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Inspection carried out on 16 and 17 August 2016 and 20 October 2016.

During an inspection to make sure that the improvements required had been made

Derby Teaching Hospitals NHS Foundation Trust serves a population of over 600,000 people in and around Southern Derbyshire.

The trust has two hospitals, the Royal Derby Hospital, an acute teaching hospital and London Road Community Hospital. Derby Teaching Hospitals NHS Foundation Trust is one of the largest employers in the region with a workforce in excess of 8,000 staff.

Derby Teaching 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
  • Maternity and midwifery services
  • Surgical Procedures
  • Termination of pregnancies
  • Treatment of disease, disorder or injury

Derby Teaching Hospitals NHS Foundation Trust were inspected on 16 and 17 August 2016. We carried out an unannounced visit on 20 October 2016.

This inspection was a focused follow up inspection of following our comprehensive inspection in December 2014.There had been a compliance actions issued against this provider at the time of our last inspection, these were issued under 2010 regulations, which were superseded by new regulations in 2014. These are now known as requirement notices. At this inspection, we inspected the key question of safe in maternity and gynaecology, the key question of safe in medical care (including older people's care) and the key question of effective in end of life care to ensure the service was complaint with the requirement notices we issued at our last inspection. We did not rate the trust overall.

Our key findings were as follows:

  • Care and treatment of patients at the end of their lives was effective and delivered in line with legislation and evidence based standards.
  • Staff had good access to both the specialist palliative care team and access to comprehensive online information to support them to deliver care to patients at the end of their lives.
  • Decisions made regarding cardiopulmonary resuscitation were made in line with the trust’s policy and the Mental Capacity Act 2005 in the majority of cases.
  • Across the medical wards, there was a good track record in safety.
  • There were assurance processes in place for monitoring safety and quality of care.
  • There was an open culture, for reporting incidents and evidence of lessons learnt. When something went wrong, patients were given an explanation and received an apology.
  • Areas were mostly visibly clean and tidy. Staff took appropriate steps to reduce the risk of hospital-acquired infections. Equipment was readily available and medicines were managed and stored safely.
  • Within the maternity and gynaecology service, patients’ records were stored securely; documentation was accurate and complete.Risks to patients were assessed and suitable actions taken.
  • Staffing levels and skill mix were planned, implemented and reviewed to keep patients protected from avoidable harm. Patients who accessed maternity care had a named midwife.
  • There was a lone worker policy in place and staff within the community midwifery team reported they felt safe.

However,

  • Across the medical wards, when patients required a sepsis screen this was not always carried out. Staff did not always escalate or respond to high early warning scores and staff appeared unfamiliar with the use of the electronic observation system.
  • Within the medical wards, there was not a robust system in place for checking suitability of resuscitation equipment and patient records were not always stored securely.
  • Within the maternity service, not all staff had completed mandatory training, including appropriate safeguarding training. We were not assured that midwives caring for patients in the high dependency unit had received appropriate training to do so.
  • Midwifery staff expressed concerns about the electronic patient record, stating that information could easily be overlooked.
  • Within the maternity service, there were no formal multidisciplinary meetings to discuss serious incidences and deaths, and consultant presence did not reflect national the recommendations.

We saw one area of outstanding practice:

  • Patients on the respiratory medical wards who were receiving oxygen therapy wore colour-coded wristbands to identify how much oxygen they needed. This minimised the risk of patients receiving too much oxygen.

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

Importantly, the trust must:

  • Review arrangements for training maternity services staff in level three safeguarding to ensure timely compliance with the intercollegiate guidelines of March 2014.
  • The trust must ensure patients’ notes are stored securely on medical wards to ensure their confidentiality.
  • The trust must ensure all patients who meet the criteria for sepsis screening are screened and any interventions are carried out in line with trust protocol and national guidance.
  • The trust must ensure all staff are trained in the screening, management and treatment of sepsis and that all staff are familiar with and have easy access to the sepsis screening proforma.
  • The trust should ensure staff on the medical and elderly care wards adhere to and follow the trust guidelines in relation to the escalation of deteriorating patients.
  • The trust must ensure compliance with same sex guidance in the monitored bay on the medical assessment unit.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 08-10 December 2014

During a routine inspection

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 carried out on 16, 17 January and 11 March 2014

During an inspection in response to concerns

We visited the ophthalmology ‘eye’ out-patients department in response to concerns that essential standards, relating to the care and welfare of people who used the service were not being met. We spoke with fifty patients who were attending the department. We also spoke with several relatives who were present.

