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We are carrying out a review of quality at Chesterfield Royal Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.
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Inspection report

Date of Inspection: 17 May 2011
Date of Publication: 12 July 2011
Inspection Report published 12 July 2011 PDF | 155.41 KB

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The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We reviewed all the information we hold about this provider, carried out a visit on 17/05/2011, checked the provider's records, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services.

Our judgement

People benefit from safe, quality care, treatment and support because there are effective systems in place ‘from ward to board’ that monitor the quality of the service provided.

User experience

Some people we spoke with said they had looked at the hospital’s website and were aware of how to make comments if they needed to. Some people said they had completed surveys after previous admissions, giving their views on the service provided.

The surveys and other information we looked at indicated that people were usually satisfied with the quality of care provided.

Other evidence

We asked the provider to send us written information about how they were complying with regulations. The provider told us they had a range of systems in place to monitor the quality of the services they provided. These systems included patient and public involvement projects, clinical audits, and audit and analysis of incident reports. The provider had developed a Feedback Learning and Improvement Programme which they said “brings together audit results, patient experience, incidents and complaints data, training attendance and contextual information to give an overview of performance.”

The provider told us there were two areas where they needed to take action to ensure full compliance with this regulation. The provider said they needed to increase involvement of people’s relatives in discussion and decisions about whether resuscitation should be attempted. Also, that there needed to be improved adherence to a policy about consent to imaging. The provider told us they would make the necessary improvements by September 2011 and provided details of how this would be achieved.

We saw from the minutes of meetings of the board of governors that the governors received reports about the monitoring of quality of services provided and the action taken to make improvements.

The surveys we looked at indicated that most staff felt their role made a difference to patients. Just over half the staff who responded said they were able to contribute towards improvements at work.

Staff we spoke with confirmed that they could bring up ideas for improvements at team meetings. One member of staff told us they felt their ideas were listened to and sometimes acted on, depending on budget and other constraints.

The provider told us they identify, monitor and manage risks to people who use, work in, or visit the hospital. They said “Incidents, complaints and claims are all reviewed to identify any changes in practice required, or issues that can be used for educational purposes to minimise the risk of recurrence. Complaints are reviewed at directorate clinical governance groups and actions updated.”