Royal Derby Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

People were involved in assessments of their needs. Staff mostly reviewed assessments taking account of people’s communication, personal and health needs. Care was based on the latest evidence and good practice. Staff made sure people understood their care and treatment to enable them to give informed consent. They involved those important to patients to make decisions in people’s best interests where they did not have capacity.

We have not awarded this service a score for Effective.

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

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

People’s needs were not consistently assessed using a range of assessment tools to ensure their health and care needs were understood.

Staff followed up-to-date policies and had access to assessment tools to plan and deliver care according to best practice and national guidance. However, the assessment tools were not consistently used in line with guidance with all patients. Policies were based on guidance from the National Institute for Health and Care Excellence (NICE) and from royal speciality colleges, such as the Royal College of Emergency Medicine (RCEM). Leaders made changes in policy which reflected national and local changes.

The service did not regularly take part in all national audits. National audits help drive quality improvement, ensure patient safety, and set standards in EDs by benchmarking performance. Benchmarking helps clinicians see how their department performs against others and where they need to implement changes for better patient outcomes. However, they took part in the RCEM 2026 quality improvement programme on time critical medicines audit. The submission date was February, so the audit results were not available at the time of writing.

An audit of records for patients at high risk of developing sepsis showed improvement in the management of these patients from November to December 2025, however, compliance declined in January 2026. This meant patients had a raised risk of poor sepsis management whilst in the department. However, the trust had an improvement plan that had started in October 2025 and was expected to complete in March 2026.’

We saw staff using nationally recognised tools to help monitor risk. For example, they used the National Early Warning Score (NEWS2) for adult patients in the ED, the Paediatric Early Warning Score (PEWS) for children and young people, and the Modified Early Obstetric Warning Score (MEOWS) for pregnant and postpartum women. The trust’s deteriorating patient audits included NEWS2 completion and treatment of potentially septic patients. The audits demonstrated NEWS2 was only completed within timescales set by the trust in 36% of cases in December 2025, this was an increase from 33% in 2024. However, compliance fell to 31% in January 2026. Overall compliance with the sepsis six bundle for patients with confirmed sepsis also improved between 2024 and 2025. However, there was a marked downturn in compliance in January 2026.

Falls risks were not consistently assessed for all patients including those with a history of falls. The trust had a plan to reduce the number of falls across its hospitals. However, this plan did not include any actions to improve falls risk assessment in the ED. Available tools were not used to assess risk of clinical frailty or venous thrombosis.

Members of the psychiatric liaison team completed full bio-psychosocial assessments. The Psychiatric liaison team completed full bio-psychosocial assessments for the four patients whose records we reviewed.

The trust had a Mental Health Act liaison officer who sat within the Reducing Restrictive Practice team. They ensured rights were being read to patients who were detained under the Mental Health Act and monitored any potential unlawful detentions. They reported into the trust’s vulnerable people group.

The service worked well across some teams and services to support people. Staff made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The hospital had an internal professional standards (IPS) document that had been agreed by the different specialisms to ensure their patients were not left in the ED longer than necessary. The IPS included information outlining the expectations of specialist teams to assess patients within 60 minutes of referral rather than waiting for ED investigation. The IPS was designed to ensure safe, effective and timely care for patients. However, doctors in the ED team told us the trust’s IPS were not being followed by the speciality teams. We saw evidence of speciality teams keeping their patients in the ED. For example, there were 3 ear nose and throat (ENT) patients in the main ED waiting room on the morning of our second day on site. The ENT team did not take ownership of these patients but requested the ED team complete diagnostic tests. Nursing staff told us they could not refer to the surgical SDEC even if the patient came in with a doctor’s letter (which was a direct contradiction to the IPS). This delayed patients moving out of the ED and led to overcrowding, long waits and increased the workload for staff in the ED. The process of keeping patients in the ED was also not aligned with the trust’s ‘policy for decision to admit’ or the ‘trust wide capacity and escalation policy’.

Resident doctors told us that speciality teams behaviour could be, “rude and aggressive” when they were trying to get a clinical review for patients. They also described speciality teams as, “handing patients back to the ED” and refusing to refer on to other teams appropriate to the patient’s treatment needs. They gave an example of the gynaecology team refusing to admit women to the gynaecology assessment unit “leaving patients to miscarry in the ED”.

We observed good handovers between staff from the ambulance trust and the ED staff, including when they were due to receive a patient for resuscitation who had been pre-alerted. Ambulance crews told us they got on well with ED staff and they felt listened to and supported when raising concerns about patients. For example, when they had safeguarding concerns. They also said they typically waited for less time to handover patients to the department than they experienced at some other local hospitals.

The ED team had a designated handover doctor in majors who the doctor from resuscitation could hand patients over to when they were being stepped down.

We saw a good handover from ED staff to a doctor from the intensive care unit. This included a discussion about the patients presenting condition and treatments already given.

The medical care in-reach team was based in the department each day and were responsible for all patients in the ED waiting for a bed on a medical ward. ED staff said they worked well with this team and felt they made a significant improvement to safety during their operating hours.

