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Provider: Chesterfield Royal Hospital NHS Foundation Trust Good

On 25 January 2019, we published a report on how well Chesterfield Royal Hospital NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Reports


Inspection carried out on 6 Sept to 8 Nov 2018

During a routine inspection

Our rating of the trust stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well led as good. In rating this trust we took into account the four core services not inspected this time. We did not take into account the ratings from the core services providing primary medical services.
  • We rated well led for the trust as good. The leadership, management and governance of the organisation assured the delivery of high quality and person-centred care, supported learning and innovation and promoted an open and fair culture. Leaders had the capacity and capability to deliver high quality care. Leaders understood the challenges to quality and sustainability and they were visible and approachable. Leaders were visible and approachable. The strategic plans for the trust linked to those of the wider health and social care system which the trust played an active part. There were processes for managing risk issues and performance.
  • The medical service was rated as good overall. Effective, caring, responsive and well led were rated as good but the rating of safe domain required improvement. This was because, although the service generally controlled infection risk well, not all staff followed the infection control guidance or complies with trust’s policy. Outcomes for patients had been improving and there were action plans in place to improve outcomes even further. Services were planned to consider the individual needs of patients and adjustments were made for patients living with a physical disability. The service was committed to improving services by learning from when things went well and when they went wrong, promoting training research and innovation.
  • The surgical service was rated as good overall, with all five domains being rated as good. The service had enough staff to keep people safe and staff were supported by managers and had annual appraisals. The environment in the operating theatres was clean, tidy and equipment was readily available, clean and well maintained. There were thorough pre- assessment screening processes for patients requiring surgery and they considered patients individual needs. Managers supported staff, promoted learning from incidents and used available information to improve to the service. However, the systems that were in place to protect people from infection were not always robust. The trust took immediate action to rectify our concerns.
  • The children’s and young people’s service was rated as good in all of the five domains. The service had made improvements to all the areas that required improvement following our last inspection. Staff knew how to identify and respond to changing risks to babies and children in their care. This included deteriorating health, medical emergencies and challenging behaviour. There were reliable systems in place to prevent and protect people from a healthcare associated infection. Staff were observed adhering to trust policy regarding infection prevention and control. There were facilities appropriate for children and their families. This included child-friendly signage and play areas and rooms with en-suite facilities and space for a bed for a parent/carer to stay with their child for long-stay patients. There was a dedicated children’s outpatient service at the hospital, known as ‘The Den’ which included a same-day phlebotomy service. The Den was child friendly and members of the multidisciplinary team reviewed and treated children. The service investigated and responded to all serious events. We saw that the service had put additional measures in place to ensure that children who had their scheduled surgery cancelled due to being unwell were reviewed by the paediatric consultant for a full examination before going home. The service worked in partnership with the community nursing team, specialist nurses and GPs to provide a comprehensive discharge plan. There was a direct referral facility for GPs and other health professionals to admit a child directly onto the ward via the assessment unit. Children with a long- term condition and those recently discharged also had direct access to the unit. Some children with complex conditions could be self-referred on a long-term basis.
  • The end of life care service was rated as good with the caring domain rated as outstanding. Safe, responsive and well led were rated as good with the effective domain rated as requires improvement. Staff had a good understanding of how to protect patients from abuse and could describe what safeguarding was and the process to refer alerts. There were comprehensive risk assessments completed in the medical and nursing notes. We saw good examples of good multi-disciplinary working and involvement of other agencies and support services. Staff cared for patients with compassion. We saw several examples of staff from all disciplines being supportive and kind to patients and their relatives. Most patients and their relatives told us they were fully included in discussions around their plan of care. The majority, (49%) of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders we viewed were not completed properly and reflected the information included in the patient’s mental capacity assessment.
  • The child and adolescent mental health service was rated as good. Safe, effective, responsive and well led were rated as good and caring was rated as outstanding. The service had suitable premises and equipment and looked after them well. The psychiatrists prescribed within guidance and any off-licence prescribing was done in discussion with the pharmacy team. Records were clear, up-to-date and available to all staff providing care. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The service had enough staff with the right qualifications, skills, training and experience to provide the right care and treatment. There was good multi-disciplinary working within the team and good joint working with external professionals. However, Caseloads were high, particularly for core CAMHS staff and psychiatrists. Waiting lists were long for Attention Deficit Hyperactivity Disorder assessment, Autism Spectrum Disorder assessment and Cognitive Behavioural Therapy and EMDR (Eye movement desensitisation and reprocessing).


