University Hospitals of Derby and Burton NHS Foundation Trust

Derby Hospitals NHS Foundation Trust provides both acute hospital and community-based health services. There are two inpatient hospitals, the Royal Derby Hospital and London Road Community Hospital. The trust serves a population of over 600,000 people living in Derby and the surrounding areas. In total the trust has 1,100 beds.

Derby is an urban area with a deprivation score of 63 out of 326 local authorities (with one being the most deprived). This means that Derby Unitary Authority has a significantly deprived population and is worse than the national average on a range of population health measures.

Life expectancy for men is lower than the England average and is 12.2 years lower between the most deprived and the least deprived areas of Derby. For women the difference is nine years lower. Reducing inequalities in health is one of the local priorities across the Derby health community.

We inspected Derby Hospitals NHS Foundation Trust as part of our comprehensive inspection programme.

We carried out an announced inspection of the Royal Derby Hospital, London Road Community Hospital as well as the community-based services between 8 and 11 December 2014. In addition, an unannounced inspection was carried out between 5pm and midnight on 22 December 2014. The purpose of the unannounced inspection was to look at the accident and emergency (A&E) department, critical care and a number of wards in both the Royal Derby Hospital and London Road Community Hospital.

We made judgements about all of the services the trust provided and because just three out of the eleven core services we inspected required improvement we rated this trust  as “good” overall and noted some outstanding practice and innovation. However, improvements were needed to ensure that services were safe, effective and well led. 

Our key findings were as follows:

Cleanliness and infection prevention and control

• There was a dedicated inspection prevention and control team and good arrangements in place to prevent the spread of infection.  All of the wards at the Royal Derby and the London Road Hospitals appeared to be clean.  We saw staff adhered to the policies for infection prevention and control, for example, staff washed their hands regularly and between patient contact.  where infections did occur, they were subject to an investigation.  We saw examples of these investigations and the learning points to come out of them. 

Nutrition and hydration

• We saw patients received help to eat and drink.  There were systems in place to identify patients who needed help, such as the "Red Tray," and protected mealtimes.  There were nutritional assistants available at meal times.  We also noted some good practice for patients where the day rooms were used to have communal meals and create a more informal atmosphere to help stimulate patients to want to eat and enjoy their meals. 
• Nutritional risk assessments were completed appropriately, but most importantly we saw the outcomes of risk assessments were acted upon.  Food charts were maintained and there was accurate recording and totalling of fluid balance charts. 

Mortality

• We did not have concerns about mortality rates at the trust.  Where there had been any identification of trends that required further investigation the trust reviewed data and submitted their responses appropriately.  There had been a mortality outlier which intelligence systems had identified in February and March 2014.  This concerned coronary atherosclerosis and other heart disease.  An investigation had been undertaken which identified a need to ensure improvements in coding and documentation. The clinical treatment of the patients was not found to be of any concern.
• The trusts Summary Hospital-level Mortality Indictor (SHMI) and the Hospital Standardised Mortality Ratios (HSMR) mortality measures show the trust as being within expected limits between August 2013 and July 2014. SHMI and HSMR are ways in which the NHS measures healthcare quality by looking at the rates of mortality in the trust.

