Nuffield Health Derby Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority and embedded through a culture of openness and learning. Staff told us they felt confident to report incidents and raise concerns, and learning was shared through team meetings, safety huddles and governance processes.

There were systems in place to identify and manage risks. Patients were only accepted for care when it was safe, and staff used clear escalation pathways to respond to deterioration. Safeguarding arrangements were embedded, and staff demonstrated a good understanding of how to recognise and report concerns.

Staff worked with patients to understand and manage risk. Patients told us risks, treatment and side effects were explained clearly, and they were given information about when to seek urgent help.

The environment and equipment were safe, clean and well maintained. Infection prevention and control systems were effective and supported by governance arrangements and national standards.

There were enough suitably trained staff to provide safe care, and staff received appropriate training to respond to risks and emergencies. At our last inspection we rated this key question good. At this inspection, the rating has remained good. Patients were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

Managers and leaders created a proactive, positive learning culture based on openness and honesty that protected patients. Staff across services described them as approachable and supportive, and said they felt confident raising concerns and sharing feedback to improve care and safety. Medical services staff consistently reported this, noting that leaders encouraged open discussion and welcomed challenge

The service ensured staff had appropriate training, skills and ongoing support to work safely and contribute to learning from incidents. Managers described clear expectations for staff competence and training, which supported a consistent and proactive safety culture.

Managers described an environment where incident reporting, including near misses, was actively encouraged. Staff across clinical and non-clinical roles used an electronic incident reporting system. They told us it was easy to access and that they understood when and how to report incidents. Staff were encouraged to report concerns and take part in investigations and reviews, which promoted shared learning rather than blame.

Incidents were reviewed regularly at departmental and governance meetings, assigned levels of harm and investigated in line with policy. We saw evidence of incidents that had been reviewed and investigated. Managers described clear timescales for responses. For example, incident investigations were completed within 30 days.

Managers shared learning from incidents in a range of ways to reach staff working across different roles, services and shifts. This included daily safety huddles, weekly team meetings and monthly clinical governance meetings. Learning was also shared using digital communication platforms so staff who were not on duty, including bank staff, could access information promptly.

The provider used a structured ‘Outcome with Learning (OWL)’ approach, which clearly set out what had happened, what actions had been taken and what learning had been identified. This helped staff understand how incidents resulted in change. Staff were able to describe examples where learning had led to improvements in practice, showing learning was embedded rather than only reported.

We scored the service as 3. The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

Systems were in place to ensure people were only accepted for care when it was safe to do so. Staff used defined admission and inclusion criteria, supported by an inclusion criteria policy, to guide decision-making about suitability for treatment. The team considered clinical complexity, comorbidities, anaesthetic risk, and postoperative care needs. When patients fell outside agreed criteria, they discussed cases in multidisciplinary and preoperative patient safety meetings and escalated them to senior clinicians when needed. This process enabled them to identify risks early and refer patients appropriately or direct them to alternative pathways when they could not provide safe on-site care.

In the oncology unit, we saw evidence of a clear pathway for escalation and transfer when patients contacted the oncology rapid response line. The pathway outlined how teams assessed concerns and gave clinical advice. Staff followed a nationally used triage tool to escalate to on-site review, ambulance services, or NHS transfer.

Transfers to external services were managed to support people’s safety and continuity of care. The service had a clear transfer out policy that set out decision making, escalation, communication, documentation and transport requirements. Staff described consultant led decision making for transfers, use of pre‑transfer risk assessments, appropriate ambulance services and clinical escorts where required. Structured verbal and written handovers were completed, and transfer documentation accompanied people to receiving services. Staff also described keeping people and their relatives informed throughout the transfer process.

Care was managed across the hospital and with partners to keep everything connected. Care teams worked closely with partner organisations like NHS trusts, ambulance services and community providers to share responsibility for people’s care. In oncology, information from team meetings, consultants, pharmacy and treatment plans was all brought together in patient records. Digital systems helped track patients in real time, report symptoms and flag concerns, so staff could act early and follow up quickly.

Staff shared information to support safe transitions between teams and shifts. Staff used structured handovers, daily safety huddles and briefings to review risks, staffing levels and people’s needs. This supported continuity of care.

