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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

Patient flow and care coordination were impacted by ongoing capacity pressures, frequent use of escalation areas, delays in assessment and discharge, and poor communication, reducing continuity of care.

Risk assessments and care planning were not consistently completed, despite consistent use of tools designed to monitor deterioration in patients' health. Staffing shortages, redeployment, and low training compliance further affected service delivery.

There were significant safety concerns, including poor environmental standards, inadequate equipment checks, unsafe medicines management, and weaknesses in infection prevention and overall oversight.

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.

There were elements of a developing safety culture; however, this was not consistently embedded across the service. Systems were in place to report and investigate incidents, although not all staff felt psychologically safe to raise concerns.

There was evidence of a developing learning culture within the service. Incident investigation reports and associated action and learning plans showed that learning had been identified and that actions were planned to support improvement. In the 3 incident responses we reviewed, duty of candour had been applied, reviews had been completed, and learning was clearly documented. The duty of candour is a general duty to be open and transparent with people receiving care, especially after a serious incident has happened.

Staff described being familiar with the trust’s electronic incident reporting system and understood what should be reported. Staff told us that learning was generally shared through handovers, team meetings, and email updates. Staff confirmed that patients were informed when incidents occurred, and outcomes were communicated in line with duty of candour requirements.

Some staff, however, told us they were sometimes reluctant to report incidents because they did not consistently receive direct or individual feedback after submitting a report, and they felt there was a blame culture within the service. They said they often heard about incidents through huddles or general email summaries, rather than receiving feedback linked to their own reporting.

Incident themes continued to be discussed at handovers to support ongoing team awareness. Senior leaders had oversight of incident and complaint themes, and medicine divisional governance meetings reviewed reporting levels, progress against actions, and duty of candour compliance. These forums were used to ensure learning was monitored and shared across the division.

Debrief sessions were available following serious incidents, and staff described these as an opportunity to review what had happened.

The evidence showed some shortfalls. The service did not always work well with patients and healthcare partners to establish and maintain safe systems of care. Staff did not always manage or monitor patient’s safety. They did not always make sure there was continuity of care, including when moved between different services.

Daily safety briefings and board rounds were in place and provided a structured approach to reviewing admissions, transfers and discharges. These supported oversight of patient flow.

During our assessment, we observed that staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary information to ensure continuity of safe care.

Corridor care, which is a term used for non-designated clinical areas used during periods of increased demand, were available on wards to support patient flow. However, staff reported that these areas were in frequent use, with wards regularly operating above planned capacity.

As a result, corridor care areas were used as part of routine practice rather than for short-term escalation, reducing flexibility within the system. This contributed to more standardised working arrangements within these spaces over extended periods.

When staff in the emergency department decided to admit a patient, the patient was transferred to other areas in the hospital such as the Medical Assessment Unit (MAU) or other inpatient wards. Due to a lack of space in the wider hospital, some patients were moved from ED to corridor care areas, which are not designed for inpatients but are temporarily used for that purpose due to overcrowding. For example, some patients were moved to a corridor care area called the quad, where they waited for onward transfer to MAU, an inpatient ward, or discharge.

Corridor care areas were also available on wards to support patient flow. However, staff reported that these areas were in frequent use, with wards regularly operating above planned capacity.

The medical Same Day Emergency Care (mSDEC) unit managed high patient volumes and operated between 08:30 and 23:00. The purpose of SDECs is to rapidly assess, diagnose, and treat patients on the same day of arrival, allowing them to return home rather than being admitted to a hospital bed. At the time of inspection, patients were waiting for both assessment and specialty review. Staff reported that demand regularly led to delays in assessment and onward referral, which impacted flow through the ED.

The frailty Same Day Emergency Care (fSDEC) unit supported timely assessment and same‑day discharge. The consultants reported that 60–70% of patients were discharged home on the same day following multidisciplinary review. However, staff told us that the development of fSDEC had reduced triage capacity within the emergency department, contributing to delays in initial assessment.

Patients were moved between wards frequently, primarily due to bed capacity pressures, which affected continuity of care.

The Discharge Assessment Unit (DAU) had 14 beds; however, at the time of inspection, six were in use by mSDEC. The unit also shared its space with the Surgical SDEC, which was based in one of the bays within the area, reducing capacity for patients awaiting discharge. Referrals were made directly from wards to DAU, with the nurse in charge responsible for accepting or declining patients. There was an established process for patients to transfer with a discharge letter. Patients who had been in hospital for less than 10-days are supported to transfer to DAU without their discharge letter being complete, it is then completed upon their arrival to DAU by the Doctor. Patients were required to be medically fit for discharge prior to transfer to DAU, with an expected length of stay of up to 48 hours. Therapy staff and resident doctors supported discharge planning and reviewed patients who remained beyond 24 hours to confirm medical fitness for discharge. We identified examples of extended stays, including 1 patient who remained for 4 days due to delays in accessing essential community equipment. Patients in DAU who were managed in a chair without an allocated bed and were unable to be discharged by the end of the day, and who required overnight care, were transferred to an inpatient bed where available; if capacity was full within the unit, they were relocated to a ward.

