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 people were protected from abuse and avoidable harm, had a proactive and positive culture of safety, established and maintained safe systems of care, worked with people to understand and manage risks, assessed and managed the risk of infection and maintained safe and effective staffing levels.

At our last inspection we rated this key question as good. At this inspection the rating has remained good. This meant that patients were safe from avoidable harm. The service established and maintained safe systems of care, maintained safe and effective staffing levels and worked with patients to understand and manage risks. Staff assessed and managed the risk of infection and had a proactive and positive culture of safety.

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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well and lessons were learnt to continually improve practice. The expectation was that the local manager or staff member responsible for reviewing incidents reviewed the incident and a second review was done by the radiation compliance team. However, due to time constraints the radiation compliance team would often close incidents with no harm. This allowed local management to prioritise and look at cases with patient harm. When staff reported incidents, staff told us that they were usually involved in investigations and asked for their input. Staff told us they mostly received feedback from incidents they reported, and learning was shared in team meetings, huddles and by email. Some staff in the MRI department were not clear on feedback received from incidents that happened within the department. This department did not have team meetings at the time of the inspection. These team meetings were put in place following the inspection.

There was a culture of prioritising patient safety and learning across the department. Staff were encouraged to report incidents and leaders told us there was a good incident reporting culture across the service. Staff told us they did not feel blamed and were not treated negatively when things went wrong. Staff told us they were supported by their managers and colleagues and were treated with understanding. We saw evidence staff were debriefed and received support after a serious incident.

As part of the inspection process we requested the previous 12 months incident reports, between 22 November 2024 and 20 November 2025 689 incidents were reported across the hospital’s diagnostic departments. Of these 689 incidents, 2 resulted in moderate harm to the patient and one resulted in serious harm to the patients.

There was evidence that changes had been made because of incidents reported. We reviewed several incidents as part of the post inspection data request and could see that all incidents had clearly identified learning and actions where required, including for incidents that did not result in harm. Learning was shared between different areas. There was evidence of working across different areas, such as the emergency department, when incidents crossed between sectors. Actions following incidents included additional training and support for staff where learning needs were identified. There was also an example of a new procedure put in place following patient deterioration during a diagnostic scan.

Staff told us lessons were learned from safety incidents and changes were made to reduce risks. Staff were mostly able to provide examples of recent incidents and share what was learnt or changes to practice made as a result. Some staff in the MRI department were not able to identify learning from incidents that happened in the department. Leaders acknowledged there was a barrier in the chain of information getting from managers to operational staff at times, and this was being worked on.

Staff generally understood their responsibilities around duty of candour and when this should be applied. The duty of candour is a legal and ethical obligation in healthcare for providers and professionals to be open, honest, and transparent with patients when something goes wrong with their care, potentially causing harm or distress.

We scored the service as 3. The evidence showed a good standard. The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when patients moved between different services.

Depending on the departments, diagnostic imaging could be provided to patients from within the hospital, including on an emergency pathway or from wards. We observed diagnostic staff getting appropriate information from emergency department and ward staff, and check patients understanding where possible. Staff from the emergency department or wards would also chaperone patients to receive scans when the patient requested this.

Healthcare partners, such as GPs, referred patients for diagnostic imaging. We observed staff across departments, where appropriate, check patients’ understanding of their referral before scanning and explain how and when the referrer would receive their report and what would happen next. External referrers would share if patients had any additional needs. Relevant information and results would then be communicated back both internally and externally. Friends and family data between April and November 2025 provided following our inspection showed that on average 92.1% of imaging patients were told how they would get the results of their examination.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving patients’ lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff received safeguarding training for their roles on how to recognise and report abuse. Medical, nursing and imaging staff were appropriately trained to level 3 in both adult and children safeguarding. However, not all staff were trained to the levels of safeguarding as outlined by national best practice documents. Non-clinical staff who had contact with adults and children were trained to level 1. The intercollegiate documents (Adult Safeguarding (2024 Edition): Adult Safeguarding: Roles and Competencies for Health Care Staff and Children & Young People (2025 Edition): Safeguarding children and young people & children and young people in care: Competencies for health care staff) state these staff should be trained to level 2. This was raised with the trust who confirmed that this was due to be reviewed and that there was a plan in place to increase training for non clinical staff to level 2.

Data provided following our inspection showed that safeguarding mandatory training compliance amongst most staff groups met or was above the trust target. The average compliance across all departments for safeguarding Level 3 was 90%. However, amongst the ‘medical and dental’ staff group, compliance was only 68.9%. The average compliance across all departments for safeguarding Level 1 was 98%.

The trust had safeguarding policies and procedures covering all sites for both adults and children. Staff knew what constituted a safeguarding concern and knew their responsibilities to follow safeguarding policies and procedures. Staff we spoke to knew how to access trust safeguarding policies and procedures. Staff knew their designated safeguarding leads and told us if they were in doubt they could get contact details of the centralised trust safeguarding team on the intranet.

All staff were able to report safeguarding concerns. Staff across multiple departments were able to provide examples of reporting safeguarding concerns quickly and appropriately.