We scored the service as 3. The service worked with patients and healthcare partners when needed to keep people safe. Staff considered what safety meant for each person. Staff chose the best way to achieve this.

Staff concentrated on protecting patients’ rights to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Clear safeguarding systems and leadership arrangements were in place. A named safeguarding lead was in place. Staff across services described knowing who the safeguarding leads were and said they felt confident escalating concerns to them when required. We saw safeguarding process posters displayed in the nursing office, which supported staff to recognise and escalate safeguarding concerns appropriately.

Staff received safeguarding training appropriate to their role and demonstrated good awareness of safeguarding risks. Mental Capacity Act (MCA) training formed part of mandatory training.

The service promoted a culture where safeguarding concerns could be raised openly. Staff reported feeling supported to speak up and said concerns, including safeguarding issues, were taken seriously. Staff were able to explain how to recognise safeguarding concerns, raise concerns through the electronic incident reporting system and involve safeguarding leads promptly.

Safeguarding concerns were identified and managed appropriately. We heard from staff a clear example of a safeguarding concern that had been raised in relation to domestic abuse. Nursing staff described how they spoke with the patient in a private and safe space, escalated the concern to the safeguarding lead and recorded the concern on the incident reporting system. Staff also described arranging alternative accommodation to support the patient’s safety. This demonstrated staff understood how to balance safeguarding responsibilities with people’s rights, choice and autonomy.

Clear safeguarding systems and leadership arrangements were in place. The service had specific safeguarding arrangements for young people aged 16 and 17 years. A registered children's nurse completed a risk assessment before treatment to assess suitability for the adult pathway. The assessment considered safeguarding factors, clinical stability, consent, psychosocial needs, communication requirements and post-discharge support arrangements. Where concerns were identified, staff escalated these to senior leaders, consultants and anaesthetists before care proceeded. Young people were supported to understand the adult care environment and pathway decisions were clearly documented. Senior leaders with level 3 safeguarding training were available on site, and safeguarding policies included dedicated guidance for children and young people.

We scored the service as 3. The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patients to do the things that mattered to them.

Staff worked with patients to explain risks clearly, review them regularly and adapt care when needs or circumstances changed. Patients said staff took time to explain treatment, risks and side effects before treatment started and when plans changed. One patient told us staff explained treatment changes thoroughly and allowed time for questions, supported by written information. Another patient said staff explained prognosis, treatment, risks, benefits and side effects. This helped people understand risks and feel confident in decisions about their care.

Staff provided clear information about when to seek urgent help and how to access support. For example, patients we spoke with under the care of the oncology unit consistently told us they were given emergency contact details and could access advice 24 hours a day.

In addition, the oncology unit used a digital platform that encouraged people to record symptoms and treatment related side effects between appointments. This allowed staff to monitor reported concerns daily, review symptom trends and contact people proactively where risks increased. Staff told us alerts from the system prompted timely review and advice, helping to prevent deterioration and reduce avoidable harm.

Staff managed risks holistically by considering patient’s physical health, emotional wellbeing, mental health needs, lifestyles and personal circumstances. Records showed pretreatment assessments included past medical history, allergies, performance status and regular review before each treatment cycle. Where risks such as nutrition, thrombosis or treatment toxicity were identified, staff involved the wider multidisciplinary team, including dietitians, oncologists and pharmacists. Staff also carried out mental health risk assessments and reviewed these in response to changes in people’s presentation, needs or circumstances. They described assessing and managing risks such as heightened anxiety, distress, self-harm and deterioration in mental wellbeing, with actions documented in people’s care plans.

Staff demonstrated they could recognise signs of deterioration and use escalation processes appropriately. They described using the National Early Warning Score 2 (NEWS2), alongside clinical judgement, to identify deteriorating patients and escalate concerns in a timely way. In endoscopy, staff explained how they escalated patients through the theatre coordinator and sought prompt support from senior clinicians, including anaesthetists, when required. Staff also demonstrated appropriate use of structured communication tools, such as Situation, Background, Assessment and Recommendation (SBAR), and documented escalation actions and outcomes clearly. Staff reported emergency transfers to acute hospitals were managed safely, with consultant led decision making, appropriate clinical accompaniment, and clear communication with receiving services and relatives.

