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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.

Inspection Summary


Overall summary & rating

Good

Updated 25 January 2019

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

Caring, effective, responsive and well led were rated as good and safe was rated as requires improvement. During this inspection we inspected the core services of medicine, surgery children and young people, end of life care and child and adolescent mental health services.

Inspection areas

Safe

Requires improvement

Updated 25 January 2019

Effective

Good

Updated 25 January 2019

Caring

Good

Updated 25 January 2019

Responsive

Good

Updated 25 January 2019

Well-led

Good

Updated 25 January 2019

Checks on specific services

Medical care (including older people’s care)

Good

Updated 25 January 2019

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

  • The service had enough staff with the right qualifications, skills and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.
  • Staff assessed the risks to patients and monitored their safety to ensure they were supported to stay safe.
  • Staff provided patients with enough food and drink to meet their needs and improve their health.
  • The service managed patients’ pain effectively and provided or offered pain relief regularly.
  • Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
  • The service prescribed, gave, and recorded medicines well. Patients received the right medication at the right dose at the right time. However, we found staff had little awareness of the processes to implement should the clinical room temperatures exceed the required levels.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress.
  • The trust planned and provided services in a way that met the needs of local people. Patients could access the service when they needed it.
  • Staff involved patients and those close to them in decisions about their care.
  • The referral to treatment time (RTT) for admitted pathways for medical care was consistently better than the England average. The average length of stay was below the England average of six days at five days.
  • Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values.
  • The service had managers with the right skills and abilities to run a service providing high-quality sustainable care.
  • Continuous improvement and learning from when things go wrong was evident across the service.

However

  • The service provided mandatory training in key skills but did not ensure all nursing and medical staff completed it. However, there was an action plan in place to address this.
  • The service did not ensure all nursing and medical staff completed their safeguarding training. However, staff understood how to protect patients from abuse and the service worked well with other agencies to do so.
  • The service generally controlled infection risk well. However, not all staff followed the infection control guidance or comply with trust’s policy regarding the wearing of jewellery which meant there was a risk of patients not being kept safe from the spread of infection.

Services for children & young people

Good

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.

Critical care

Good

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.

End of life care

Good

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.

Maternity and gynaecology

Good

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.

Outpatients and diagnostic imaging

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.

Surgery

Good

Updated 25 January 2019

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

  • We rated safe, effective, caring and responsive and well-led as good.
  • The service had enough staff, who had completed required training. Staff were supported by managers and had annual appraisals.
  • In theatres the environment was clean, tidy and equipment was readily available, clean and well maintained.
  • The service had thorough pre-assessment screening for patients requiring surgery that considered peoples individual needs.
  • The service stored and administered medicines well.
  • Staff worked well in multidisciplinary teams and provided compassionate, appropriate and individualised care to ensure good outcomes for patients.
  • Managers supported staff, promoted learning from incidents and used available information to improve to the service.

However, we also found that

  • The systems the service had in place to protect people from infection and for ensuring wards were clean and free of clutter were not always robust. The trust took steps during the inspection to address this.
  • We observed two incidents where staff had not kept patient records secure. The trust took action during the inspection to address this.

Urgent and emergency services

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.

Child and adolescent mental health wards

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.

Other CQC inspections of services

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