Chesterfield Royal Hospital

Updated 26 July 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Chesterfield Royal Hospital.

We inspected the maternity service at Chesterfield Royal Hospital as part of our national maternity 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.

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

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

The maternity department at Chesterfield Royal Hospital comprises of the Birth Centre with consultant led and midwife led beds, a combined antenatal and postnatal ward, a bereavement suite, pregnancy assessment centre, antenatal clinic and scanning services.

We did not review the rating of the location therefore our rating of this hospital stayed the same

Chesterfield Royal Hospital is rated Requires Improvement overall.

Our reports are here: https://www.cqc.org.uk/location/RFSDA

How we carried out the inspection

During our inspection of maternity services at Chesterfield Royal Hospital NHS Foundation Trust we spoke with 30 staff including leaders, obstetricians, midwives, and maternity support workers.

We visited all areas of the unit including the antenatal clinic, pregnancy assessment unit, the birth centre and the ante and postnatal ward. We reviewed the environment, maternity policies while on site as well as reviewing 9 maternity records. Following the inspection, we reviewed data we had requested from the service to inform our judgements.

We ran a poster campaign during our inspection to encourage pregnant women and mothers who had used the service to give us feedback regarding care. We received feedback from over 230 women and birthing people in response to the campaign. Comments were generally positive about the birthing experience, but less so about care on the postnatal ward. Women and birthing people commented that staff did not always have the time to provide support, especially with breastfeeding whilst on the ward.

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 29 May 2020

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

• Staff did not always follow infection control principles including the use of personal protective equipment (PPE).
• Nursing and medical staff received but did not keep up-to-date with their mandatory training.
• The trust set a target of 90% for completion of safeguarding training. Not all nursing and medical staff had received training specific for their role on how to recognise and report abuse.
• The design of the environment did not always follow the Health Building Note guidance. For example, across most medical wards we visited we found the environment cramped with equipment stored on corridors.
• Staff did not always escalate deteriorating patients in a timely manner. We found inconsistencies with national early warning sign escalation in five out of nine electronic records we looked at.
• Records were not always stored securely. We found some patient records left unattended on trolleys across most wards and records were not always kept in locked trolleys to maintain confidentiality.
• The service participated in relevant national clinical audits. Outcomes for patients were not always positive, consistent or met expectations, such as national standards.
• There were inconsistencies in the decision-making processes for Deprivation of Liberty Safeguards (DoLS).

However,

• All staff knew what incidents to report and how to report them.
• Managers monitored waiting times and made sure patients could access services when needed and received treatment within agreed timeframes and national targets.
• Patients said staff treated them well and with kindness.
• The senior matron and all matrons were visible on the wards.

Updated 17 May 2017

We rated CAMHS overall as requires improvement because;

There were high caseloads within core CAMHS without a clear process or management tool being used to manage or monitor them. It was not clear if risk assessments and care plans were being updated as any updates were recorded within the body of the clinical notes.

Some staff were not receiving regular clinical supervision and it was not always recorded as per the clinical supervision policy.

They did not take self-referrals. There were long waits for specific interventions and there was not a clear process for how young people’s mental health should be monitored while waiting. The service relied on the young person or their family to contact CAMHS. The service operated Monday to Friday 0900 to 1700.

However, we also found;

The environment was clean. Clinical staff participated in clinical audit.

All staff were trained in safeguarding children level 3. Staff completed comprehensive assessments in a timely manner.

There was good participation of young people and their parents throughout service delivery.

Updated 25 January 2019

Our rating of services stayed the same. We rated it them as good because:

The service had made improvements to all the areas that required improvement following our last inspection.

• Staff knew how to identify and respond to changing risks to babies and children in their care. This included deteriorating health, medical emergencies and challenging behaviour.
• There were reliable systems in place to prevent and protect people from a healthcare associated infection. Staff were observed adhering to trust policy regarding infection prevention and control.
• There were facilities appropriate for children and their families. This included child-friendly signage and play areas and rooms with en-suite facilities and space for a bed for a parent/carer to stay with their child for long-stay patients.
• There was a family room where families could spend time with their child and siblings away from the bedside, and included toys, soft furnishings and space for siblings to play.
• Private facilities were provided for mother to express breast milk.
• There was a family sleep-over bedroom on the neonatal ward for parents to stay with their baby to prepare for discharge after a long stay in hospital.
• There was a dedicated children’s outpatient service at the hospital, known as ‘The Den’ which included a same-day phlebotomy service. The Den was child friendly and members of the multidisciplinary team reviewed and treated children. Children’s waiting areas were well equipped and supplied with age appropriate toys and books.
• The service investigated and responded to all serious events. We saw that the service had put additional measures in place to ensure that children who had their scheduled surgery cancelled due to being unwell were reviewed by the paediatric consultant for a full examination before going home.
• The service worked in partnership with the community nursing team, specialist nurses and GPs to provide a comprehensive discharge plan.
• There was a direct referral facility for GPs and other health professionals to admit a child directly onto the ward via the assessment unit. Children with a long- term condition and those recently discharged also had direct access to the unit. Some children with complex conditions could be self-referred on a long-term basis.

