Royal 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 for everyone, and leaders embedded a culture of openness and collaboration. We checked that women were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked women’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question Inadequate. At this assessment the rating has improved to Requires Improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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.

The service did not have a proactive and positive culture of safety based on openness and honesty. Leaders did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Leaders did not ensure that staff reported incidents in line with trust policy as staff believed they did not need to. We found delays in induction of labours, caesarean sections and other elective procedures were not reported. We found there were delays to investigations and learning from incidents was not always embedded.

The service did not use the perinatal mortality review tools to learn lessons to improve care, reduce poor outcomes and improve women’s experience as cited in the warning notice at the last inspection. We reviewed 7 completed PMRT’s which failed to recognise risk or escalate concerns. Trust and national guidelines in relation to medical reviews and smoking cessation had not been followed. Delays in medical reviews on the pregnancy assessment unit and on labour ward were identified in several PMRT’s which were reported by the service in cases whereby the care may or likely had an impact on the outcome for babies. Due to the inaccuracy of the risk assessments women were placed on the incorrect care pathways to meet their needs. Small for gestational age babies (SGA) and fetal growth restricted (FGR) babies were not always identified. Risk assessments were not always completed or risks managed in accordance with national guidance, this was putting babies at risk of harm despite repeatedly being identified through the cases and PMRT process.

The service did not work well with women and health system partners to establish and maintain safe systems of care. Staff did not manage or monitor women’s safety. They did not make sure there was continuity of care, including when women moved between different services

At this inspection we found staff continue to not use an evidence-based, standardised risk assessment tool for maternity triage
Staff used a form to prioritise women accessing the Triage unit that prompted staff to assess if immediate, medium and low risk but there was not a clear framework which underpinned and supported clinical decision-making. At this inspection we found there had been no improvement in this area

On the first day of our inspection, the service had just commenced a telephone triage service which would direct women to the most appropriate location for their needs. Due to the timing of this we were unable to identify the effectiveness of this process.

The service has still not implemented a formal handover process for the ‘Situation, Background, Assessment, Recommendation’ (SBAR) process. Staff are using a non standardised process which risks safe and effective communication which can affect service users care.

Managers still did not regularly complete audits to ensure staff shared key information to keep women safe when handing over their care to others. This formed part of our enforcement activity following our onsite inspection.

The service did not work well with women and healthcare partners to understand what being safe meant to them and how to achieve that. Staff did not concentrate on improving women’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not share concerns quickly and appropriately.

We were not assured the safeguarding training was in accordance with the both the vulnerable adult and children and young people’s intercollegiate guidance, as level 3 safeguarding training should take place 50% face to face and 50% online. During the factual accuracy process the service informed us they held action learning sets, and group cases discussions to meet this requirement. However, we were not provided with evidence which stated how the service assured staff would attend the action learning sets and case discussions.

Although staff had completed online safeguarding training specific for their role on how to recognise and report abuse, they did not always apply this in practice. During the inspection we observed staff left a baby with their parent unsupervised which was not in accordance with the baby’s safeguarding child protection plan. Staff did not respond or recognise this as a concern.

Staff reported that they were not well practiced in abduction procedures. The service did have an up to date policy in place for child abductions. However, staff told us that they were not always involved in the drills or knew the frequency of these drills.

The service did not work well with women to understand and manage risks. Staff did not provide care to meet women’s needs that was safe and supportive.

Staff told us it was difficult to get doctors to review a patient if their condition changed or the midwife team disagreed with a person’s care plan. This would mean at times midwives were working without a doctor’s advice and therefore putting women at risk and possibly working outside the scope of their practice.

Following the last inspection in 2023 the CQC imposed urgent conditions on the location registration, to take immediate action to implement to ensure that staff were competent to review, interpret and escalate fetal monitoring traces. The service was supported by the NHS England Maternity Safety Support programme. Whilst we noted there had been improvements, they remained variable and needed to be embedded. This had not been achieved, and the risk remained. However, we saw PMRT’s and incidents which identified that not all CTG’s were being interpreted, acted on and escalated in accordance with national guidance therefore CTG interpretation remained a significant risk to women, and babies

At the last inspection the trust required by the commission, to take immediate action to ensure that staff completed hourly ‘fresh eyes’ during intrapartum care, which they have now achieved. Compliance for completion of these observations has been above 90% compliance since March 2024, apart from September where we noted a slight decrease to 86%. Evidence on site indicated that on the two days of inspection cardiotocograph (CTG) “fresh eyes” buddy system CTG checks had improved. Between April and November 2024. Fresh eyes reviews by the midwife supporting in labour ranged between 95% and 86% were carried out on time. Fresh eyes completed by an independent reviewer ranged between reviewed by 86% to 96% completed on time.

The service used the regional operational pressures escalation levels (OPEL) to assess and respond to the demands of the service. The OPEL framework enabled service to take specific actions and escalations in accordance with the framework to monitor the service, reduce risk, improve flow and outcomes and communicate the pressures to the regional midwifery team. During the inspection we observed senior midwifery staff inaccurately score the OPEL level as amber when it should have been scored as red. A service on red status would prioritise and deflect women, to other hospitals. We were told staff were able to use professional judgement as part of the tool, however, this can lead to inconsistency based on the risk appetite of the person calculating the score. Staff were not using the tool accurately to indicate the level of pressure on the systems therefore missing opportunities to take actions to manage the service and mitigate the risk to women.