CQC inspections of services

Service reports published 25 January 2019
Inspection carried out on 6 Sept to 8 Nov 2018 During an inspection of Specialist community mental health services for children and young people Download report PDF | 405.93 KB (opens in a new tab)Download report PDF | 3.08 MB (opens in a new tab)
Service reports published 4 August 2015
Inspection carried out on 21-24 April 2015 During an inspection of Community health services for children, young people and families Download report PDF | 322.48 KB (opens in a new tab)
Inspection carried out on 20 February 2017

During an inspection to make sure that the improvements required had been made

Chesterfield Royal Hospital NHS Foundation Trust was one of the first hospitals in the country to become a Foundation Trust in January 2005, and serves a population of around 441,000 across the Bolsover, Chesterfield, Derbyshire Dales and North Amber Valley, High Peak and North East Derbyshire districts.

Chesterfield Royal Hospital is a medium sized District General Hospital based a mile outside the centre of Chesterfield in an area known as Calow. The hospital is the town’s largest employer with a workforce in excess of 3,500 staff and has a total revenue of £221.2 million.

Chesterfield Royal Hospitals NHS Foundation Trust is registered to provide the following Regulated Activities:

  • Assessment or medical treatment for persons detained under the Mental Health Act 1983
  • Diagnostic and screening procedures
  • Family Planning
  • Management of supply of blood and blood derived products
  • Maternity and midwifery services
  • Surgical Procedures
  • Termination of pregnancies
  • Treatment of disease, disorder or injury

Chesterfield Royal Hospital NHS Foundation Trust was inspected on 20 February 2017. This inspection was a focused inspection following a comprehensive inspection in April 2015. The purpose of this inspection was to review how the provider was leading the organisation.

Our key findings were as follows:

  • The trust had a clear vision of where it wanted to be which was articulated by staff.
  • There were clear lines of accountability and appropriate board sub committee’s in place.
  • Information being provided to the board was relevant, timely and the narrative statements in reports supported the quantitative data being presented.
  • The board used an integrated assurance system which provided the board with assurance of quality and performance. We reviewed the papers for the board and found papers to contain key information about performance and assurance. They were well organised and structured and actions monitored.
  • Risks were reported to the trust board through the board assurance framework and the significant risk register, with the top risks being reviewed by the board at every meeting.
  • Senior leaders were knowledgeable about the risks for the organisation.
  • The leadership team were very cohesive and worked well together. They were clear about the direction of the trust and were committed to delivering the strategic vision.
  • Staff told us there had continued to be a positive culture change in the organisation and staff were supported to develop. Leadership development had continued and the programme was highly valued by staff.
  • There were systems in place for staff to be able to speak up. We did not receive any concerns from staff during this inspection in relation to bullying or harassment. The staff survey results for 2016 echoed this and the percentage of staff reporting they experienced bullying or abuse by staff was much better than the national average.
  • The staff survey response rate was low with 34% of respondents completing the survey compared with 56% in 2015.
  • The results of the 2016 NHS staff survey were disappointing. Their overall staff engagement score was 3.71 which put them in the lowest (worst) 20% when compared with trusts of a similar type. There had been no improvement in this score for the past four consecutive years.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust should:

  • The trust should take action to increase the response rate for the annual NHS Staff Survey.
  • The trust should take action to improve the overall staff engagement score in the NHS Staff Survey.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 21-24 April 2015

During a routine inspection

Chesterfield Royal Hospital was built in the 1980s and became a foundation trust in 2005. The hospital serves five local districts with a population of approximately 441,000. There is a small ethnic minority population, with over 96% of the population belonging to a white ethnic group. Life expectancy for both men and women in two districts (Chesterfield and Bolsover) is worse than the England average.

The hospital provides 682 inpatient beds and employs over 3,500 staff. In the year 2013-14, there were more than 71,000 inpatient admissions and 257,000 outpatient attendances; over 67,000 patients attended the accident and emergency department.

