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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

Staff reported a poor culture where their concerns about patient safety and staff wellbeing were not acted on. Governance processes did not consistently ensure safe care was being delivered. However, there was some work being undertaken to try and reduce health inequalities in the local population.

The service was in breach of legal regulation in relation to governance because governance processes were not being used to improve the safety of the service.

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 service had a vision and strategy to support the delivery of the vision. This was based on an understanding of the challenges and the needs of people and their communities.

The vision was to deliver high quality, safe care that was timely and effective. The strategy to implement the vision was unambitious; it focused on integrating further with the trust’s other ED at Queen's Hospital Burton to share the best aspects of each ED to reduce workforce vulnerabilities and improve the culture.

Staff told us they enjoyed working with their colleagues and said they valued their team. Although most of the staff we spoke with in the ED described low morale in the team and feeling burnt out. Nursing and medical staff told us that they didn't feel listened to by the wider organisation. Medical staff told us they felt that the risk within the hospital was being held in the ED rather than shared by the wider organisation. They felt the lack of adherence by speciality teams to the internal professional standards (IPS) and the failure of the trust to enforce them underpinned this.

Senior leaders understood that the ED was carrying significant risk. They believed speciality teams were not responding in line with the trust’s IPS. They saw this as a long‑standing cultural problem whereby speciality teams focused on risks within their own areas. Speciality teams did not fully recognise the risks faced by the ED.

Senior department leaders told us there was a lot of fatigue within the nursing and medical staff because they had been working in a high pressure and increasingly busy environment since the start of the COVID-19 pandemic. They said staff were so fatigued that small work changes made no real difference. These changes did not improve team responsiveness or motivate staff to work differently. The senior leaders were hopeful that the redesign of the department would have a significant impact on how staff felt about coming to work. However, the end date for this work was 18 months in the future.

Senior leaders also understood that staffing levels in the ED were having an impact on staff morale. A trust wide recruitment freeze had meant that some of the staff who worked in the department were from other parts of the hospital. Others were bank or agency staff that did not know the department and were not familiar with urgent and emergency medicine. This not only impacted on the skill mix of the staff team but also meant staff did not consistently know if they would be working with their regular teammates or not. The senior leaders said a phased recruitment plan had begun to “safely and consistently staff the department” and they were getting this message out to staff to help boost morale.

Findings from the most recent national NHS staff survey (2024) demonstrated work-related fatigue and frustration were commonly reported by staff in the ED. Staff reported they felt worn out at the end of their working day. Few ED staff felt they had a good work‑life balance. Only a small proportion felt their work was valued. Very few staff said they were free from harassment, bullying or abuse from the public. All of these results were much worse than for the trust overall.

The trust had a disability equality network, a race equality network, and a Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, and more (LGBTQ+) network. The role of the networks included visible representation and acceptance of difference within the workforce, and safe space where people could access advice and information.

Senior leaders told us staff feedback from staff with protected characteristics under the Equalities Act (2010) had shown they were more likely to have a less favourable experience at work than others. Senior leaders invited leads from the equality diversity and inclusion networks to the divisional board meetings to help understand the reasons for their experiences and to develop meaningful strategies to redress these inequalities.

To generate a sense of belonging the medicines divisional leaders had started sending a divisional staff email. Senior leaders told us they had a positive response to these emails. There had been an increase of 5.9% in the number of staff from the division who completed the last staff survey which they attributed to this more personal form of communicating with staff. Following on from the 2024 staff survey “Time to Talk” sessions were introduced to provide staff with a safe and informal space to share their thoughts, concerns, and ideas directly with the divisional leadership team.

Staff in the CED reported a very different view to ED staff on the direction and culture of their department. They were very complimentary about one another and said things like, “I love the team” and “The team are supportive and feel like family”. They described a supportive and learning focused culture with a flat hierarchy. They told us staff worked together as a team who learnt from each other and valued each other’s contribution. They said their vision was focused on meeting the needs of patients and their families and the wider community.

The service had leaders who understood the context in which they delivered care, treatment and support. Leaders had the skills, knowledge, and experience to lead effectively. They did so with integrity, openness and honesty.

