews with an educational supervisor.

• The multidisciplinary huddle within the emergency department was informative and effective and valued by the team and wider trust staff.

• As a pilot fixed term project, a pharmacist worked in the department to support all aspects of medicines management. Data showed this was beneficial to patients and speeded up admission processes.

• The trust had a clear vision of how its clinical environments could be made dementia friendly. They had realised this vision in the refurbishment of the discharge lounge.

• Each clinical area had its own improvement plan . This meant ward matrons and their staff were clear about the various quality and safety improvement initiatives in progress, how they would be achieved, and how they were inter-related.

• The trust had reacted positively to audit data and had embarked on a local health and social care economy project to produce and implement a dementia and delirium patient treatment pathway. Manvers ward had introduced patient based communication folders which allowed written requests for information to be made and responded to within 24 hours.
• There was good multidisciplinary and collaborative working both internally and externally. Examples of this were the child development clinics and the joint working between the children in care team and the local authority.
• The service for children and young people with diabetes did not discharge children who did not attend for appointments. If children did not attend, they and their parents or carers were reminded by letter of the need for regular reviews and the long term health implications of diabetes.
• The children in care team provided young people at 18 years old with a health summary and history report. The format of the report had been designed in consultation with young people. The report included information the young person may not have known, such as their birth weight and the age they achieved developmental milestones. The report also gave useful information about promoting good health and accessing local services, such as housing associations.
• Children attending appointments at The Den could watch 3D short films designed to calm and distract them. This was particularly useful for children with a learning disability or autistic spectrum disorder, or those who were anxious.
• Community nurses were providing a flexible service. This meant children could be seen after their school day and was also helpful for working parents. Community nurses negotiated with young people when arranging appointments to ensure the least possible disruption to the young person’s education.
• The service for children and young people with epilepsy included clinic sessions to discuss potential problems for young adults with epilepsy, such as using alcohol or learning to drive. These sessions also included preparation for transition to adult services.
• Children in care whose final plan may be for adoption were identified prior to their initial health assessment and the assessment was sufficiently thorough to serve as an adoption medical. This saved repeated assessments and medical examinations for the child. It also helped to avoid delays in the legal system for adoptions as all the information required was incorporated into one report.
• The trust provided "Team Teach," which was commissioned by Derbyshire County Council. This team provided training for non-trust staff working with children and young people with complex health care needs. The training was delivered to staff such as care workers supporting children and young people in their own homes, foster carers and school staff. The service provided by Team Teach reduced the workload of community nurses who otherwise would have provided the training required.

However, there were also areas of poor practice where the trust needs to make improvements.

Action the hospital MUST take to improve

• Ensure there is appropriate and timely monitoring of deteriorating patients within the HDU department.

• Ensure ward staff are supported to identify and manage very sick or deteriorating patients in ward areas.

• Ensure that people who may lack capacity to make decisions about their care have an adequate assessment of their mental capacity, and that decisions about DNACPR are taken in line with the requirements of the Mental Capacity Act (2005).

• Ensure that an accurate record is kept for each baby, child, and young person which includes appropriate information and documents the care and treatment provided.

• Ensure all DNACPR order forms are completed accurately and in line with trust policy.

• Ensure that numbers of registered nurses meet national guidance, and meet the needs of patients at all times, including throughout the night.

• Ensure that an experienced, senior children’s nurse is available during the 24-hour period to provide the necessary support to the nursing team.

• Ensure that there are sufficient numbers of staff to provide the dermatology outpatient service.

• Ensure that at least one nurse per shift in each clinical area (ward / department) within the children’s and young people’s service is trained in advanced paediatric life support or European paediatric life support.

• Ensure all staff involved in caring for patients at the end of life receives adequate training in end of life care.

• Ensure the resuscitation trolleys and their equipment are checked, properly maintained, and fit for purpose in all clinical areas.

• Ensure there are robust waste management procedures in place.

Action the hospital SHOULD take to improve:

• The trust should ensure sufficient cover in the accident and emergency department to allow all staff to attend necessary training sessions.
• The trust should consider the effectiveness of signage in the emergency department reception area to advise patients when their condition requires them to proceed to the front of the queue.
• The trust should ensure safe and effective processes for the disposal of clinical and chemical waste.
• The trust should review its medical bed capacity to ensure that the majority of patients are cared for in the correct speciality bed for the duration of their hospital admission. It should also review its arrangements for the management of patients outlying in non-speciality beds to ensure the quality and safety of their care is not compromised.
• The trust should review its arrangements for quality assuring Root Cause Analyses, and for monitoring the implementation and efficacy of any associated action plans to ensure that RCA’s identify remedial actions that are fully implemented and evaluated.
• The trust should review its arrangements for ensuring the monitoring of in-dwelling intravenous devices in line with “Saving Lives” guidance.
• The trust should review the provision of the continuous piped oxygen and suction issue in the cardiac catheter laboratory and associated recovery areas.
• The trust should ensure that all confidential patient records in clinical areas, and confidential waste, are securely stored to minimise the risk of unauthorised access.
• The trust should review how it can provide both rehabilitation and follow up for patients who are discharged from intensive care to meet NICE guidance.
• The trust should take steps to reduce the number of patients being discharged from the critical care unit overnight.
• The providers should ensure suitable storage in the critical care unit is available so that equipment can be plugged in when being stored.
• The trust should ensure intravenous fluids are stored safely in the critical care unit.
• The trust should ensure that staff in the fracture clinic where children and young people are seen, understand their roles and individual responsibilities to prevent, identify and report abuse when providing care and treatment.
• The trust should ensure that they have written formal arrangements in place with the children and adolescent mental health team so that the needs of children and young people with mental health problems are met.
• The trust should ensure that agreed care pathways and written guidance are in place to guide staff when caring for children and young people who have mental health conditions.
• The trust should ensure there is an effective link nurse structure to enable local support and guidance in end of life care in the absence of the specialist palliative care team.
• The trust should review the hours of service provided by the specialist palliative care team to include a face-to-face specialist palliative care service from at least 9am to 5pm, seven days per week.
• The trust should consider reviewing their local and national audit activity in order to monitor the effectiveness of end of life care services and benchmark against end of life services nationally.
• The trust should review the storage of patient property following a patient’s death.
• The trust should ensure a risk assessment is undertaken for those patients who are waiting within outpatient areas with no clinical oversight.
• The trust should ensure a clearly defined governance structure across the entire outpatient services. There should be more monitoring of patient outcomes and performance such as waiting times within clinics.
• The trust should ensure that there is a clear process for triaging of test results in Dermatology outpatients. by appropriately trained staff to ensure patient safety.
• The trust should review the environment within dermatology outpatients to ensure the privacy and dignity of patients.
• The trust should ensure that medical records are stored securely within outpatients.
• The trust should ensure staff leading on serious investigations working in the maternity service are appropriately trained in investigatory processes and report writing.
• The trust should strengthen the investigation of serious incidents within maternity services to include multidisciplinary involvement, the development of SMART action plans, and senior review and approval, in line with the Serious Incident Guidance, March 2015.
• The trust should ensure women who have undergone a termination of pregnancy are cared for in an area that provides them with dignity and respect.
• The trust should ensure staff working in the maternity service are given feedback on complaints received identifying themes and preventative actions.
• The trust should review its complaints handling procedures to ensure that patient complaints are responded to in a timely manner. It should also ensure that staff understand the role and function of the Patient Advice and Liaison service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Overall rating for this core service Good l

Chesterfield Royal Hospital NHS Foundation Trust provided a range of community health services for children, young people and families in Chesterfield and north Derbyshire. The services were managed from Chesterfield Royal Hospital and clinics were held in The Den, a dedicated facility for children and young people.

We inspected the following regulated activities that the trust is registered with CQC to provide:

• Diagnostic and screening procedures

• Treatment of disease, disorder or injury

During our inspection we spoke with 30 people using the service, including children, young people and their families. We spoke with 44 staff including nurses, doctors, speech and language therapists, occupational therapists, physiotherapists, administration staff and health care support workers. We visited clinics at various locations including The Den at Chesterfield Royal Hospital, and Buxton Health Centre. We accompanied community nurses visiting children and young people in their own homes or at school. We looked at a total of 15 records of care and treatment.

There were reliable systems, processes and practices in place to keep children and young people safe and safeguarded from abuse. Staff understood their responsibilities to raise concerns and to record and report safety incidents, although near miss incidents were not always reported. Lessons were learned from incidents and action taken to improve the service. Staff demonstrated a sound awareness of safeguarding issues and knew the procedures to follow if abuse was alleged or suspected.

Staffing levels and caseloads were planned and reviewed so that children and young people received safe care and treatment. There were identified problems with staffing levels in some teams. Appropriate action was being taken to monitor the risks and to resolve the issues.

Children and young people had care and treatment in line with legislation, best practice and evidence based guidance. The outcomes of care and treatment were monitored through local and national audits. Results of audits were used to improve outcomes for children and young people using the service. There was collaborative and effective multi-disciplinary and multi-agency working to understand and meet the needs of children and young people using the service. This included the arrangements for young people moving to adult services. Children, young people and their families were treated with dignity, respect and kindness and were involved in their care and treatment.

Staff had the relevant skills, knowledge and experience to deliver effective care and treatment. Staff were supported through supervision and annual appraisal, though not all staff had received an appraisal in the last year. Services were planned to take account of the needs of the local population and of the individual needs of children, young people and their families. The leadership, governance and culture promoted and supported the delivery of high quality person centred care. There was a clear and effective governance structure for this service.