There was information on chaperones for patients across all departments, letting patients know they could request one if they would feel more comfortable. An NHS chaperone is a trained healthcare professional present during examinations to protect and support both the patient and clinician.

Safeguarding information posters with tear-away contact stickers were placed in clinical area toilets. These provided discreet access to support resources for vulnerable people.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff carried out risk assessments for people who used the service to ensure scans and tests were carried out as safely as possible. Each department had appropriate procedures in place to make sure that patients were safe prior to use. Staff identified and responded appropriately to changing risks to people. Patients we spoke to were aware of the use and risk of radiation. We saw information posters in some waiting areas explaining the risk and benefit of the use of radiation.

Staff followed the Society of Radiographers “pause and check” guidance when checking patient’s identity and verifying critical information before proceeding with radiographic examinations and administering injections. The imaging department used a modified version of this process, which also included the trusts procedures. Managers monitored how well staff did the 'pause and check' process by observing staff. The person completing the observation completed a form on how well the process was followed; and any areas for improvement were recorded.

Staff in MRI completed forms to check the patient’s identity and complete a safety screening for patients and any accompanying persons before any procedures. This was to make sure patients were safe to be scanned; for example that patients did not have any metal in their body which could mean the scan would be unsafe. Managers audited how well staff undertook safety checks before MRI scans. Between January and December 2025, the service scored 100% in each month and each area apart from one month when consent was 95%. Staff in MRI were clear on the process for safely evacuating a patient.

At the time of inspection, the service did not have local guidelines for managing deteriorating patients in imaging departments at this hospital as this was covered by trust policies and guidelines. However, a recent incident at a trust community site led to a review which decided that the trust guidance is not appropriate for imaging departments. Information provided following the inspection showed that draft guidance for staff for treating ‘Patients who are injured, become unwell or whose condition deteriorates whilst in the imaging department’ had been created. At the hospital staff had access to the emergency department if a patient became unwell.

Staff carried out safety checks to find our if patients were pregnant prior to scans. This is necessary to minimise the risks like developmental delays and birth defects to a foetus. There were posters displayed for patient information to advise of the risks of receiving certain scans when pregnant.

We scored the service as 3. The evidence showed a good standard. The service mostly detected and controlled potential risks in the care environment. They mostly made sure equipment, facilities and technology supported the delivery of safe care.

The environment was suitable and safe for patients. We observed that waiting areas for all patients across departments for were fit for purpose, with appropriate seating areas and facilities, including changing areas and toilets. Staff locked away chemicals and substances used for cleaning purposes that are hazardous to health (COSHH). Staff completed imaging specific health and safety checklists regularly across all imaging departments.

The service had suitable signage to warn people where ionising radiation was being used across all relevant departments and side rooms. For example, there was signage at the entrance to the MRI unit to warn people about the strong magnetic field and associated risks.

Staff carried out appropriate safety checks on radiation equipment. Staff followed quality assurance processes to ensure that imaging equipment was tested and maintained appropriately for use. However, across the trust, 24 pieces of equipment were in equipment replacement phase. Of these 14 pieces of equipment were at or beyond replacement. Leaders ensured this equipment was tested to ensure it could still be used safely and effectively. Staff had access to an up to date procedure for managing equipment in the event of a fault.

However, we saw that some non-radiation electrical equipment was not always tested and serviced in a timely fashion with some equipment we looked at displaying stickers that indicated a service was due.

Resuscitation equipment was readily available for both adults and children, and staff checked them regularly. The service completed regular radiation risk assessments for all uses of radiation, which took account of occupational safety. This included the annual radiation protection advisor survey across all areas. Staff working with ionising radiation wore radiation dose monitoring badges which were monitored by the service to identify over exposure risks. Staff and carers used personal protective equipment when needed.

We scored the service as 2. The evidence showed some shortfalls. The service made sure there were enough qualified, skilled and experienced staff. However, not all staff had completed mandatory training or received an appraisal in line with the trust policies. They worked together well to provide safe care that met people’s individual needs.

Staffing levels and skill mix were planned and reviewed so that patients received safe care and treatment, and staff did not work excessive hours. Actual staffing levels and skill mix during our inspection was at the planned levels. Bank and agency staff were used as necessary and staffing was reallocated to provide cover for staff absence and shortfalls. Staffing levels were escalated appropriately and leaders were kept informed on staffing issues. Staff told us where regular bank and agency staff were used, they were included as part of the team and could access hospital systems.

Staff felt there were generally enough radiologists and radiographers to meet the demands of the service and they were managing despite high workloads. Staff told us they were never asked to work in unsafe conditions. As part of the inspection process we requested staffing data, as of January 2026 the service had 92.4% of whole time equivalent (WTE) staff, with a vacancy rate of 7.6% WTE staff. This was slightly above the NHS national average for vacancies.

Staff had appropriate inductions in the areas in which they worked. Staff we spoke to on the inspection told us they were well supported by managers and other staff during their induction period. Data provided following our inspection showed appropriate completed induction and preceptorship documentation for all the different imaging departments and locations across the hospital.