We scored the service as 3. The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The service had effective systems in place to identify, assess and manage risks within the care environment. Leaders monitored environmental safety through routine inspections, audits, risk registers and action plans, ensuring that equipment, facilities and technology supported the delivery of safe care.

Environmental risks were identified through internal and external risk assessments. A patient representative group carried out a Patient Led Assessments of the Care Environment (PLACE), a direct environmental observation. The hospital achieved high PLACE scores across all domains, including cleanliness (98.8%), privacy, dignity and wellbeing (94.4%), condition, appearance and maintenance (96.0%), dementia (90.8%) and disability (90.3%). Patient assessors reported they were confident or very confident that the environment supported good patient care and experience. Environmental reviews identified a small number of improvement opportunities, such as refurbishment of some areas, reviewing access arrangements and enhancing dementia-friendly features. Leaders recorded and monitored actions through an established action plan. The assessments found the environment to be clean, well maintained and accessible, with ongoing improvement work supporting a positive experience for patients, visitors and staff.

Environmental observations of the oncology unit confirmed that areas were clean, organised and appropriately equipped. Fire exits were unobstructed, non‑slip flooring was in place, emergency equipment was accessible, electrical equipment was in date for safety testing, and infection prevention infrastructure supported safe practice. We observed that medical and electrical equipment was managed to ensure it was safe and fit for use. Equipment was routinely serviced, tested and labelled to confirm safety status. There was an oxygen port at each pod with airway equipment available. Patients and staff could easily access call bells and emergency buttons at each pod (seat for patients receiving treatment), as well as in other facilities such as toilets.

The oncology unit accessed its nearest resuscitation trolley, which was located on the ward. Staff took part in a simulation to assess the time taken for staff to access the resuscitation trolley from the ward to the unit. We saw a written statement from the service’s resuscitation lead confirming that the oncology unit could access the nearest resuscitation trolley within one minute.

We noted that access to the oncology unit was controlled by a keycode lock; however, the door remained open during operational hours. We raised a concern regarding the privacy and security of people using the oncology service. The unit manager informed us that a member of staff was always present at the reception area to monitor access and provide oversight. However, the manager acknowledged our feedback and told us they would take this into consideration and ensure the doors remained closed when appropriate to help maintain people’s privacy and the security of the unit.

Endoscopy procedures were delivered within the theatre environment for this location. For further information on theatre environment please refer to surgery report.

We scored the service as 3. There were enough qualified, skilled and experienced staff to provide safe care and treatment, and staff worked together effectively to meet people’s individual needs. Staff received support, supervision and development, and arrangements were in place to maintain competence and manage risks safely.

The hospital used formal workforce planning tools across wards, theatres, oncology, and outpatient services. Managers reviewed staffing levels and skill mix daily in safety huddles and adjusted them to match patient needs and demand. Leaders and managers said the workforce was stable, with low turnover and little reliance on agency staff.

The hospital maintained 24-hour on-site Resident Doctor (RD) cover, ensuring medical support was always available. RDs told us consultant support was readily available, including out of hours, and that escalation pathways were clear. One RD told us consultants were “supportive and responsive” when contacted for advice.

Staff told us training requirements for oncology were clear and supported by managers, which helped them feel confident to raise concerns and contribute to improvements in care and safety.

Mandatory training requirements were monitored at organisational and local level. Staff received role specific training or procedure specific competencies where relevant. Leaders described how training compliance was overseen corporately and followed up locally. Mandatory training reports showed overall compliance levels for permanent staff at 94% at the time of the inspection, with any gaps followed up through local management oversight. Staff we spoke with were aware of training expectations and felt supported to maintain and update their skills.

Leaders monitored mandatory training compliance through monthly governance processes. The organisation's target for compliance was 90% or above. At the time of inspection, compliance for immediate life support training was 91%, meeting the target, while basic life support training was 87%, below the target but within the organisation's satisfactory range. Leaders told us they reviewed compliance regularly, discussed non-compliance at daily operational meetings and governance forums, and arranged additional training sessions where needed to improve compliance. There were always advanced life support (ALS) qualified practitioners on site, including the resident doctor.