The discharge team were involved in supporting ward staff and therapy teams. They worked with social services and community partners to facilitate discharge, rehabilitation and continuity of care. However, coordination was not always effective in practice. We observed an ambulance arrive to transfer a patient to a nursing home. Ward staff and therapy teams were not aware of the planned discharge. Staff told us the transport had been arranged by the discharge coordinator. Staff also told us that there was a lack of clarity regarding ward-based discharge coordinator cover, including which wards they were responsible for on any given day. There was no single point of contact or designated phone number for the discharge lead. Some staff were unclear about when and how to involve the discharge team. Delays in arranging onward care packages and limited access to therapy services also continued to impact timely discharge, particularly for patients with complex needs. These challenges were mor[AM5] [LH6] e pronounced in areas with limited access to rehabilitation services.

Systems to manage medicines were not always safe. Staff reported that the use of different prescribing systems to prescribe medicines in the emergency department and on inpatient wards introduced additional risks. This increased the potential for omissions or discrepancies during medicines reconciliation.

The service worked with patients and healthcare partners to understand how best to keep patients safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting patient’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The data showed overall safeguarding training compliance of 84.75%, below the trust’s target of 90%. Compliance varied across safeguarding levels: 93.5% of staff had completed Level 1 training, while only 78.6% had completed Level 2 and 86.3% had completed Level 3. Both Level 2 and Level 3 were below the trust’s expected compliance threshold of 90%.

All staff we spoke with told us they had completed their safeguarding training. They were able to explain how to raise a safeguarding concern, how to make a referral, and who to speak to if they had worries about a patient’s safety. Staff were also able to provide examples of how to protect patients from harassment and discrimination, including those with protected characteristics. The hospital had a designated safeguarding lead, and staff described them as approachable and supportive.

Resident doctors, registered nurses, and healthcare assistants demonstrated an understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). MCA documentation we reviewed had been completed appropriately.

However, not all staff were trained to the level required by national intercollegiate guidance. Some non‑clinical staff who had direct contact with adults and children had only completed Level 1 safeguarding training, despite national expectations that these roles should receive Level 2 training. This training gap meant the service did not have full assurance that all staff had the required level of knowledge to recognise and respond to safeguarding risks.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Not all patients received risk assessments in line with trust policy. Records showed that risk assessments for venous thromboembolism (VTE), pressure ulcers and falls were not consistently completed on admission. In one case, a patient receiving anticoagulation had no documented VTE risk assessment. Audit data over the previous 10 months showed compliance below the 95% target, indicating that VTE risk was not consistently assessed.

We reviewed 13 patient records of which, 5 contained care plans, which meant 8 patients records did not have a care plan. Despite incomplete care plan documentation in the notes we reviewed, patients described receiving care that met their needs. Staff were able to explain how they tailored support on an individual basis.

We saw that staff used the National Early Warning Score (NEWS) tool to identify and monitor patients at risk of deterioration. All 13 patient records showed that NEWS observations were completed within expected timeframes, with clear evidence of escalation when required. The service also completed audits for appropriate action taken in response to high NEWS. These showed for the months of December, January and February 2026 staff took actions to keep patients safe between 94.12% and 98.48% of the time.

Staff used sepsis pathways and were able to access outreach and resuscitation teams to support timely clinical intervention.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities supported the delivery of safe care.

We identified environmental issues that affected the delivery of safe care. The fSDEC unit was small and overcrowded, with limited seating which meant some frail patients were left standing.

Only two rooms were available for examinations and assessments, limiting the ability to carry these out safely and appropriately.

Within the quad area we observed there was visible dust on the resuscitation trolley and other surfaces. The office area, although offering visibility of patients, was cluttered with boxes of paperwork, bags of shredding and broken equipment stored on the floor. This contributed to a generally untidy environment that made it difficult to maintain standards of cleanliness and created trip hazards. Patients we spoke to said that they were happy with the care they received in this area. Following the inspection, leaders advised that the quad area is no longer in use as of April 2026.

Across several wards, equipment had been placed in front of “keep clear” signs due to limited storage space.

Staff did not consistently complete required checks of emergency equipment. Daily resuscitation trolley checks had significant gaps. In one area, staff had completed 11 days instead of 31 for January despite a requirement for daily monitoring. Several anaphylaxis boxes contained medication that was out of date or close to expiry. Staff told us that if a box was required in an emergency, they were instructed to obtain one from another ward, which could delay the response to a clinical emergency.