We found examples of outstanding practice in this service. See the Outstanding practice section above.

Updated 17 May 2017

This was a follow up focussed inspection and therefore we did not rate the critical care service overall. We inspected the safe domain only and rated the critical care provision at Chesterfield Royal NHS Foundation Trust as good for safe. We found there had been improvements to the service since our previous inspection in 2015.

Staff knew how to use the trust electronic incident reporting system, could demonstrate learning form incidents and understood the principles of duty of candour. However, staff told us they did not always receive feedback from reported incidents.

Patient records were legible, signed and dated in accordance with General Medical Council (GMC) guidance and included a comprehensive range of patient assessments. Care plans were clear and we saw evidence of staff working with them.

Staff adhered to trust policies on infection control and hygiene and both ITU and HDU had positive infection control audit results. Equipment was well maintained. There was access to resuscitation equipment, which was checked regularly and ready for use. Staff were trained in safeguarding and were confident about escalating any concerns.

A key improvement since our last inspection was patients were reviewed in a timely manner and the service had established systems to audit and challenge the timeliness of response by medical staff. There was a plan to move to a new model of critical care in September 2016, which meant HDU patients would be managed by critical care consultants. The service had escalation procedures for managing deteriorating patients and for discharging patients to wards. The service had introduced new procedures for monitoring and managing patient discharges which was audited.

Staffing levels met recommended guidelines and handovers for medical and nursing staff were effective.

However, issues identified were critical care consultants did not receive feedback from mortality and morbidity meetings and staff were frequently moved to support staff shortages in other areas of the hospital, resulting in a risk ofstaff not working to recommended guidelines and staffing ratios.

There was no critical care outreach team, although recruitment was taking place in preparation for commencing this service in September 2016.

Updated 25 January 2019

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

• Staff had a good understanding of how to protect patients from abuse and could describe what safeguarding was and the process to refer alerts.
• Staff were aware of the trusts whistleblowing procedures and what action to take if they had

concerns.

• There were 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.
• We saw good examples of good multi-disciplinary working and involvement of other agencies and support services.
• Staff cared for patients with compassion. We saw several examples of staff from all disciplines being supportive and kind to patients and their relatives.
• Most patients and their relatives told us they were fully included in discussions around their plan of care.
• From July 2017 to June 2018, the trust reported no incidents classified as never events within end of life care.
• During our last inspection in 2016 we found the trust did not have a process for identifying non-cancer patients requiring end of life or palliative care support. During this inspection we saw the service had added a category to the palliative care team referral document identifying non-cancer patients
• There were systems in place to ensure that staff affected by the experience of caring for patient at end of life were supported. For example, members of the Hospital Palliative Care Team had access to counselling, through a self-referral system as well as a psychologist who provided clinical supervision to individuals or groups, as required.

However

• The majority, (49%) of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders we viewed were not completed properly and reflected the information included in the patient’s mental capacity assessment.

Updated 26 July 2023

Updated 17 May 2017

We rated outpatient and diagnostic imaging services as good overall.

Staff reported patient safety incidents and there was evidence of learning from incidents and patient complaints. Senior staff had oversight of risks in their areas. Emergency equipment and resuscitation trolleys were not consistently checked. The patient waiting areas were attended by staff so patients could be observed.

Outpatient departments appeared visibly clean and staff used personal protective equipment (PPE), such as gloves and aprons. Patients care and treatment was delivered in line with current national standards and legislation. Staff demonstrated a commitment to patient-centred care. Patients were treated with dignity and respect and spoke highly of the staff. Patient input and feedback was actively sought and several areas had established patient focus and support groups.

There were some areas that provided a proactive service to patients which included several one-stop clinics which provided efficient co-ordinated care. Quality governance knowledge was shared amongst staff at team meetings. Staff felt supported by immediate line managers and clinicians. They said they were listened to and able to raise concerns.

Updated 29 May 2020

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

• The service mostly had enough staff to care for patients and keep them safe. Training was available in key skills, staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Not all staff were up to date with their mandatory training.
• Some serious incidents were not reported within the trusts target of 14 days.
• Outcomes for patients were generally similar to or better when compared to other trusts but did not always meet national standards.
• The percentage of last-minute cancellations at the trust where the patient was not treated within 28 days was higher than the England average.

Updated 29 May 2020

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

• The service had enough staff to care for patients and keep them safe. There were plans in place to increase consultant staffing.
• Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records.
• They managed medicines well. Improvements in management and storage of medicines were noted since our August 2019 inspection.
• The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

• People could not always access the service when they needed it and had to wait too long for treatment. The Department of Health’s standard for emergency departments is that 95% of patients should be admitted, transferred or discharged within four hours of arrival in the emergency department. From October 2018 to September 2019 the trust failed to meet the standard. However, it outperformed the England average in six out of 12 months.