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We are carrying out checks at Chesterfield Royal Hospital using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary


Overall summary & rating

Good

Updated 17 May 2017

Chesterfield Royal Hospital NHS Foundation Trust was one of the first hospitals in the country to become a Foundation Trust in January 2005, and serves a population of around 441,000 across the Bolsover, Chesterfield, Derbyshire Dales and North Amber Valley, High Peak and North East Derbyshire districts.Chesterfield Royal Hospital is a medium sized District General Hospital based a mile outside the centre of Chesterfield in an area known as Calow. The hospital is the town’s largest employer with a workforce in excess of 3,500 staff and has a total revenue of £221.2 million.Chesterfield Royal Hospitals NHS Foundation Trust is registered to provide the following Regulated Activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Diagnostic and screening procedures
  • Family Planning
  • Management of supply of blood and blood derived products
  • Maternity and midwifery services
  • Surgical Procedures
  • Termination of pregnancies
  • Treatment of disease, disorder or injury

Chesterfield Royal Hospital NHS Foundation Trust were inspected between 13-14 July 2016. Unannounced visits were carried out on 20 July 2016. This inspection is a focused follow up inspection following a comprehensive inspection in April 2015. The purpose of this focused follow up inspection was to inspect domains that had previously been deemed to require improvement.We did not rate the trust overall. We looked at domains that had previously been rated as less than good. We made judgements about seven services across the trust as well as making judgements about the five key questions that we ask.

Our key findings were as follows:

  • There was an effective incident reporting system. However, there were incidents that had not been closed on the reporting system. There was an open and honest culture, and people who used the service were told when something went wrong.
  • The environment where care was delivered was visibly clean. There were systems, processes and procedures in place for infection prevention and control which were adhered to by the majority of staff.
  • The day time ward staffing levels were planned in line with the National Quality Board guidance published in 2013 and 2016.
  • There was ongoing, and on occasions, significant numbers of bank and agency staff being used.
  • Generally systems were in place to assess and respond to risks where patients were identified as deteriorating.
  • There was no critical care outreach team within the hospital, although one was being established.
  • Medications were stored appropriately and administered safely.
  • An assessment tool was used to assess patient’s pain. Where patients experienced pain this was managed well.
  • Most equipment, including resuscitation equipment was checked, serviced and safe for use, however some resuscitation equipment was not checked in line with trust policy.
  • The trust had recently introduced a new system for staff to access and record their training activities. At the time of the inspection the trust was experiencing difficulties accessing current accurate data of the number of staff who had attended their mandatory training, therefore the trust was not certain on how many staff were currently trained.
  • Patient care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation.
  • There were a significant number of patients being moved between wards in the hospital and moves routinely happened after 10pm. These were predominantly from the initial assessment wards to inpatient wards.
  • Since our last inspection in April 2015 the trust had achieved the appropriate level of suitably qualified nursing staff per shift with the European paediatric life support (EPLS) qualification.
  • There was effective multidisciplinary working to deliver patient care.
  • Patients were supported, treated with dignity and respect. Relatives and friends were involved in patients care. We saw staff carrying out care with a kind, caring and compassionate attitude.
  • Systems were in place to acknowledge complaints within three days. A triage system was in place to establish response times to complaints depending on the complexity. Response times to complaints had improved since our last visit after an action plan was put in place.
  • Concerns resolved at ward level were not reported on the incident reporting system; therefore opportunities for learning could be missed however a pilot was taking place to start capturing this information.
  • High bed occupancy levels above the trust target was identified as an operational risk with the potential to impact on staffing levels and the quality of patient care. This was being managed on the trust’s risk register and a weekly report was being prepared for the commissioners.
  • Staff we spoke with were aware of, and understood, the vision and values of the trust. Staff identified the “proud to care” initiative to look after patients.

We saw several areas of outstanding practice including:

  • The neonatal gentamicin prescription sheet that had been produced because of lessons learnt from gentamicin medication errors was outstanding. This has reduced the number of incidents to zero within the department and ensured that all patients received the correct management.
  • “Toolbox talks”- had been developed and trialled amongst porters with the aim of increasing knowledge of end of life care. “Toolbox talks” were short talks developed and delivered to the porter service manager who then delivered this to their teams. There was a plan in place to roll this out to other non-clinical staff within the trust.
  • Members of staff on Markham Ward had written a poem to provide support to relatives of end of life patients. “The palliative approach” poem was sensitively written and described how the ward would care for relatives and their loved ones on the ward.
  • Markham Ward had created a “comfort tin” for relatives of patients in the last days or hours of life which included biscuits and tissues had been developed.
  • A “comfort tin” for relatives of patients in the last days or hours of life, which included biscuits and tissues, had been developed. We also saw the use of “comfort packs” , which included essential toiletries, such as toothbrushes and cleansing wipes.

