Royal Derby Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service did not demonstrate a clearly embedded vision, inclusive culture or consistent leadership, with staff working under sustained pressure from high acuity, staffing gaps and patient flow challenges. While commitment to patient care was strong, some staff reported burnout, variable support and a perceived blame culture, with limited confidence in raising concerns. Governance and oversight were inconsistent, and although improvement processes existed, these did not consistently lead to sustained improvements in practice, outcomes or equality.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Leaders described a shared direction shaped by ongoing pressures, including rising patient acuity, staffing gaps and challenges with patient flow. The focus was on maintaining safe care through prompt triage and early involvement of the appropriate specialty team. Work was underway to increase specialty input within the emergency pathway and to strengthen community in-reach to help reduce avoidable admissions and delays. Leaders recognised that, if embedded, these approaches would support improved patient flow across the system, with the potential to reduce unnecessary admissions to medical wards, ensure patients were managed in the most appropriate setting, and alleviate pressure on ward capacity and staffing.

Staff reported a strong team ethos and commitment to patient care, although many described working in a very busy environment due to patient complexity. Some staff reported feelings of burnout, which were acknowledged by senior staff as a significant issue consistent with wider national pressures. A number of staff described a perceived blame culture across the service, which was reported to influence how concerns and errors were discussed. This issue had been raised with senior leaders and had been discussed within patient safety group meetings.

Wards were reported to support each other through redeployment to maintain safe staffing levels and to provide additional support to the Emergency Department during periods of high demand. While this approach was described as supporting risk management, challenges were reported for staff working away from their usual teams, and consideration was being given to how additional support could be provided.

Senior nursing staff maintained a regular ward presence through walkarounds, drop‑ins and governance discussions to remain connected with frontline teams. Communication had been strengthened through the introduction of a divisional inbox and targeted updates, which had facilitated increased staff feedback.

Some staff with protected characteristics reported less favourable experiences. In response, Equality, Diversity, and Inclusion (EDI) network representatives attended divisional board meetings to support oversight and monitoring of these issues.

System pressures, including delayed discharges and medical staffing fragility, particularly out of hours, were reported to affect the working environment and contributed to reliance on temporary staff. These challenges were being discussed with system partners.

The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

Leaders showed awareness of pressures such as staff fatigue, increasing patient acuity and the emotional demands of care. However, leadership development and support were not fully embedded, and mentoring opportunities remained limited. This led to inconsistency in leadership capability across the service.

Although development opportunities for matrons were in place, including leadership training and apprenticeships, these were not consistently established or accessed. Leaders understood operational pressures, but this was not always reflected in effective support for staff.

Communication had improved and there were opportunities for staff to give feedback. However, some staff told us that when they raised concerns, they did not feel these were always acted on, which reduced confidence in leadership.

Staff spoke positively about their immediate managers, particularly ward sisters, who were seen as supportive and attentive to staff wellbeing. However, this good practice was not consistent across all areas.

The evidence showed some shortfalls. Staff did not always feel confident to speak up or that their concerns would be heard, and data indicated perceptions of a culture of bullying and harassment.

Staff told us they understood how to raise concerns and were aware of the Freedom to Speak Up (FTSU) routes available to them. However, many said they did not feel confident that concerns were investigated properly, as they rarely received feedback after speaking up. Staff also told us they did not always feel that concerns raised with managers or the FTSU team were handled sensitively or confidentially. This led to a loss of trust in the process. Several staff shared an example where bullying was reported, but the individual involved later became aware of who had raised the concern. Staff felt this was due to poor handling or a breach of confidentiality by managers or the FTSU team, and this has made some reluctant to raise concerns again.