All but one of the patients we spoke with said that they felt that they had received an appropriate assessment and treatment of their condition, and that staff explained their condition and treatment options well.

Comments from patients included ''I think the whole process has been very good, from getting the tests done to getting the treatment and then getting follow-up appointments. I think I’ve been treated very well; I’ve had an improvement from 40% vision to 80% vision in three months, which is all down to the doctors here. That’s been fantastic for me; every time I’ve been I’ve understood everything and they don’t seem to rush you if you’ve got questions.''

However one patient told us “I have confidence in one particular consultant, and was told them they would be dealing with my complex case. I’m very disappointed that I haven’t seen the right person for a second time in recent weeks”.

The numbers of patients attending the department continues to increase each year. The trust acknowledged that this had posed a significant challenge in terms of resource and space, and had led to increased work pressures. In response to this, the trust had appointed additional staff to meet the increased demands on the service. The department was also looking at alternative ways of working to improve the efficiency of the service, and to reduce staff workloads.

We found that patients generally received care and treatment that met their needs and ensured their welfare. However processes in place to assess and monitor patients’ care, treatment and conditions required strengthening, so that the trust could be assured that patients received appropriate care or treatment.

Inspection carried out on 15, 16 July 2013

During an inspection to make sure that the improvements required had been made

We spoke with patients on two medical and surgical wards. We also spoke with several relatives who were present.

Patients told us that they were generally satisfied with the care and service they received. Comments received from patients included ''the staff team are marvellous, they look after us well, the staff work hard, they treat me quite well and I am involved in my care and treatment''. All patients and relatives with the exception of one person told us that they had not had reason to raise a concern or make a complaint. One person who had made a complaint recently told us ''my concerns were dealt with in a timely manner to my satisfaction''.

Following our visit we spoke with five people who had made a complaint to the trust in the last six months, to obtain their views as to how their concerns were managed. Three out of the five people told us that their complaint was dealt with in a timely manner and was resolved to their satisfaction. Whilst two people told us that their complaint was not handled appropriately and resolved to their satisfaction.

The complaints procedure was not well publicised or understood by patients and visitors. The trust was not meeting its response timescales, which meant that complaints were not always responded to in a timely way. Improvements were being made to ensure that complaints were handled effectively and were acted on to improve the service for patients.

Patients’ records generally included appropriate information about their care and treatment although some care records did not provide an accurate account of all care and treatment provided to each patient. The lack of information meant that people were not protected against the risks of unsafe or inappropriate care and treatment.

Inspection carried out on 16, 17 October 2012

During a routine inspection

We spoke with patients on the medical and surgical assessment units, two medical and surgical wards and patients awaiting discharge in the discharge lounge.

The majority of patients able to express their views felt involved in decisions about their care and treatment.

The majority of patients told us that they were satisfied with the care and service they received. Patients comments included “you could not beat the medical care I have had, I have been treated really well, I cannot complain about anything, you could not pay for better care, to the treatment is just above average.”

Patients told us that they were involved in planning their discharge. Some patients expressed concerns as to the length of time they had had to wait for results, or for discharge medication from the hospital Pharmacy.

The majority of patients told us that they were satisfied with meals and drinks provided. However a few patients told us that the meals were not to their liking and did not meet their dietary needs.

Patients told us they felt safe and able to report any concerns to staff. However most patients were not aware of how to make a complaint, if they were unhappy with the care or service.

The majority of patients felt that the staff were friendly and helpful and that they spoke to them appropriately.

Inspection carried out on 21 March and 28 May 2012

During a themed inspection looking at Termination of Pregnancy Services

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Inspection carried out on 5 January 2012

During an inspection in response to concerns

We focused our inspection on the experiences of the people using the adults Emergency Department (ED). This was in response to recent news reports that ambulance services are facing delays as they are left waiting with emergency patients when handing over to hospitals in England.

The department relocated to new premises at Royal Derby Hospital in May 2009, and is over four times the size of the previous department. The department sees over 300 people on average each day. The hospital has a separate children’s and adults department.

We talked with patients and their relatives as well as nursing, medical and support staff, trust management staff and paramedics. We made general observations of the environment and activities within the department.

Patients we spoke with said they were satisfied with the care and treatment they received and felt that their needs were been met. One patient told us ’’The department has a good team of staff and is well organised; I can’t fault the care and treatment I have received’’.

Patients felt that staff were polite and respectful in their approach and attitude. Most patients felt involved in decisions about their care and treatment.

Some patients said they had not been told how long they were likely to wait for test results or treatment, and whether they could eat or drink.

Relatives we spoke with said they were aware of the care and treatment their family member was receiving.