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

  • The trust must ensure the resuscitation equipment provides a full range of equipment to meet all sizes of children, young people and adults.
  • The trust must ensure that in areas where children are treated, appropriate safeguarding measures and staff training are in place.
  • The trust must ensure nursing staff who deliver end of life care are familiar with and receive training in the Mental Capacity Act (2005).

In addition the trust should:

  • The trust should ensure all DNACPR order forms are completed accurately and in line with trust policy.
  • The trust should improve infection control training within the medical division.
  • The trust should ensure there are consistent processes in place to assure cleanliness of equipment including the birthing pools within maternity and gynaecology services.
  • The trust should ensure cleaning records are maintained for the milk fridges within maternity and gynaecology services.
  • The trust should ensure all staff are compliant with trust targets and intercollegiate standards in regards to safeguarding level three training.
  • The trust should ensure there is a consistent process for assuring the safety of electrical items and they are clearly marked with details of when safety checks are next required. It should be ensured staff are aware to the process for ensuring equipment is checked and safe to use.
  • The trust should ensure there is a formalised risk assessment produced for the paediatric resuscitation trolley on Nightingale Ward remaining unlocked.
  • The trust should ensure all investigations involving a child or young person should have representation from the Women and Children’s division.
  • The trust should ensure the sepsis management of children and young people is fully embedded within the service.
  • The trust should ensure they work closely with the local hospice in finalising the service level agreement.
  • The trust should ensure they continue with the plan to monitor how rapidly patients are discharged from hospitals once identified for “fast track”.
  • The trust should ensure they audit the achievement of patient's preferred place of death.
  • The trust should ensure the legal process of the Mental Capacity Act 2005 is followed where a patient lacks the capacity to make decisions, particularly in relation to ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders.
  • The trust should consider reviewing the process for transferring obese deceased patients to the mortuary.
  • Consider the environment in Hollywell Day Case Unit to ensure the environment where trolleys are located and equipment is washed is suitable to ensure effective infection prevention and control measures can be adhered to.
  • Ensure that all ward and department staff receive information on the policy for the monitoring and recording drug fridge temperatures including details of any actions they are accountable for.
  • The trust should continue to prioritise reviewing the open incidents, ensure actions are taken to minimise risk ,and ensure actions are completed, learning is shared and records updated.
  • Should ensure that the surgical department morbidity and mortality quarterly meetings are established and that there is a robust system is in place to secure attendance and enable learning to be shared.
  • Ensure all staff receive annual appraisals.
  • Ensure all staff attend mandatory training days.
  • Ensure all staff complete safeguarding training suitable to their role and grade.
  • The trust should ensure there is a consistent process for assuring the safety of electrical items and they are clearly marked with details of when safety checks are next required. It should be ensured staff are aware to the process for ensuring equipment is checked and safe to use.
  • Ensure where resuscitation trolleys are shared between two wards both wards carry out and document the checks as per the trust policy.
  • Ensure VIP scores are recorded in a consistent manner and that there is no duplication of information.
  • Ensure data is captured when complaints/concerns are resolved at ward level, and ensure that learning is shared.
  • Ensure patient transfers are effectively managed to minimise the number of patients transferred after 10pm.
  • Ensure sufficient medical staffing is available to meet periods of increased demand and to cover staff absences.
  • Ensure the safer steps to surgery check list is fully completed and audit monthly to achieve 100% compliance.
  • Ensure the safer steps to surgery check list is used for invasive procedures.
  • Ensure all of the divisions have shared governance structures which are consistent and collective.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 4 August 2015

Effective

Good

Updated 17 May 2017

Caring

Good

Updated 4 August 2015

Responsive

Good

Updated 17 May 2017

Well-led

Good

Updated 4 August 2015

Checks on specific services

Maternity and gynaecology

Updated 17 May 2017

This was a follow up focussed inspection and therefore we did not rate the maternity and gynaecology overall. At this visit we inspected the safe domain.