Temporary escalation spaces did not always have required equipment to provide safe treatment. To increase bed capacity, some single occupancy side rooms had been converted to accommodate three patients. In some of these areas, two of the beds did not have access to fixed oxygen or suction. Although a Trust wide Standard Operating Procedure (SOP) stated that patients requiring oxygen therapy should not be placed in these beds, staff told us that patients from the emergency department were sometimes allocated to the area without discussion and occasionally arrived requiring oxygen. Staff then had to move patients between wards to ensure clinical needs could be met. Treatment rooms had also been repurposed as side rooms. Staff reported an incident where a patient fell and hit their head on a cupboard that remained in place from when the room was previously used for storage. Although an action plan had been created to address the issue, staff reported that the cupboards had not been removed after the incident.

Across all wards visited, we found that the Control of Substances Hazardous to Health (COSHH) chemicals were not being stored securely. Chemicals were left in unlocked cupboards or behind doors that were not secured, and some chemicals were being prepared in sinks and lids were left off. On one ward, this posed a particular risk because a patient with a known tendency to place inedible items in their mouth could have accessed these substances. Managers were aware of these issues; however, they had not been added to the risk register, limiting oversight and preventing a formal plan for mitigation.

There were concerns regarding the safe preparation and management of cleaning chemicals. Several solutions were found mixed and left without lids or date labels. Staff told us that healthcare assistants and housekeepers were responsible for preparing the chemicals; however, they confirmed they had not received any specific training and relied only on the information provided on a poster. IPC leads acknowledged that dedicated training for chemical preparation was not in place and agreed that further training was needed. Post inspection leaders told us that manufacturers of the peracetic acid and the IPC support worker undertook training on the use and safe storage of the Enhanced peracetic acid across in November and December 2025. The peracetic acid product and mixing bottles were not released to the clinical areas until the training had been completed. Approximately 1,500 staff received training, with the expectation that the training was cascaded to colleagues.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

The staffing data reviewed of the medical wards and MAU shows that actual registered nurse (RN) staffing levels were often below planned levels across a number of wards and dates. This was seen consistently in medical areas, with Ward 401 and Wards 404–406 frequently below template, suggesting ongoing differences between planned and actual staffing over the reporting period. In response to RN gaps, unregistered staff (such as Healthcare assistants) were used, often at or above planned levels, to mitigate staffing shortfalls and support service delivery. Patient-to-nurse ratios varied and were often higher than expected, commonly around 1:7 to 1:10, with higher values on some occasions, particularly at night where Ward 401 reached around 1:17 to 1:18. National guidance recommends a nurse-to-patient ratio of 1:8 during the day; however, there is no defined national guidance for night-time staffing ratios. Overall the data shows a gap between planned and actual RN staffing.

During November and December 2025, when staffing pressures were identified as being higher, PALS concerns within Acute Medicine (Derby) increased by 45%. This shows that the period of increased staffing pressure coincided with a rise in patient concerns. While this does not confirm a direct link, the timing of the increase suggests it may be associated with higher workload and staffing pressures.

At the same time, the trust was operating under a recruitment freeze, while overall capacity (patient numbers and acuity) within the service had increased. Side rooms had been converted to hold up to three patients. Corridor care areas were in continuous use. Treatment rooms were repurposed for patient care, and additional areas such as fSDEC and the quad had opened. Staff reported that although patient capacity had expanded, workforce numbers had not increased accordingly, creating challenges in maintaining safe cover across all areas.

Vacancy levels remained a challenge across both Nursing & Midwifery and Medical staffing groups. Nursing vacancies in medical wards were slightly higher than other trust areas such as ED.

Nursing and medical colleagues told us they were frequently redeployed from their usual areas to maintain minimum cover. Junior doctors described being moved at short notice, which affected their ability to carry out expected duties. However, they said they felt supported by the consultant body and received regular appraisals. Individuals across clinical teams reported that they worked well together. Doctors described the nursing workforce as competent and supportive in managing patient care. They also reported raising concerns about the impact of frequent redeployment and said the issues had not been fully resolved.

Training compliance was significantly below the trust target. For example, the MAU showed overall compliance of 83.16%, with key resuscitation training including basic life support (BLS), automated external defibrillator (AED), immediate life support (ILS) all under the trust target. This meant a substantial number of staff had not completed essential life support training, increasing the risk that patients may not receive timely and effective care in an emergency.