We inspected this trust as part of our in-depth hospital inspection programme. The trust was selected as it was an example of a low risk trust according to our new intelligent monitoring model. Our inspection was carried out in two parts: the announced visit, which took place on the 21,22,23 and 24th April 2015; and the unannounced visit which took place during the evening of the 2 May 2015.

Our key findings were as follows:

  • All of the services we inspected were found to be caring. Staff were kind and caring towards patients, and treated patients with dignity and respect. Most patients and visitors we spoke with were complimentary about the care they were receiving.

  • Overall we observed the hospital and clinic environments were visibly clean, hygienic and well-maintained. Improvements were needed in relation to the storage of clinical waste in the Eye Centre, within the Outpatients service. Patients told us they were impressed with the standards of cleanliness. There had been 30 cases of C difficile (a bacteria which causes diarrhoea) infection in the year up to February 2015 which was worse than the England average. Fifteen of the 23 (65%) confirmed patients with C difficile had one or more lapses in the quality of care identified as part of the investigation process. There had been two cases of Methicillin Resistant Staphylococcus Aureus (MRSA) reported between April 2013 to Nov 2014, both occurring in 2013. The trust had 17 cases of Methicillin-Susceptible Staphylococcus Aureus (MSSA) throughout the same period but this was similar to the England average. MRSA and MSSA are types of bacteria that can cause infections. We found there were systems in place to deal with infection prevention, and control and we observed staff to be following the trust guidelines.

  • Nursing staffing levels had been reviewed and there had been an increase in nursing and midwifery staff. We found the day time staffing levels were in line with national guidance and generally, both the day and night time staffing was in line with the numbers of staff the trust had identified they needed. There was an escalation process in place so that staff could flag if they were concerned about the staffing levels on each shift. In some areas, particularly within medicine, staff didn’t feel there were always enough staff on duty overnight. Some of the staff told us they didn’t report their concerns about the night staffing levels through the incident reporting system. We raised this with the trust and they took action straight away to review their staffing levels at night. There was a reliance on bank and agency nursing staff in some areas and like many trusts, they faced difficulties recruiting nurses.

  • There had been an increase in the number of midwives, and although the trust was not meeting national recommendations for birth to midwife ratios, staffing was comparable with other maternity services across the region. The trust was not able to provide a band six registered children’s nurse to be on duty at all times. This was due to difficulties in recruiting suitably experienced children’s nurses.

  • Medical staffing was at safe levels in most of the services we inspected; however in some areas there were vacant posts and reliance on locum medical staff.

  • Patients were provided with the assistance they needed to eat and drink and the risk of malnutrition or dehydration was assessed. Speech and language therapists provided support to ward areas to carry out swallowing assessments, and dieticians provided nutritional advice.

  • Patients’ pain was assessed and generally well managed. There were no specialised tools in place to assess pain in those with a cognitive impairment such as a learning disability or those living with dementia. Women in labour were given a choice of pain relief and provided with non-pharmacological options such as aromatherapy and the use of a birthing pool. Epidural pain relief was available on request, and the waiting time for this was within an acceptable 30 minute timeframe.

  • Monitoring by the Care Quality Commission had not identified any areas where medical care would be considered a statistical outlier when compared with other hospitals. The trust reported data for mortality indicators, the summary hospital-level mortality indicator (SHMI) and hospital standardised mortality ratio (HSMR). These indicate if more patients were dying than would be expected given the characteristics of the patients treated there. The figures for the trust were as expected. Information about patients’ outcomes was monitored. The trust participated in all of the national audits it was eligible for. Where improvements were identified, the trust was responding and was making progress implementing its action plans in order to improve the quality of care they were providing.

  • Like many trusts in England, the hospital was busy and the trust had faced challenges in access and flow, especially during the winter months. Bed occupancy in the hospital had been consistently over 90% which was above the England average of 88%. In the medical division, bed occupancy was 95.5% in February 2015. It is generally accepted that when bed occupancy goes over 85% it can start to affect the quality of care provided to patients and the running of the hospital. Due to issues with patient flow, medical patients were transferred or admitted to beds that were designated for other specialities.

  • The trust had a clear vision and a set of values which the vast majority of staff understood. This had been developed alongside staff and other stakeholders. There were a number of strategies in place and these all had clear goals which were measurable. All actions from the working strategies were being monitored. This allowed performance to be closely monitored.