Staffing

• There were significant staffing problems within the community nursing teams. There were high levels of vacancies as well as staff sickness and absence which meant case loads were high. The complexity of the patients being cared for at home was also increasing. In addition, the community nursing teams were providing a service that exceeded what it was commissioned for. The district nursing activity was over target and for seven of the last 18 months, district nursing teams carried out more than twice as much work as they were scheduled for.  All of these factors meant the community nursing teams were under immense pressure and the service was not sustainable. The concerns about staffing levels had been escalated and it had been an item at the trusts safer staffing board.
•  At the Royal Derby Hospital, a recognised safe staffing tool had been used to calculate nurse staffing levels.  During 2014, a review had taken place and changes to the establishment had taken place.  Wards displayed their staffing levels on a board and it compared the daily planned numbers of staff with the actual staff on duty.  Patients at the Royal Derby Hospital told us the nurses were busy.  Many staff told us they felt under pressure and worried that their workloads kept on increasing as the demand for services increased. Despite this, we found all of the services we inspected apart from medicine and end of life care were adequately staffed with nurses. In medicine and end of life care, there were some occasions where the nursing staff ratios dropped to below the required level.   
• Within the community services, the trust had used a  recognised safe staffing tool to assess the staffing levels required on the inpatient wards at the London Road Community Hospital.  This had resulted in increased funding to employ additional nurses.  We were encouraged to see the trust had reduced bed numbers on the wards as an interim measure while they ensured they had adequate staff in place. 
• The trust employed more consultants and junior doctors than the national average but less registrars and middle grade doctors than the national average. Doctors we spoke with were generally positive about the medical staffing arrangements and we did not identify any concerns with the numbers of medical staff employed by the trust. 

Complaints

• The trust  had a compliance action set by the Care Quality Commission in July 2013 to improve the handling of complaints.  The trusts target for responding to complaints within the 25 or 40 day timescale had improved. In December 2014, performance was 72% which was slightly better than the trusts own target of 70%. We reviewed nine complaints during the inspection and we found not all of these had been responded to in the time set.  the trust had met their quality target set by the commissioners for complaints handling.  we judged the compliance action had been met, but the improvement needed to continue and be sustained.

We saw several areas of outstanding practice including:

• The trust was providing responsive care for patients who had dementia.  On the Medical Assessment Unit there was a dedicated lounge known as the FEAT lounge (frail elderly assessment team).  A dedicated healthcare assistant with qualifications in caring for patients living with dementia to assist patients was available in this lounge every day.  We found this was providing care to patients that was very responsive to their individual needs. 
• Ward 205 should be commended for helping to improvement the mental wellbeing of elderly patients and patients with dementia through the use of the reminiscence room, pictorial information and advanced service planning to further enhance care.
• The MAU had pharmacists on the ward 12 hours each day, seven days a week. They worked as part of the frail elderly team with the aim of optimising the use of medicines. The overall aim was to help patients make the most of their medicines.
• Respiratory medicine had introduced the use of patient colour-coded wristbands to identify how much oxygen each patient needed. Excessive amounts of oxygen can be dangerous for some patients and it is important that the correct amount of oxygen is administered.
• Echocardiography was used as the main monitoring tool of cardiac output and fluid status for intensive care patients.  Point of contact echocardiography for these patients is a highly innovative and valuable service.
• The maternity department bereavement service had been recognised by the Royal College of Midwives. The lead midwife had been nominated for the Royal College of Midwives Award 2015 National Maternity Support Foundation Award (NMSF) for Bereavement Care, improving the environment, which was known to be an important key to effective bereavement care.
• The Nightingale Macmillan Unit was dedicated to providing end of life care to patients with life-limiting illnesses and staff were able to respond appropriately to meet the individual needs of patients. The facilities and resources available for patients on the unit were excellent.
• The trust worked with the Arts Council and had an initiative in place knows as Banishers of Boredom.  this was a small team of staff of staff who worked with patients to participate in different activities.

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

Importantly, the trust must:

• Ensure that patients thought to have reduced mental capacity, or those who lack mental capacity, to make decisions about their care and treatment, receive prompt and effective assessments in line with the Mental Capacity Act (2005).
• Ensure all DNA CPR order forms are completed accurately in line with trust policy and the Mental Capacity Act (2005).
• Ensure that at all times there are sufficient numbers of suitably qualified, skilled and experienced  nursing staff in the district nursing, medicine and end of life services, employed for the purposes of carrying on the regulated activity.
• Ensure that all district nursing staff are able to attend mandatory training and other essential training as required by the needs of the service.