Some staff told us workforce pressures affected their ability to engage in appraisal processes. As of January 2026, appraisal compliance was 68.40% in acute medicine (Derby) against a trust target of 98%. However, the trust reported no outstanding GMC revalidations at the time of the review.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some areas of the service were visibly clean. Other parts of the environment were cluttered, which limited the ability of staff to clean effectively and did not support good IPC practice.

Staff complied with best practice and trust policies when caring for patients. Staff across clinical areas were observed to be bare below the elbow which enabled more effective hand washing. Staff had access to PPE and clear IPC signage was displayed at suitable areas such as side rooms where infectious patients were placed. Across the wider site, appropriate signage was displayed on doors leading into clinical areas, and visitors were consistently observed using hand sanitiser when entering and exiting wards.

Not all staff were able to prepare, use or store cleaning products safely, which reduced assurance that cleaning processes were effective in preventing infection. On one ward, staff reported using washing-up liquid in place of appropriate cleaning chemicals. We also observed domestic staff using unsuitable equipment, including a sharps bin as a bucket. This increased the risk that infection control standards were not maintained, potentially placing patients at risk.

Waste management processes were observed to be appropriate. Which means staff disposed of waste in line with trust policies. Clinical waste was kept separate from domestic waste.

Audit data from late 2025 and early 2026 showed variation in IPC performance. On the Medical Assessment Unit, IPC assurance increased from 79.80% in November 2025 to 97.94% in December 2025, remaining high at 95.05% in January 2026, with bed and mattress cleanliness at 99.23% in November 2025 and 93.85% in January 2026. Across inpatient wards overall, the average IPC assurance for January 2026 was approximately 95%, with hand hygiene compliance averaging close to 100%.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Staff did not always store medicines safely and securely in areas we inspected. Medicine storage areas in treatment rooms such as cupboards and fridges were found unlocked in different ward areas. We observed medicines on open shelves of medicine trolleys and on top of oxygen cylinders where medicine waste bins were overflowing. Trust audit findings identified these issues, but they remained an issue at the time of inspection, indicating a lack of effective action and assurance.

Staff did not consistently monitor the temperature in medicine storage areas. Staff did not record maximum and minimum fridge temperatures despite paperwork being available for them to record this on. Concerns were escalated to the pharmacy team. During our inspection, we noted areas were warm and ambient temperature monitoring was not always in place. This meant there was a risk that medicines could be stored and used outside of their product license. Leaders told us that ambient room temperature monitoring was not mandated on this site of the trust which did not provide assurance that products were stored in line with manufacturer's storage condition.

Staff did not label all insulin pens to identify to which patients they were for, or what dates these were opened. This means that staff could not be assured that the medicine was effective. Discharge medicines were found in one ward area on an open shelf area within a treatment room. These were not locked away.

Controlled drugs were mostly stored securely and record-keeping was legible. However, in one area, a controlled drug was found that had not been recorded in any of the registers kept within this area. Staff were not checking the stock levels properly, even though regular stock checks were supposed to happen. This meant the medicines were not being kept as secure as they should be.

Medicines contained within resuscitation trolleys were not always checked or managed well. We found that staff did not consistently complete daily checks of medicines on resuscitation trolleys as required by trust policy. It was unclear whether weekly contents checks had been completed for review of expiry dates. A shortage of in-date anaphylaxis drug boxes was identified. Where a ward was unable to replace the contents of their resus trolley, using trust supplies, they had to put processes in place to retrieve a box from a nearby ward. This issue was known to the pharmacy team responsible for allocation of these boxes. However, no communication had been cascaded across the hospital at the time of inspection This meant there was not a wider awareness of this safety risk.

There was a clinical pharmacy presence on wards, with pharmacists and technicians actively working within multidisciplinary teams. Pharmacy teams supported medicine reconciliation processes, made interventions on critical medicine prescribing and supported timely discharges. The admissions pharmacy team prioritised patients for review to ensure critical medicines were prescribed on time and high-risk needs were identified. This could be identified easily on electronic systems when patients were transferred to other wards.

Staff used a mix of paper and electronic prescribing systems, with paper prescribing in the emergency department requiring transcription to electronic systems at ward level. This caused delays in getting people’s usual medicines started when they were admitted. Medicines reconciliation often did not happen until several days later. As a result, people sometimes waited too long for their regular medicines, including those that were time‑critical. One example was a patient whose epilepsy medicine was not marked as urgent and was prescribed at a lower dose than they normally took. A pharmacist corrected the dose when they reviewed the patient, but there was no clear record showing that anyone had checked for an important interaction between this medicine and an antibiotic started on admission. This was later escalated to another member of the pharmacist team who resolved the issue. Audit data showed that 88% of patients had a medicines reconciliation were completed by the pharmacy during admission, with 38% of these being completed within 24 hours of admission. Which is below national standard.