The ED was part of the medicines directorate and the CED was part of the women and children’s directorate. Both directorates were led by a triumvirate. A triumvirate leadership is three leaders who worked together to run the service. They combined medical, nursing and management skills. This helped them make decisions that were safe for patients and worked in real life.

Staff in the ED told us their line managers demonstrated they understood the challenges they faced and valued the work they did. Staff told us managers helped with patient care during the busiest times to reduce pressure on other staff. For example, by providing portering. The nursing staff spoke very highly about a recently appointed matron who had improved communication and made changes to ways of working that, “made the department feel safer”. However, staff were less complimentary about more senior managers. They told us they did not regularly see managers above matron level, and they did not receive support from the divisional leadership team.

Leaders in the ED understood staff were exhausted by the continuous high level of demand the service was under. They tried to keep an open‑door policy so staff felt heard. But this meant they worked extra unpaid hours because so many staff needed support.

Resident doctors told us senior doctors were approachable and visible.

Staff in the CED told us their managers, including managers from the senior leadership team were visible and approachable and did a walk around of the department each morning and also joined the staff safety huddles. We saw evidence of strong leadership through the comments of the staff team. Staff told us their leaders gave them a sense of autonomy in their work, opportunities to learn, and a feeling of a sense of togetherness.

Leadership training was available for managers.

The service did not always foster a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with did not know who the trusts freedom to speak up guardian was. However, they felt confident that they would be able to find the details of the service on the intranet if they needed them.

Staff told us they did not always feel heard by hospital leaders. The staff and leaders we spoke with were open and honest about the risks in the ED. However, there was a culture of acceptance of their working conditions and a shared understanding that they could not consistently provide the level of care they wanted for their patients, and a sense of apathy about how things could change.

Patients, their families and carers were provided with information to explain how they could raise a concern on the trust website. Staff knew how to help patients and their relatives to make a complaint. There were policies to support the complaints process.

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 service had clear responsibilities, roles, and systems of accountability but their governance processes did not consistently support the delivery of safe care. Leaders did not always act on the best information about risk, performance and outcomes.

There were structures, processes and systems of accountability to support the delivery of care in the ED. However, the processes did not consistently align with expected standards. For example, the standard operating procedure (SOP) for ‘temporary escalation spaces (TES) version 5’ had not been reviewed in November 2025 as stipulated in the SOP, so staff were using out of date guidelines and information to manage non-designated clinical spaces.For example, information about oxygen therapy did not match current guidance so patients requiring oxygen were being placed in the temporary escalation spaces (corridor care). There was no reference to Ward 101 being used as a temporary escalation space (corridor care).

The service did not have a consistently proactive and positive culture of safety. Staff did not report all incidents and near misses in line with hospital policy because there was a strong culture of accepting low staff numbers, overcrowding, and long waits for treatment in the department. Leaders followed governance processes to promote learning but did not always use these to improve quality and safety due to ongoing high levels of demand in the department.

Mortality and morbidity was regularly reviewed as part of the clinical governance structure. Care of patients who had died in the department was thoroughly investigated to look for lessons learnt. Sub optimal care was frequently identified in these reviews but almost never contributed to death. Clinical incident reporting was used to report failures to meet fundamental standards of nursing. The risks associated with long waits in the department was also carefully monitored to identify patient harm. Again, these investigations often identified sub optimal care/failures to meet fundamental standards of nursing. The risk register included information from clinical incidents which were tagged to risks. This demonstrated that rather than reducing risk, repeated clinical incidents were being tagged to the risk.

Staff in the ED told us their top risks were the number of patients in the department and patients with a long length of stay. Senior leaders told us their main risks were overcrowding in the department, the environment for patients who have a long length of stay, staffing, and violence and aggression towards staff.

Senior leaders had recognised they had some challenges around reviewing and updating divisional risks around the ED, so they had introduced plans to improve this. This was an improvement since our last inspection. However, some managers told us senior hospital leaders simplified complex issues and did not fully understand the risk held in the ED. Specifically that it was constantly at or over capacity and was staffed by a team that had no inbuilt resilience. Managers gave the example of the size of the current department being increased at short notice in October 2025. This was done to stop patients having long waits on ambulances, which managers said everyone agreed was safer for patients and meant ambulance crews had more capacity to help patients in the community. However, they said the increase in patient numbers was not matched by an increase in staffing levels which led to a reduction in nursing standards being met and an increase in the length of stay in the department for many patients. Leaders told us the current configuration of the department meant overcrowding was more obvious to people visiting the ED so they felt the level of risk was becoming more visible to the executive team.

