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Inspection Summary


Overall summary & rating

Good

Updated 31 March 2015

Derby Hospitals NHS Foundation Trust provides both acute hospital and community-based health services. There are two inpatient hospitals, the Royal Derby Hospital and London Road Community Hospital. The trust serves a population of over 600,000 people living in Derby and the surrounding areas. In total the trust has 1,100 beds.

Derby is an urban area with a deprivation score of 63 out of 326 local authorities (with one being the most deprived). This means that Derby Unitary Authority has a significantly deprived population and is worse than the national average on a range of population health measures.

Life expectancy for men is lower than the England average and is 12.2 years lower between the most deprived and the least deprived areas of Derby. For women the difference is nine years lower. Reducing inequalities in health is one of the local priorities across the Derby health community.

We inspected Derby Hospitals NHS Foundation Trust as part of our comprehensive inspection programme.

We carried out an announced inspection of the Royal Derby Hospital, London Road Community Hospital as well as the community-based services between 8 and 11 December 2014. In addition, an unannounced inspection was carried out between 5pm and midnight on 22 December 2014. The purpose of the unannounced inspection was to look at the accident and emergency (A&E) department, critical care and a number of wards in both the Royal Derby Hospital and London Road Community Hospital.

We made judgements about all of the services the trust provided and because just three out of the eleven core services we inspected required improvement we rated this trust as “good” overall and noted some outstanding practice and innovation. However, improvements were needed to ensure that services were safe, effective and well led.

Our key findings were as follows:

Cleanliness and infection prevention and control

  • There was a dedicated inspection prevention and control team and good arrangements in place to prevent the spread of infection. All of the wards at the Royal Derby and the London Road Hospitals appeared to be clean. We saw staff adhered to the policies for infection prevention and control, for example, staff washed their hands regularly and between patient contact. where infections did occur, they were subject to an investigation. We saw examples of these investigations and the learning points to come out of them.

Nutrition and hydration

  • We saw patients received help to eat and drink. There were systems in place to identify patients who needed help, such as the "Red Tray," and protected mealtimes. There were nutritional assistants available at meal times. We also noted some good practice for patients where the day rooms were used to have communal meals and create a more informal atmosphere to help stimulate patients to want to eat and enjoy their meals.
  • Nutritional risk assessments were completed appropriately, but most importantly we saw the outcomes of risk assessments were acted upon. Food charts were maintained and there was accurate recording and totalling of fluid balance charts.

Mortality

  • We did not have concerns about mortality rates at the trust. Where there had been any identification of trends that required further investigation the trust reviewed data and submitted their responses appropriately. There had been a mortality outlier which intelligence systems had identified in February and March 2014. This concerned coronary atherosclerosis and other heart disease. An investigation had been undertaken which identified a need to ensure improvements in coding and documentation. The clinical treatment of the patients was not found to be of any concern.
  • The trusts Summary Hospital-level Mortality Indictor (SHMI) and the Hospital Standardised Mortality Ratios (HSMR) mortality measures show the trust as being within expected limits between August 2013 and July 2014. SHMI and HSMR are ways in which the NHS measures healthcare quality by looking at the rates of mortality in the trust.

Staffing

  • A recognised safe staffing tool had been used to calculate nurse staffing levels. During 2014, a review had taken place and changes to the establishment had taken place. Wards displayed their staffing levels on a board and it compared the daily planned numbers of staff with the actual staff on duty. Patients at the Royal Derby Hospital told us the nurses were busy. Many staff told us they felt under pressure and worried that their workloads kept on increasing as the demand for services increased. Despite this, we found all of the services we inspected apart from medicine were adequately staffed with nurses. In medicine and end of life care, there were some occasions where the nursing staff ratios dropped to below the required level.
  • The trust employed more consultants and junior doctors than the national average but less registrars and middle grade doctors than the national average. Doctors we spoke with were generally positive about the medical staffing arrangements and we did not identify any concerns with the numbers of medical staff employed by the trust.

We saw several areas of outstanding practice including:

  • The trust was providing responsive care for patients who had dementia. On the Medical Assessment Unit there was a dedicated lounge known as the FEAT lounge (frail elderly assessment team). A dedicated healthcare assistant with qualifications in caring for patients living with dementia to assist patients was available in this lounge every day. We found this was providing care to patients that was very responsive to their individual needs.
  • Ward 205 should be commended for helping to improvement the mental wellbeing of elderly patients and patients with dementia through the use of the reminiscence room, pictorial information and advanced service planning to further enhance care.
  • The MAU had pharmacists on the ward 12 hours each day, seven days a week. They worked as part of the frail elderly team with the aim of optimising the use of medicines. The overall aim was to help patients make the most of their medicines.
  • Respiratory medicine had introduced the use of patient colour-coded wristbands to identify how much oxygen each patient needed. Excessive amounts of oxygen can be dangerous for some patients and it is important that the correct amount of oxygen is administered.
  • Echocardiography was used as the main monitoring tool of cardiac output and fluid status for intensive care patients. Point of contact echocardiography for these patients is a highly innovative and valuable service.
  • The maternity department bereavement service had been recognised by the Royal College of Midwives. The lead midwife had been nominated for the Royal College of Midwives Award 2015 National Maternity Support Foundation Award (NMSF) for Bereavement Care, improving the environment, which was known to be an important key to effective bereavement care.
  • The Nightingale Macmillan Unit was dedicated to providing end of life care to patients with life-limiting illnesses and staff were able to respond appropriately to meet the individual needs of patients. The facilities and resources available for patients on the unit were excellent