Where agency or bank staff were used, this was limited and primarily to cover short notice absence. Agency staff were inducted locally using a checklist that included fire safety, escalation processes and clinical orientation. Bank staff received the same induction and mandatory training requirements as substantive staff. Resident doctor (RD) were recruited through an approved agency and treated as part of the core team. The hospital had robust systems to ensure consultants were skilled and experienced for their roles. Practising privileges were granted only following a formal credentialing process, including verification of professional registration, indemnity, appraisal and scope of practice. Practising privileges enable independent consultants to provide care and treatment within a hospital under an agreed contractual arrangement. Practising privileges were reviewed regularly with Medical Advisory Committee oversight, and consultants were permitted to work only within their approved scope.

We scored the service as 3. The service assessed and managed the risk of infection. Staff detected and controlled the risk of infections spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

Staff followed organisational and local arrangements for infection prevention and control. Responsibilities for infection prevention were clearly defined from board level through to hospital and departmental level. The service had effective systems to detect and monitor infection risks. Monitoring of healthcare associated infections, including surgical site infections and post‑discharge infections, was carried out across pathways. Infection data was reviewed regularly at local infection prevention meetings and shared with people who needed to know. We saw evidence that in 2025, all reported infections were investigated, reviewed by infection prevention leads and discussed with specialist microbiology input.

The service worked effectively with external agencies and partners. Staff had links with a local NHS trust, including access to microbiology advice and shared investigation of infection cases.

Staff controlled the risks of infection spread through their everyday practice. In the oncology unit staff kept areas visibly clean and well maintained. Clinical equipment was cleaned between use and labelled accordingly, and cleaning schedules were in place and up to date. Staff followed hand hygiene expectations, including being bare below the elbows, and handwashing and sanitising facilities were readily available throughout the unit. Personal protective equipment was accessible at multiple locations, and sharps were managed safely, with bins dated, clean and not overfilled. We observed that clinical and non-clinical waste was managed appropriately.

The endoscopy service had standard procedures for decontaminating reusable medical equipment. These covered flexible endoscopes and heat sensitive devices. The procedures set clear expectations for cleaning, high‑level disinfection, drying, storage, and traceability. Staff cleaned equipment promptly after each procedure. They used validated automated processes for decontamination.

Mandatory infection prevention training was in place for all staff, supported by defined competency frameworks for infection prevention nurses, coordinators and link practitioners.

The endoscopy service at this location held Joint Advisory Group (JAG) accreditation, providing additional assurance that infection prevention and control standards aligned with national recognised practice.

We scored the service as 3. The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

Medicines were stored safely and securely in all clinical areas seen on this inspection. All medicines checked were within their expiry date. Outpatient prescription pads were kept securely with record keeping processes in place for monitoring their use.

The oncology unit provided treatments to patients safely and in a timely manner. Chemotherapy medicines and take-home prescriptions were prepared in advance of admission to prevent delays in treatment and discharge.

Medicine reconciliations were completed during pre-screening for chemotherapy. Some records did not include all vital medicines information. The pharmacy team identified this as an area for improvement. They planned a quality improvement project. The project aimed to standardise practice.

Staff recorded patient allergies during the medicine reconciliation process, but natures of allergic reactions weren’t always documented. This was important as it helps healthcare professionals understand the severity of an allergy. Medicine reconciliations were taken on paper charts then uploaded onto the electronic systems used for prescribing. We found an instance where an allergy status written on a paper chart wasn’t added onto the electronic prescribing system, which risks patients receiving medicines that might harm them.

Processes were mostly in place for provision of patient counselling when prescribing high risk medicines. There were resources available for patients on discharge to understand more about the treatments they were receiving. However, the unit did not have resources for counselling people on the risks involved with taking fluoroquinolones (a type of antibiotic) and potential side effects to look out for. This was escalated during inspection as we identified a person prescribed fluoroquinolone antibiotics as part of their chemotherapy treatment.

The unit kept resuscitation equipment on a nearby ward. Staff completed scenario based training to test emergency response skills. They checked the resuscitation trolley regularly. All items were in date.