Staff recruitment and retention was a potential risk across all departments within imaging. The risk register for the service included many references to staffing such as the following, failure to recruit, retain, and develop our workforce in line with the clinical strategy’. The trust and division had recruitment plans in place. Leaders we spoke to in departments had specific local plans to train staff that come into the department and ‘grow their own’, to help raise and maintain staffing levels within their departments. Good examples of this were provided by nuclear medicine and clinical measurements.

According to data provided by the trust as part of the inspection process, the average sickness rate across the imaging business unit was 6.1% across 2025, which was slightly higher that the NHS national average for sickness. The average turnover rate across the imagine business unit was 6.7% across 2025, which was well below the NHS national average for turnover.

Not all staff were in date with their mandatory training. Overall compliance in mandatory training for the ‘medical and dental’ staff group was below the trust target in several modules. However, staff were offered training appropriate to their role. New staff were supported with structured induction and preceptorship programmes. Staff told us they received appropriate inductions and were well supported by leaders and colleagues during the induction period. Staff told us they had time to complete training.

The service had radiation risk training as standard for staff members who could be exposed to radiation whilst at work. Not all staff had completed this training, with several staff groups not meeting the training completion target. Data provided following our inspection showed that completion amongst the following groups fell below the 90% target; Fluoroscopy (0%), Physiotherapy (42%), Theatre staff (43%), Ultrasound (61%), Assistants (75%), BSU Registrars (79%) and BSU Radiologists (89%).

Staff did not always receive meaningful appraisals in a timely manner. Data provided following our inspection showed that not all staff members were up to date with their appraisals. As of October 2025, across the imaging department the average completion was 70.1%. The highest completion rate was amongst the ‘nursing and midwifery’ staff group who sat at 78% and the lowest being ‘additional clinical services’ which sat at 63.2%.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Across the inspection we observed that all departments were visibly clean and tidy throughout, including side rooms, toilets and patient waiting areas. There was signage across all departments to promote good hand hygiene. Hand sanitiser dispensers were provided at entrances to departments and throughout and always had sanitiser in them. Staff kept cleaning records were up to date and cleaned regularly.

Staff followed processes to regularly clean the environment and equipment. We found, across all departments, equipment was clean and ‘I am clean stickers’ in place. We observed staff cleaning equipment between use. There were sharps bins available for the safe disposal of sharps. Whilst on the inspection all sharps bins we checked were dated, clean and not overfilled. We observed that staff separated waste appropriately and disposed of clinical waste safely.

Most staff were trained in infection control, some staff were trained to level 2, and some staff were trained to level 1. Overall compliance across all departments for infection control level 1 was 98%. Overall compliance across all departments for infection control level 2 was 84%, below the trust target of 95%. Compliance amongst the staff group ‘medical and dental’ was only at 59%.

We observed that hand hygiene practice was appropriate and staff were bare below their elbows throughout the inspection. Staff identified people with infections which allowed staff to offer appropriate appointments. Staff told us they would see people with infections at the end of the day to reduce risk of spreading infections. In the event of a patient attending with an infectious disease, staff had access to onsite cleaning materials. We saw staff had access to personal protective equipment (PPE), and they had enough time to perform cleaning between appointments.

The service had an audit schedule to monitor cleanliness and infection prevention. Audits included hand hygiene compliance, IPC assurance compliance, couch cleanliness, treatment chair cleanliness, bed and mattress cleanliness and transfer trolley cleanliness. Data provided following our inspection showed from November 2024 to October 2025 the average result across 43 audits was 97.7%. Only 3 of the 43 audits averaged below 90%, these were; bed and mattress cleanliness in ultrasound (87.8%), transfer trolley cleanliness in fluoroscopy (87.7%) and couch cleanliness in fluoroscopy (81.4%).

There were also regular cleanliness audits undertaken by an external cleaning company, every department passed the 85% required to pass the audit, with areas of failure clearly identified.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

There were systems in place to ensure that medicines were prescribed and administered appropriately, including contrast media (an injected substance used to enhance the visibility of internal structures).

Staff mostly stored and managed medicines safely. Staff monitored the temperature of warmer cabinets to ensure contrast was stored at an appropriate temperature to maintain effectiveness and help prevent extravasation. Extravasation is when a medication or contrast dye accidentally leaks out of the vein and into the surrounding tissue instead of staying inside the bloodstream. Contrast was stored in secure rooms away from patients. Where medicines were stored in fridges to maintain effectiveness, staff mostly monitored temperatures to make sure these were in line with the medicine manufactures guidance. However, there were some missing dates for the interventional radiology department, which was raised at the time of inspection. Apart from one example, all medicines we checked were in date and stored correctly. Pharmacy routinely stocked medicine across all departments. Staff told us they could get support from pharmacy colleagues if needed. Where controlled drugs were stored in departments, we observed this was managed appropriately and controlled drugs books were signed. The pharmacy team audited the use of controlled drugs in imaging departments and developed action plans where needed.

The service had patient group directions (PGD) in place for radiographers and sonographers. PGDs provide a legal framework that allows some registered health professionals to administer medicines within their scope of practice so that the patient does not have to see a prescriber. We could see this process was reviewed in clinical governance meetings.