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

Importantly, the trust must:

 

  • Ensure all DNA CPR order forms are completed accurately in line with trust policy and the Mental Capacity Act (2005).
  • Ensure there are sufficient numbers of suitably qualified and skilled staff within the medical and end of life care services.

In addition the trust should:

 

  • Ensure that the lone working policy and arrangements for community maternity staff are reviewed to ensure they feel safe and secure when out in the community.
  • Ensure that patients notes are stored securely to ensure that confidential patient information is not accessed inappropriately.
  • The trust should ensure that there are sufficient numbers of suitably qualified, skilled and experienced nursing staff on the adult emergency observation ward to safeguard the health, safety and welfare of patients.
  • The trust should ensure that there is sufficient storage available to enable equipment to be appropriately stored and enable safe access to bathrooms on medical wards.
  • The trust should consider providing information for patients and friends and family comment cards in different formats and different languages. This will enable people with learning disabilities, those who's first language is not English or those with cognitive impairment to access information and provide their feedback.
  • The trust should review arrangements for undertaking venous thromboembolism (VTE) assessments on the surgical assessment unit.
  • The trust should consider reviewing arrangements for the care of patients on high dependency units who would be categorised as level two as current arrangements are not meeting the Core Standards for Intensive Care Units 2013.
  • The trust should consider developing their electronic prescribing system to enable it to be used in intensive care as for other wards and departments in the hospital. The use of different systems across the hospital meant there was a risk of poor communication about previously administered medications.
  • The trust should ensure that staff on Puffin ward are trained and supported to care for patients who require a CAHMS assessment whilst on the ward so that they can ensure their welfare and the welfare of other patients is protected.
  • The trust should ensure that all clinical single use equipment is stored safely and appropriately; and disposed of when it has expired it used by date.
  • The trust should ensure that the design and layout of the neurology outpatient clinic at London Road Hospital is suitable for the needs of all patients, including those with limited mobility.
  • The trust should consider improving the facilities for patients who need to collect prescription medicines from the pharmacy within Royal Derby Hospital. This is to reduce the long waiting times for prescriptions to be dispensed and the pharmacy and improve access for patients with limited mobility.
  • The trust should consider hearing "patient stories"  during their public board meetings to ensure the positive and negative experience of patients is taken account of when they make decisions. 

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 31 March 2015

Effective

Good

Updated 31 March 2015

Caring

Good

Updated 31 March 2015

Responsive

Good

Updated 31 March 2015

Well-led

Good

Updated 31 March 2015

Checks on specific services

Maternity and gynaecology

Good

Updated 3 February 2017

Medical care (including older people’s care)

Good

Updated 3 February 2017

Urgent and emergency services (A&E)

Good

Updated 31 March 2015

The adult and children’s emergency departments at Royal Derby Hospitals were safe. Reliable systems and processes were in place to promote safe care, and emergency preparedness plans were in place. Patients received care and treatment based on best available national evidence-based standards and guidelines. Effective and consistent levels of care were available 24 hours a day, seven days a week.

Patients and relatives were all positive about the care they had received. Staff offered care that was kind, respectful and considerate. They responded to patients’ anxiety or distress with compassion, and offered emotional support.

The department was not consistently meeting the four hour waiting time target for emergency departments. However, staff in the department were leading work within the wider trust to support improvement in this area. The department was dealing with unprecedented demand at the time of our visit, but there was always a calm atmosphere and a clear sense of purpose amongst the staff team. Leadership and management of the emergency department focussed on the delivery of high-quality, person centred care. There was a positive culture with a strong team ethos and consultants in the department were approachable, committed and passionate about continuous improvement.

Surgery

Good

Updated 31 March 2015

The surgical division had systems and processes in place to keep patients safe. Staff had a good awareness of the process for identifying and recording patient safety incidents.

Arrangements to minimise risks to patients were in place, with measures to prevent falls and pressure ulcers, the early identification of patient risk during surgery, good infection prevention and control practice and, the safe management of medicines.

Staff were competent and suitably trained to deliver care in line with trust policies and procedures, national guidance and, National Institute for Health and Care Excellence (NICE) quality standards.

Access to care, treatment and surgical outcomes for patients were mostly within the national average. Where improvements were required these had been identified and measures were in place.

Intensive/critical care

Good

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.

Services for children & young people

Good

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.

End of life care

Requires improvement

Updated 3 February 2017

Outpatients

Good

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.