Patient safety data could be viewed easily by senior hospital leaders. When performance was lower than expected leaders told us improvement plans were developed and shared with staff at all levels to ensure staff were aware of operational priorities. A dedicated member of staff was tasked with ensuring work was completed to improve performance, for example, to reduce incidents of pressure ulcers and falls. However, this did not match the lack of risk-based tools being used in the ED that were designed to improve patient safety, or the inability of nursing staff to consistently give medicines or perform clinical observations on time due to the level of demand the ED was under.

Immediate patient safety information was not available to key members of staff in the ED. The lead emergency physician in charge (EPIC) and the nurse in charge (NIC) did not have a system that could give them oversight of clinical acuity of patients. Staff needed to go into a second system and look at individual patients to view the level of information required to monitor deterioration. The NIC told us they relied on nurses who had a coordinator role in each area of the ED to identify patients at risk of deterioration or sepsis and feed this information to them.

The trust continuously collected data to understand the demand on the system. They collected and regularly analysed patient care indicators to try to improve safety and overall patient satisfaction. Patient care indicators in the ED and CED include the 4-hour wait target, ambulance patient handover times, time to initial assessment/treatment, unplanned re-attendance rates, left without being seen rates, and patient experience scores from surveys.

Improvements made by the trust included reducing ambulance patient handover times as discussed above. Improvements had not been made in reducing other patient care indicators.

Staff in the service understood their duty to collaborate and work in partnership so services worked seamlessly for people. Staff shared information and learning with partners and collaborated for improvement.

The trust were stakeholders in various multi agency groups. There was a mental health multi-agency group which covered topics such as Mental Health Act compliance, policy developments, targets and performance metrics. The executive trust lead for mental health was the Chief Nurse. All staff we spoke to said there were strong working relationships between the trust and the mental health trust.

The trust had a mental health framework. This was in the process of being reviewed and revised. There was a service level agreement and specification in place between the trust and a local mental health trust.

The senior leadership team said they had limited public engagement, but they were engaged with gathering data about the location of patients’ using the SDEC to map if there was higher demand from locations with higher levels of deprivation. They envisaged this would help them to identify areas needing proactive screening or outreach programs so people could receive, “targeted routine preventative care through the local health economy”. In addition to this they had invited patients with Parkinson's disease into the department so they could give feedback on what would improve the experience of care for people with Parkinson’s.

Demographic information was collected as part of the patient satisfaction survey for the patients who used the SDEC and adults ED. This data was used to explore if a long-term health condition, disability, ethnicity, gender, age, sexuality, or religion impacted on patients’ level of satisfaction with treatment. The data was also interrogated to identify if veteran or serving members of the armed forces status impacted on patients’ satisfaction with treatment.

Senior leaders had worked with their local ambulance trusts to design a service that improved patient handover times. This included expanding the footprint of the ED so a higher number of patients could be taken into the pitstop for triage, assessment, and diagnostic tests. This demonstrated leaders understood the risk facing the community when ambulances could not quickly respond to patients requiring urgent and emergency care.

The department had a lead for people who frequently attended the ED. They worked with system partners to understand how this cohort of service users could be supported and directed to the most appropriate services to meet their needs.

Staff in the CED showed they recognised the different cultural events celebrated by patients and staff. While we were onsite they were displaying posters to celebrate the Chinese New Year.

The adult ED was not always capable of focussing on innovation and improvement.

One manager in the ED said, “day to day firefighting has made quality improvement projects difficult to sustain”.

However, there was more scope for innovation and improvement in the CED and for adults presenting in mental health crisis. There was an ongoing project to get autism accreditation in the CED. This was building on work already completed, for example, the sensory cubicle. The trust had undertaken an enhanced therapeutic observation project which focused on a shift in mindset of staff relating to mental health observations. The project highlighted the need for more therapeutic interaction with patients requiring observation and this had been embedded through staff training.

There was a building plan that had been signed off to increase the footprint of the ED and to create a brighter and more modern looking environment.