We reviewed the current data provided by the Freedom to Speak Up team. This shows that a total of 72 colleagues within medicine across the whole trust raised concerns. Of these, a small proportion spoke up anonymously (10%), and many concerns included elements of patient safety (61%). Concerns relating to behaviours such as bullying and harassment were also present (33%), and many staff raised issues affecting wellbeing or worker safety (65%). The themes indicated that staff are using the routes available to report issues; however, the feedback we received shows that many do not feel assured that the process is confidential, supportive or results in meaningful action. Post inspection, leaders told us that within this total, 23 cases related to a group concern raised within one area, each logged individually, and that the Freedom to Speak Up team undertook extensive work with this team to address the issues, which was shared through Trust governance processes.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance of patient records was a concern in medical areas. Both paper and electronic systems were used to record and store patient information. Summary care record cards were found left in computers, affixed to drug trolleys and notes trolleys were found open on ward areas. This meant that they were easily accessible by visitors to the ward. During the inspection, we observed staff logging off or locking their computers promptly after accessing or updating patient records, demonstrating good practice in maintaining confidentiality and protecting personal information. Despite this, staff told us they experienced challenges due to the use of multiple record keeping systems, including both electronic and paper notes. They said this made it difficult at times to access a complete and up-to-date record of a patient’s care because information was not stored in a single place. Some staff said this created uncertainty about what had been completed and what required follow up, increasing the risk of duplication or missed actions. Patient records on all wards were stored securely.

The service had a governance framework in place; however, it was not consistently effective in ensuring reliable oversight or supporting staff in their day‑to‑day roles.

Work was underway to strengthen oversight arrangements and escalation processes. Governance structures were becoming more consistent, though variation remained between specialities and further standardisation was required.

Staff understood their responsibilities and could access information needed to deliver care, but they told us they rarely received feedback when they raised a concern. This meant they were often unclear about whether issues they highlighted had been reviewed or acted upon, which limited opportunities for learning and improvement. However, although these forums enabled senior leaders to consider key information, staff reported that the outcomes of these discussions were not always communicated clearly, and this reduced their awareness of ongoing actions or changes required at ward level.

At trust level, daily site conference calls were held to monitor capacity and patient flow. These supported staff to maintain awareness of operational pressures and enabled timely decision making and escalation.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They share information and learning with partners and collaborate for improvement.

The division worked closely with a third-party community interest service to develop alternative pathways that reduced unnecessary Emergency Department (ED) attendances. Leaders highlighted joint work between DHU Healthcare and the trust’s virtual wards to support safe community‑based care and reduce avoidable hospital presentations.

Partnership working with primary and community care was positive in some areas, though leaders acknowledged variation across localities. Good joint working was described in specialties such as respiratory and cardiology, supported by the trust’s general practice (GP) engagement playbook.

Integrated working was demonstrated through the frailty Same Day Emergency Care (fSDEC) service, which accepted direct referrals from community teams and helped prevent avoidable ED attendances. Leaders also outlined collaboration with voluntary and patient groups, including participation in the Parkinson’s Centre of Excellence and targeted outreach to increase bowel cancer screening uptake.

Leaders recognised that public involvement in service design remained underdeveloped and was often reactive. They also acknowledged wider system challenges, particularly delays in accessing community services, which impact discharge and patient flow. This required continued joint working across health and social care partners.

The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The Trust has governance systems in place to support learning and improvement, including audits, incident reviews, and dashboards. Data on sepsis, falls, and tissue viability was requested, providing some visibility of risks and helping to inform action plans. However, the quality and impact of audit activity are variable. There is also limited evidence that learning from these processes, and the resulting action plans, is consistently translated into sustained improvements in practice or outcomes.

Audit findings show that changes identified through action plans are not reliably embedded. In sepsis, despite action plans and high audit activity, performance remains below the 90% target, with screening rates around 50–60% and some monitoring elements significantly lower, with little evidence of sustained progress. In the falls programme, where multiple actions are in place, results show variation and deterioration over time, including escalation of postural hypotension reducing from 94% to 25% and only partially recovering, and completion of enhanced care bundles fluctuating between 22% and 72%. In tissue viability, despite ongoing actions, overall compliance remains below the 90% target at around 85–87%, with some key areas declining despite progress in isolated elements.

These findings indicate that, although risks are identified and action plans are in place, their impact is inconsistent and not sustained. The Trust is not yet able to demonstrate consistent improvement in compliance or patient outcomes. There is also limited evidence that innovation is consistently embedded or that learning has led to improvements in equality of outcomes, and further work is needed to strengthen the Trust’s contribution to wider improvement or research.