The design of the environment followed national guidance. The maternity unit was fully secure. The service had two maternity theatres and 4 enhanced care beds for women requiring a higher level of monitoring after the birth.

Following our last inspection the service had undertaken ligature risk assessments, and actions had been taken to mitigate risks.

The service monitored and controlled any potential risks in the care environment including facilities and technology. However, we saw the service did not always make sure emergency equipment was readily available. We saw neonatal resuscitation equipment for the birthing centre was placed behind a locked door. This meant that there was a delay in acquiring the equipment which meant babies were being put at risk from avoidable harm.

The service did not always ensure there were enough skilled and experienced staff to keep women safe. Although the service met the safe staffing numbers on most shifts, however, the skill mix was variable We saw occasions when there were multiple newly qualified midwives were duty during their preceptorship period. The trust could not be assured that every shift was staffing with midwives who had the experience, skills and competence to keep women safe.

As part of the previous enforcement action the services was required ensure that all staff at Royal Derby Hospital had completed annual mandatory fetal monitoring and PROMPT training. This had not been fully achieved. Compliance for as of November 2024, we saw evidence which showed, 94% of doctors, 92% anaesthetists, and 97% midwives had completed PROMPT training. Compliance for fetal monitoring training was 91% for doctors and 94% for midwives. Compliance for neonatal life support training was 97% for doctors, 94% for midwives. However, there was a separation between Obstetric doctors in post before 1st July 2024 from those that started in the Trust after 1st July 2024. We found rotational obstetric medical staff who commenced work on or after July 2024 compliance was at 60% for prompt and 68% for fetal heart monitoring. There was a plan in place to recover this position. Due to the seriousness of the concerns we found at the last inspection and the impact this has for women we would have expected the trust to expedite this training for all staff working within the service.

Staff found it difficult to call the ward during work hours to share information. We found that staff members who were trying to call the ward may have the phone ignored or hung up on. However, patients had access to a 24/7maternity triage telephone to speak with staff without delay.

The service did not always have enough nursing and midwifery staff to keep women, birthing people and babies safe. The service reported maternity ‘red flag’ staffing incidents in line with National Institute for Health and Care Excellence (NICE) guideline 4 ‘Safe midwifery staffing for maternity settings. A midwifery ‘red flag’ event is a warning sign that something may be wrong with midwifery staffing. We observed and staff told us about delays in inductions of labour (IOL), were a frequent occurrence. We were told that staff were not always reporting these as they were told not to by leaders. We saw no reference to maternity red flags within published board papers; therefore, we were not assured the board had oversight of all aspects maternity staffing. During the factual accuracy process the service provided evidence that maternity red flags were reported as part of the biannual maternity workforce report. We are still not assured the board has full oversight of the staffing challenges within the maternity service.

The service assessed and managed the risk of infection. Ward areas were clean and had suitable furnishing which were clean and well maintained. Staff adhered to infection control principles, using personal protective clothing and handwashing techniques. Equipment and ward areas were cleaned after they have been used and labelled.

However, we saw sharps bins stored on the floor, which is not in line with best practice. And medical waste was not correctly discarded nor made secure. For example, we found placentas in clear plastic bags were discarded into buckets on the floor of dirty utility. Staff told us this was routine practice and to not replace the lid on the placenta bucket. Guidance states they should be placed in individual yellow bags then added to the placenta bucket.

The service monitored the number of women who were readmitted within 6 weeks following their delivery, however we could not identify if these was related to post-partum infection. Evidence provided showed between April and November 2024, 117 women had been readmitted within 6 weeks of birth. We were not assured the service was investigating this and implementing processes to reduce the number of readmissions. During the factual accuracy process the service informed us those women who attended the hospital for longer than 6 hours was identified by their electronic system as an admission.

The service did not always make sure that medicines and treatments were safe and met women’s needs, capacities and preferences. Staff did not always involve women in planning.

Staff did not ensure that medicines stored in refrigerators and freezers were monitored correctly and therefore safe to use. We found a freezer that contained medicines used for the induction of labour that did not have a working thermometer therefore, temperatures were not recorded. Staff acknowledge they were accountable for monitoring the fridge and freezer temperatures, but these were not completed during the assessment as there was no formal process of identifying an individual to check the fridge temperatures. Therefore, we were not assured that medicines were stored at the correct temperature in line within manufactures requirements. However, medicines that were not stored in refrigerators were stored and logged appropriately and staff were confident with the processes in place.

Staff followed systems and processes to prescribe and administer medicines safely. Staff completed medicines records accurately and kept them up to date.The medicines records we reviewed were clear and up to date. Staff had access to medicines used to respond to emergencies safely. On the delivery suite, staff had access to emergency trolleys and boxes to respond quickly to conditions such as pre-eclampsia, sepsis and cord prolapse

Staff reviewed each woman’s medicines regularly and provided advice to women about their medicines.

Patients had no concerns about their medication. They were given information about the medication that had been prescribed for them and staff administered on time.