In addition the trust should:

• Ensure that there are suitable arrangements in place to ensure that sufficient and suitably qualified staff are on duty on all medical wards to meet patient’s needs safely.
• Ensure that the lone working policy and arrangements for community maternity staff are reviewed to ensure they feel safe and secure when out in the community.
• Ensure that patients notes are stored securely to ensure that confidential patient information is not accessed inappropriately.
• The trust should ensure that there are sufficient numbers of suitably qualified, skilled and experienced nursing staff on the adult emergency observation ward to safeguard the health, safety and welfare of patients.
• The trust should ensure that there is sufficient storage available to enable equipment to be appropriately stored and enable safe access to bathrooms on medical wards.
• The trust should consider providing information for patients and friends and family comment cards in different formats and different languages. This would enable people with learning disabilities, those who's first language is not English or those with cognitive impairment to access information and provide their feedback.
• The trust should review arrangements for undertaking venous thromboembolism (VTE) assessments on the surgical assessment unit.
• The trust should consider reviewing the arrangements for the care of patients on high dependency units who would be categorised as requiring level two care.  Current arrangements were not meeting the Core Standards for Intensive Care Units (2013).
• The trust should consider developing their electronic prescribing system to enable it to be used in intensive care as for other wards and departments in the hospital. The use of different systems across the hospital meant there was a risk of poor communication about previously administered medications.
• The trust should ensure that staff on Puffin ward are trained and supported to care for patients who require a CAHMS assessment whilst on the ward so that they can ensure their welfare and the welfare of other patients is protected.
• The trust should ensure that all clinical single use equipment is stored safely and appropriately; and disposed of when it has expired it used by date.
• The trust should ensure that the design and layout of the neurology outpatient clinic at London Road Hospital is suitable for the needs of all patients, including those with limited mobility.
• The trust should consider improving the facilities for patients who need to collect prescription medicines from the pharmacy within Royal Derby Hospital. This is to reduce the long waiting times for prescriptions to be dispensed and the pharmacy and improve access for patients with limited mobility.
• The trust should consider hearing "patients stories" during their public board meetings to ensure the positive and negative experience of patients is taken account of when they make decisions.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Derby Hospitals NHS Foundation Trust provided a range of community health services for adults in Derby City, including district nursing, intermediate care, specialist rehabilitation and early supported stroke discharge. Services were managed at London Road Community Hospital and delivered in a range of locations, including patients’ own homes, the community hospital and community clinics. We visited several community clinics, met with staff, visited the rehabilitation centre at the community hospital and went on home visits with community nurses and therapists.

Staff did not always report patient safety incidents and the uptake of training on incident reporting was low in some teams. Staff received good feedback about incident investigations, but there was little sharing and learning across the service in order to improve practice.

District nursing teams, in particular, were under-staffed and taking on increasing workloads. Recruitment was not successful in filling vacancies, and teams were delivering far more activity than they were contracted for. Staffing shortfalls meant that nurses could not attend mandatory and other training. Although there were governance structures in place to monitor and manage risks, long-standing risks associated with district nursing staffing levels and demands on the service had not been reduced.

Staff felt well supported by their immediate line managers, but there was a lack of clarity about wider management structures and roles, and communication needed to improve. Community staff felt disconnected from the rest of the trust, and services tended to work in silos. Opportunities for sharing learning and engaging with other staff as part of community-wide services were not well established.

There were suitable arrangements for the prevention and control of infection, maintenance of the environment and equipment, and the safe management of medicines. However, staff working in the community were not always able to access current information about their patients’ care and treatment plans.

Patients received compassionate and respectful care. Patients felt involved in making decisions about their care plans. Care and treatment were evidence based and staff monitored the quality of the service they provided with a range of outcome measures. Community health services for adults were delivered through effective multidisciplinary teams. Most staff we spoke with were passionate about their jobs and were proud of their work. There were a number of successful innovative community programmes taking place both in the trust and with partners in the local health and social care sector.