Since our last inspection staff in maternity and gynaecology services had worked hard to improve the quality of the investigation of serious incidents with root cause analysis. All staff had been involved in training to conduct such investigations and many staff told us they had been involved. This resulted in better quality investigations and reports. The process provided staff with clear actions and lessons to be learnt where applicable.

A recent staffing acuity review was completed using a recognised staffing tool which highlighted the number of registered midwives and unregistered staff required to provide a safe and effective service. There were sufficient number of required registered staff; however, there was a gap in unregistered staff of 10 whole time equivalent (WTE). Despite the outcome of the review and the service having the required number of midwives, there were 55 red flags raised in the birthing centre from January to June 2016 due to staffing issues as a result of high demand. This resulted in the supernumerary co-ordinator taking on patients.

There had been improvement in the dedicated consultant hours provided to the birthing since our last inspection. Dedicated consultant hours now exceeded the recommended 60 hours of the Royal College of Obstetrics and Gynaecology (RCOG) Safer childbirth- the future workforce.

Staff used the maternity early warning score (MEWS) effectively and this had helped to improve the recognition of the deteriorating patient. An early warning scoring system was designed to enable staff to recognise and respond to acute illness and deterioration, and to trigger a clinical response proportionate to the severity of deterioration. There was evidence of good use of risk assessments for patients being admitted. Staff generally had good access to equipment when required, with the exception of the access to resuscitation equipment in the pregnancy assessment centre. Access to the resuscitation equipment in the pregnancy centre had been risk assessed was scored as a low risk.

Medical care

Requires improvement

Updated 4 August 2015

Medical care (including older people’s care)

Updated 17 May 2017

This was a follow up focussed inspection and therefore we did not rate the medical service overall. At this visit we inspected the safe and responsive domains.

The safety of medical services requires improvement.

There was ongoing, and on occasions, significant numbers of bank and agency staff being used, which did not ensure wards would be always be adequately staffed with suitably experienced staff.

There were incidents from throughout 2015 which were not reviewed. Equipment was not labelled in a way that assured staff that it had passed its safety tests.

Resuscitation trolleys were not always checked in line with the trust’s resuscitation policy.

Staff did not always fully comply with the infection prevention and control measures.

There was an open and honest culture, and people who used the service were told when something went wrong. Risks were identified and managed, where patients were identified as being at a particular risk there were procedures available to help keep them safe.

The environment where care was delivered was visibly clean.

Services were planned to meet the individual needs of patients and longer term planning was in place to ensure local people received the care they would need in the future. Individual needs were assessed and staff planned and delivered care based on their assessments.

The responsiveness of medical care services was good.

Services were planned to meet the individual needs of patients and longer term planning was in place to ensure local people received the care they would need in the future. Individualised care was provided by the enhanced care team and activity coordinators.

Discharges were planned and procedures were in place to enable patients to be discharged at a weekend. The discharge lounge supported patients on the day of their discharge.

There were a significant number of patients being moved between wards in the hospital and moves routinely happened after 10pm. The winter escalation ward had remained open and this was being used as an outlier ward for medical patients but there were also other medical outliers on surgery wards. The trust was not meeting all the cancer waiting time targets or the diagnostic six week referral target every month.

Urgent and emergency services (A&E)

Good

Updated 4 August 2015

Overall, the urgent and emergency service was good.

People were protected from abuse and avoidable harm. Reliable systems and processes were in place to promote safe care and emergency preparedness plans were in place.

People’s care, treatment and support achieved good outcomes for patients and were based on the best available evidence. Staff were appropriately qualified and received regular relevant training and appraisal, although some staff told us of difficulties accessing ‘essential training’ because of workload within the department.

Staff treated people with compassion, kindness, dignity and respect. Most patients were positive about the care they received. Services were planned, organised and delivered to meet people’s needs. However the department had been designed and built to accommodate a much smaller number of patients. At times staff struggled to provide responsive care because of environmental constraints.

Leadership and management of the emergency department focussed on the delivery of high quality care. There was a positive team culture with excellent relationships between nursing and medical staff. Junior doctors were especially complementary about the support they received from consultants and nursing staff.

Surgery

Updated 17 May 2017

This was a follow up focussed inspection and therefore we did not rate the surgical service overall. At this visit we inspected the safe and effective domains.

The safety of surgical services was good.

There was an open and honest culture, and people who used the service were told when something went wrong. Procedures and systems were available to help keep patients safe. Patient areas were visibly clean and equipment was checked to make sure it was safe for use. In one clinical area the cleaning of equipment was not carried out in a designated area.