  • The trust worked on a divisional structure which was clinically led, the chief executive described how this empowered clinical staff. There was recognition however, that this was more developed in some areas than in others, and more time was needed for this structure to become embedded.

  • The senior leaders in the trust had been working to increase the level of staff engagement. This was work in progress and we found evidence to suggest this was improving, but the staff survey results had been disappointing for the trust. Many staff told us they felt the organisation had changed over the past two years and was now one which had a real focus on the quality of care for patients.

We saw several areas of outstanding practice including:

  • Staff in the x-ray department were able to view the electronic patient information screen held in the emergency department. This meant they knew when patients were awaiting x-ray and responded promptly, usually within 20 minutes of the request being entered into the system.

  • Staff working for the local mental health trust which provides care for people with mental health problems, were able to view the electronic information screen held in the emergency department. This meant they knew when patients were awaiting review and responded promptly, usually within 60 minutes.

  • Locum doctors working in the emergency department received quarterly reviews with an educational supervisor.

  • The multidisciplinary huddle within the emergency department was informative and effective and valued by the team and wider trust staff.

  • As a pilot fixed term project, a pharmacist worked in the department to support all aspects of medicines management. Data showed this was beneficial to patients and speeded up admission processes.

  • The trust had a clear vision of how its clinical environments could be made dementia friendly. They had realised this vision in the refurbishment of the discharge lounge.

  • Each clinical area had its own improvement plan . This meant ward matrons and their staff were clear about the various quality and safety improvement initiatives in progress, how they would be achieved, and how they were inter-related.

  • The trust had reacted positively to audit data and had embarked on a local health and social care economy project to produce and implement a dementia and delirium patient treatment pathway. Manvers ward had introduced patient based communication folders which allowed written requests for information to be made and responded to within 24 hours.
  • There was good multidisciplinary and collaborative working both internally and externally. Examples of this were the child development clinics and the joint working between the children in care team and the local authority.
  • The service for children and young people with diabetes did not discharge children who did not attend for appointments. If children did not attend, they and their parents or carers were reminded by letter of the need for regular reviews and the long term health implications of diabetes.
  • The children in care team provided young people at 18 years old with a health summary and history report. The format of the report had been designed in consultation with young people. The report included information the young person may not have known, such as their birth weight and the age they achieved developmental milestones. The report also gave useful information about promoting good health and accessing local services, such as housing associations.
  • Children attending appointments at The Den could watch 3D short films designed to calm and distract them. This was particularly useful for children with a learning disability or autistic spectrum disorder, or those who were anxious.
  • Community nurses were providing a flexible service. This meant children could be seen after their school day and was also helpful for working parents. Community nurses negotiated with young people when arranging appointments to ensure the least possible disruption to the young person’s education.
  • The service for children and young people with epilepsy included clinic sessions to discuss potential problems for young adults with epilepsy, such as using alcohol or learning to drive. These sessions also included preparation for transition to adult services.
  • Children in care whose final plan may be for adoption were identified prior to their initial health assessment and the assessment was sufficiently thorough to serve as an adoption medical. This saved repeated assessments and medical examinations for the child. It also helped to avoid delays in the legal system for adoptions as all the information required was incorporated into one report.
  • The trust provided "Team Teach," which was commissioned by Derbyshire County Council. This team provided training for non-trust staff working with children and young people with complex health care needs. The training was delivered to staff such as care workers supporting children and young people in their own homes, foster carers and school staff. The service provided by Team Teach reduced the workload of community nurses who otherwise would have provided the training required.

However, there were also areas of poor practice where the trust needs to make improvements.

Action the hospital MUST take to improve

  • Ensure there is appropriate and timely monitoring of deteriorating patients within the HDU department.

  • Ensure ward staff are supported to identify and manage very sick or deteriorating patients in ward areas.

  • Ensure that people who may lack capacity to make decisions about their care have an adequate assessment of their mental capacity, and that decisions about DNACPR are taken in line with the requirements of the Mental Capacity Act (2005).

  • Ensure that an accurate record is kept for each baby, child, and young person which includes appropriate information and documents the care and treatment provided.

  • Ensure all DNACPR order forms are completed accurately and in line with trust policy.

  • Ensure that numbers of registered nurses meet national guidance, and meet the needs of patients at all times, including throughout the night.