The London Road Community Hospital is a community hospital located in Derby city centre. It had four inpatient wards with a total of 101 beds, providing ‘step down’ care for people leaving acute hospital care. The trust provided an additional 16 beds at Perth House, a Derby City Council care home. During the inspection, we visited both sites and spoke with 39 patients and 11 relatives. We observed interactions between patients and staff and we reviewed 10 sets of care records. We also spoke with 67 staff, including nurses, occupational therapists, physiotherapists, pharmacy technicians, hotel services staff, admin and clerical support staff, GPs and visiting clinical staff.

There were clear processes for the prevention and control of infection and maintaining safe equipment. Staffing levels were under pressure but were supported through reducing bed numbers and employing temporary staff. There were processes in place to ensure continuity of care with bank and agency staff as much as possible.

There were arrangements to minimise risks to patients, with measures to prevent falls and pressure ulcers. We saw elements of good practice including the use of safety dashboards, clean clinical areas and good infection prevention and control practice. However, ward staff were not consistent in reporting patient safety incidents.

Care was provided in line with national policies, with good multidisciplinary working to meet people’s needs. Most staff had attended suitable training. There was a lack of consistency in how people’s mental capacity to make decisions was assessed and not all decision-making was informed by or in line with best practice guidance and legislation.

Across all staff groups we observed a commitment to a timely, but safe and person-centred discharge for each patient. There were delays relating to the discharge process for some patients, and staff worked with other agencies to find solutions.

Staff treated patients with dignity and respect, although some patients did not feel sufficiently informed about discharge arrangements. Patients’ concerns and complaints were dealt with by senior staff at ward level and learning from feedback was shared at ward meetings.

Community inpatient staff were aware of the trust’s values and said they tried to put these into action as part of their daily work. There was still uncertainty about the future direction of the hospital. Staff felt well supported by their line managers and were proud of the service they worked in.

Derby Hospitals NHS Foundation Trust delivered community based services to people requiring palliative and end of life care throughout South Derbyshire. The community palliative care team was part of an integrated team, working alongside colleagues from the specialist palliative care team based at the Royal Derby Hospital.  The community end of life care service provided palliative and end of life care in a range of environments such as people’s own homes, London Road Community Hospital and the Nightingale Macmillan Day Unit. We visited these sites and went on home visits, the community palliative care team. We spoke with patients, carers and staff including community nurses, district nurses, community matrons, matrons, health care assistants, volunteers and doctors.

Community palliative care staff received good feedback about incident investigations, but there was little sharing and learning across the service in order to improve practice. Staff working in the community caring for people at home were not always able to access current information about their patients’ care and treatment plans, which meant they might not be fully prepared to care for a patient.

District nursing teams and the specialist palliative care team were under-staffed and taking on increasing workloads. There were high levels of sickness absence. Recruitment was not successful in filling vacancies, and teams were delivering far more activity than they were contracted for. Staffing shortfalls meant that nurses did not attend mandatory and other training.  We have included more detailed findings about the district nursing teams within our inspection report, "Community health services for adults." 

Care and treatment were evidence based and staff followed current best practice recommendations. Community staff were appropriately qualified, skilled and competent to carry out their roles, and worked well to meet the needs of patients. Community teams worked in a multidisciplinary manner and there was good team working to ensure patients received effective care in the community. Patients received compassionate care and we witnessed positive interactions between patients and staff. Staff provided emotional support for patients and their carers.

All of the staff we observed demonstrated compassion and were passionate about providing good end of life care. Community end of life care services were responsive to people’s needs. The trust had a number of initiatives to ensure patients received the care they needed in the most appropriate place.

Leadership at a local level was good and managers demonstrated a clear understanding of their services and were aware of the risks and challenges their service faced. Staff spoke positively about the contribution they made to patient care. There was some engagement with staff but this needed to improve.