Theeffectiveness of surgical services was good. Patient care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation. Service performance and patient outcomes were evaluated to inform improvements. However, some staff were not receiving regular appraisals to ensure they had the appropriate skills and support to perform their current role and to identify areas of personal and professional development. .

Intensive/critical care

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.

Services for children & young people

Updated 17 May 2017

This was a follow up focussed inspection and therefore we did not rate the children’s and young people’s service overall. At this visit we inspected the safe domain.

Since our last inspection in April 2015 the trust had achieved the appropriate level of suitably qualified nursing staff per shift, with the European paediatric life support (EPLS). This was in line with the Royal College of Nursing (2013) best practice guidance in relation to nurse staffing levels on general children’s wards.

However, the trust did not meet the Royal College of Paediatric and Child Health (RCPCH) standards for onsite consultant presence at the time of our inspection, although there were plans for how this would be achieved.

Resuscitation equipment on the children’s ward was accessible, although the section containing emergency medications were locked. The resuscitation policy for the paediatric services did not contain details on whether the whole trolley should, or should not be locked. The resuscitation trolley was consistently checked and records demonstrating these checks were reviewed. Basic airway management equipment for older children and adults on the resuscitation trolley was not immediately available, however additional equipment was located in a store cupboard.

Level three safeguarding children training did not meet intercollegiate guidance and the trusts own target of 100%, with the staff on the neonatal unit achieving 81% and staff on Nightingale ward achieving 83% however there were individual plans in place for staff to complete this. Knowledge of safeguarding within the ward areas was generally good and improvements had been made in the adult fracture clinic. There were, however no assurances about the level of safeguarding training in other outpatient areas where children may be seen.

There had been a significant improvement in the completion of patient records and a risk assessments quality. There were good infection prevention and control measures within the service and this was reflected in the low numbers of healthcare acquired infections.

Child and adolescent mental health services

Requires improvement

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.

End of life care

Requires improvement

Updated 17 May 2017

Overall, we rated the end of life service as requires improvement. However, there had been clear improvements made since our last inspection.

We rated end of life as requires improvement because

Nursing staff were unaware of the trust’s two stage assessment for assessing patients’ mental capacity in line with the Mental Capacity Act 2005 (MCA). During our review of ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) forms, we found that it was recorded on the DNACPR forms that 32 patients did not “have capacity to make and communicate decisions about CPR, nine (28%) of these did not have a Mental Capacity Act (MCA) assessment form completed and, where CPR was a potentially successful treatment which might have been offered to the patient had they capacity, a best interest decision recorded in the notes. This meant the trust’s DNACPR policy was not being adhered to, and the legal process of the Mental Capacity Act 2005 was not always followed

Nursing staff were unfamiliar with the Derbyshire Alliance End of Life Care Toolkit, which contained evidence based guidelines (including NICE guidelines) to underpin the care provided. Staff were not familiar with or adhering to the Adult Cardiopulmonary Resuscitation’ policy dated December 2014 in relation to review of DNACPR forms from previous admissions.

The trust did not have a process for identifying non-cancer patients requiring end of life, and or, palliative care support. The service did not monitor how rapidly patients were discharged from hospital if they wished to be cared for at home. The service did not monitor if end of life patients died in their preferred place of death. At the time of our inspection, the trust did not separately monitor.

Patients were supported, treated with dignity and respect, and were involved as partners in their care. Feedback from patients and their families was positive and comments included “nothing is too much trouble” and “staff do what they can to help“. We saw staff carrying out care with a kind, caring and compassionate attitude. Staff spoke to patients politely and respected their privacy and dignity by knocking on doors and asking for consent to proceed with tasks.

The leadership of end of life care was good. The leadership, governance and culture promoted the delivery of high quality person-centred care. There was a credible end of life strategy in place with well-defined objectives linked into an end of life care improvement plan. We saw the end of life strategy had been widely communicated across the trust. There was an effective and comprehensive process in place to identify, understand, monitor and address current and future risks to end of life services through the end of life strategy group. The quality of care was being monitored in most areas. Where robust monitoring wasn’t in place, there were robust plans in place to achieve this. There was a positive culture amongst staff that were committed to providing safe and caring end of life care.

Outpatients

Good

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.

Other CQC inspections of services

Community & mental health inspection reports for Chesterfield Royal Hospital can be found at Chesterfield Royal Hospital NHS Foundation Trust.