  • Ensure that an experienced, senior children’s nurse is available during the 24-hour period to provide the necessary support to the nursing team.

  • Ensure that there are sufficient numbers of staff to provide the dermatology outpatient service.

  • Ensure that at least one nurse per shift in each clinical area (ward / department) within the children’s and young people’s service is trained in advanced paediatric life support or European paediatric life support.

  • Ensure all staff involved in caring for patients at the end of life receives adequate training in end of life care.

  • Ensure the resuscitation trolleys and their equipment are checked, properly maintained, and fit for purpose in all clinical areas.

  • Ensure there are robust waste management procedures in place.

Action the hospital SHOULD take to improve:

  • The trust should ensure sufficient cover in the accident and emergency department to allow all staff to attend necessary training sessions.
  • The trust should consider the effectiveness of signage in the emergency department reception area to advise patients when their condition requires them to proceed to the front of the queue.
  • The trust should ensure safe and effective processes for the disposal of clinical and chemical waste.
  • The trust should review its medical bed capacity to ensure that the majority of patients are cared for in the correct speciality bed for the duration of their hospital admission. It should also review its arrangements for the management of patients outlying in non-speciality beds to ensure the quality and safety of their care is not compromised.
  • The trust should review its arrangements for quality assuring Root Cause Analyses, and for monitoring the implementation and efficacy of any associated action plans to ensure that RCA’s identify remedial actions that are fully implemented and evaluated.
  • The trust should review its arrangements for ensuring the monitoring of in-dwelling intravenous devices in line with “Saving Lives” guidance.
  • The trust should review the provision of the continuous piped oxygen and suction issue in the cardiac catheter laboratory and associated recovery areas.
  • The trust should ensure that all confidential patient records in clinical areas, and confidential waste, are securely stored to minimise the risk of unauthorised access.
  • The trust should review how it can provide both rehabilitation and follow up for patients who are discharged from intensive care to meet NICE guidance.
  • The trust should take steps to reduce the number of patients being discharged from the critical care unit overnight.
  • The providers should ensure suitable storage in the critical care unit is available so that equipment can be plugged in when being stored.
  • The trust should ensure intravenous fluids are stored safely in the critical care unit.
  • The trust should ensure that staff in the fracture clinic where children and young people are seen, understand their roles and individual responsibilities to prevent, identify and report abuse when providing care and treatment.
  • The trust should ensure that they have written formal arrangements in place with the children and adolescent mental health team so that the needs of children and young people with mental health problems are met.
  • The trust should ensure that agreed care pathways and written guidance are in place to guide staff when caring for children and young people who have mental health conditions.
  • The trust should ensure there is an effective link nurse structure to enable local support and guidance in end of life care in the absence of the specialist palliative care team.
  • The trust should review the hours of service provided by the specialist palliative care team to include a face-to-face specialist palliative care service from at least 9am to 5pm, seven days per week.
  • The trust should consider reviewing their local and national audit activity in order to monitor the effectiveness of end of life care services and benchmark against end of life services nationally.
  • The trust should review the storage of patient property following a patient’s death.
  • The trust should ensure a risk assessment is undertaken for those patients who are waiting within outpatient areas with no clinical oversight.
  • The trust should ensure a clearly defined governance structure across the entire outpatient services. There should be more monitoring of patient outcomes and performance such as waiting times within clinics.
  • The trust should ensure that there is a clear process for triaging of test results in Dermatology outpatients. by appropriately trained staff to ensure patient safety.
  • The trust should review the environment within dermatology outpatients to ensure the privacy and dignity of patients.
  • The trust should ensure that medical records are stored securely within outpatients.
  • The trust should ensure staff leading on serious investigations working in the maternity service are appropriately trained in investigatory processes and report writing.
  • The trust should strengthen the investigation of serious incidents within maternity services to include multidisciplinary involvement, the development of SMART action plans, and senior review and approval, in line with the Serious Incident Guidance, March 2015.
  • The trust should ensure women who have undergone a termination of pregnancy are cared for in an area that provides them with dignity and respect.
  • The trust should ensure staff working in the maternity service are given feedback on complaints received identifying themes and preventative actions.
  • The trust should review its complaints handling procedures to ensure that patient complaints are responded to in a timely manner. It should also ensure that staff understand the role and function of the Patient Advice and Liaison service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.


Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.