Staff in the CED told us they received training and support from staff at their local children’s hospital in the transfer of acutely unwell children.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service routinely monitored people’s care and treatment, and staff worked to try to ensure that outcomes were positive and consistent. However, this did not consistently lead to improvements in care being made.

Outcome data showed that patients waited longer than the national standards to access treatment when attending the adult ED. The time that patients waited for triage, waited on ambulances, waited to be seen by a doctor and the total time patients spent in the department was collected and reviewed and is discussed elsewhere in this report. There were processes for staff to follow when waits for ambulance patient handovers went over the expected time frame set by the department but there were no processes to reduce waits for triage in ambulatory care (main waiting room), or for waits to see a doctor in the ED. For example, the navigation and streaming SOP for the ED version 1.1 did not contain any guidance for staff to follow if waits for triage went above 15 minutes. While we were onsite waits for triage were typically over 45 minutes in the ED. Likewise, there was not a process for staff to follow when waits to see a doctor increased beyond an agreed threshold.

The size of the pit stop had been increased so more patients arriving by ambulance could be brought into the hospital more quickly. There was evidence that this had reduced the average time patients waited outside in an ambulance before they could be handed over to pit stop staff.

Regular meetings were held throughout the day with internal and external partners to identify ways to improve flow in the hospital and therefore improve patient outcomes. Work was underway to extend the ED to improve the space and ensure more patients were seen promptly in appropriate areas. There were also plans to increase the number of nursing staff in the ED to improve patient outcomes.

Staff monitored and evaluated outcomes related to patients health and wellbeing. However, senior leaders were aware that the number of patients in the ED and the current staffing template for nursing staff meant improvements in care did not always meet expected standards.

Audits had shown patients were receiving poor standards of nursing care in the department. In November 2025, audit data showed several areas of low compliance. Nurse rounding was completed every two hours for 15% of patients. Transfer from a trolley to a hospital bed was documented for 60% of patients. The pressure ulcer risk tool was used for 38% of patients. Ongoing skin assessments were completed for 15% of patients. To improve standards of nursing, leaders changed the model of nursing care from named nursing to task based team nursing. This meant instead of 1 nurse being responsible for meeting a set number of patient’s nursing needs, they would instead be met by 3 different teams of staff with 3 separate operational targets.

One team was responsible for intentional rounding. Another team was responsible for ensuring tasks were completed, including blood tests. A third team was responsible for ensuring patients received treatment, such as medicines. Early audit data from December showed an increase in compliance with standards of nursing care. Rounding improved to 28.5%. Documentation for trolley‑to‑bed transfer increased to 81.8%. Use of the pressure ulcer risk tool increased to 71%. Ongoing skin assessments increased to 57%.

A deeper review of patients with a long length of stay in the department was also undertaken. Data from October 2025 showed that only 53% of these patients had been triaged within 15 minutes of arrival. Forty-seven per cent had observations of their vital signs performed within 1 hour of arriving at the ED, 60% had an assessment of their skin viability and only 7% had an assessment of their falls risk. None of the patients had their falls risk assessed within the first hour of their arrival and none of the patients had an assessment of their need for a bed or bed rail. None of the patients had a long stay checklist completed.

Comfort rounding was due every 2 hours, however the audit showed this was completed sporadically. For example a patient who was in the department for over 34 hours had 5 comfort rounds (1 comfort round in just less than every 7 hours) and another patient who was in the department for 33 hours had comfort rounding every 8 and a quarter hours. The review for November 2025 showed an improvement in the number of patients who had observations of their vital signs (85%) and assessment of their skin viability (73%) but was otherwise similar to October. However, the data for December showed a decline with only 24% of patients having their vital signs observed in the first hour in the department and 47% of patients having an assessment of their skin viability.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood they did not need to obtain consent for unconscious patients who needed emergency treatment to save their life. They understood they needed to explain the reasons treatment was given once the person regained consciousness. For patients who were conscious staff understood the importance of ensuring people fully consented to treatment before it was delivered. We saw evidence of consent in patients records.

Where necessary decisions about care and treatment were made within the requirements of the Mental Health Act (1983), the Mental Capacity Act (2005), the Children Act 1989 and Children Act 2004. This included consulting others as part of best interest decision-making and ensuring that people with legal authority were involved in making any relevant decisions.

The department had a process for supporting people subject to Section 136 of the Mental Health Act. When a person attended the department under Section 136 of the Mental Health Act, they remained the responsibility of police whilst waiting for the assessment. The trust aimed to have an assessment of the patient within one hour of arrival. Staff worked with the police to try and resolve detentions as soon as practicable. The trust had a Section 136 group which met quarterly.

Gillick competence and Fraser guidelines were used to assess the ability of young people to consent to treatment and sexual health advice and treatment. Gillick competence is concerned with determining a child’s (person aged under 16 years) capacity to consent through assessment of their intelligence, competence and understanding to fully appreciate what's involved in their treatment. Fraser guidelines were used specifically to decide if a child could consent to sexual health advice and treatment.

Some patients had advance care plans that included not wanting to be resuscitated. We saw staff check these plans to make sure they were up to date and contained all the information required for staff to act accordingly with the patient’s wishes. When patients had not made an advanced care plan staff asked patients about their wishes and helped them to devise a plan if required.