We visited three wards in the hospital and spoke with people using the service and visitors on each ward. We spoke with the matrons for the three wards and also with nurses, health care assistants, doctors, a dietitian, catering and domestic staff. We found that the provider had made changes since our last inspection to protect people using the service from the risks of inadequate nutrition.

People we spoke with were satisfied with the choice, quality and quantity of the food provided. One person told us, “You get a choice of food for every meal and there’s always something I like.” We found that the menus had been expanded to provide more choice and variety.

We found that new guidance and procedures had been introduced throughout the hospital to ensure that people had the right support to eat and drink. We saw that the guidance and procedures were followed in practice on the wards we visited. One person told us, “There’s always a nurse around at mealtimes”, and we observed staff providing unhurried and sensitive help to people who needed it. Staff we spoke with felt that the new procedures made mealtimes better organised and ensured people’s nutritional needs were met.

We saw that each ward now had a designated Nutrition Champion, a qualified nurse with responsibility for ensuring that people’s nutritional and hydration needs were met. Staff we spoke with felt the Nutrition Champions had made a positive difference to the experience of people using the service.

People told us what it was like to be a patient in Chesterfield Royal Hospital. They described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an "expert by experience" (people who have experience of using services and who can provide that perspective), and a practising professional. We visited two wards, both designated as primarily caring for older people receiving medical care and treatment. The provider delivered the regulated activities 'Treatment of disease, disorder or injury' and 'Diagnostic and screening procedures' on these two wards. Each ward had 31 patients on the day of our visit. We spoke with 16 patients, three relatives, and eight staff across a range of roles.

Most patients told us they felt staff respected their privacy and dignity. We observed positive and respectful interactions between staff and patients on both wards we visited. However, we also saw examples of patients' privacy, dignity and independence not being upheld or maintained.

Patients had mixed views about the food provided. Some patients were satisfied while others wanted more variety or wanted meals to meet their specific needs. We saw that patients had a choice of meals and the food provided looked appetising. We found that patients did not always have enough support to ensure they had adequate nutrition and fluids.

Patients told us they felt safe and felt able to report any concerns to staff. We saw that staff carried out assessments to determine if patients were at risk of falling and took action to reduce this risk.

Most patients told us that staff were very good but some patients had mixed experiences and told us some staff were not as helpful as others. For example, one patient said, "It's a difference between shifts, on one nothing's too much trouble, next shift it's 'in a minute' ". We saw that although both wards were very busy on the day of our visit and staff were continually occupied, most patients said their needs were met.

We found that patients had access to their nursing care records, though none of the patients we spoke with had looked at them. We saw that nursing care records were not always accurate or fully completed and often lacked detail.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

Most people told us they felt involved in decisions about their care and treatment. Parents of children admitted to the hospital told us that they were given sufficient information and the child was also involved as much as possible where this was appropriate.

People we spoke with said that staff respected their privacy and dignity. One person said “they always make sure the curtains are closed for privacy and they’re very polite and friendly”.

People told us they were generally happy with the care and support they received. They said “I’ve been well looked after”, and said the staff were “so kind” “they do everything willingly and cheerfully”. One person told us they appreciated the helpfulness and straightforward approach of the stoma nurse so the person now knew how to manage their stoma care independently.

The people we spoke with had mixed views about the food provided. Some people said the food was good whilst others said that the food did not meet their needs and preferences. One person was pleased with the choice available for their gluten free diet. Other people said the food was tasteless and could be better presented. One person said “it all tastes the same” and another commented that the food was “abysmal”.

People told us that maintaining cleanliness and hygiene appeared to be a high priority on the wards. They said “They are in my room every couple of hours mopping and cleaning, this room is spotless”, “the cleaning routine is extremely thorough”, and “staff are always washing their hands”.

People on the new wards said they were pleased with the facilities such as the spacious bays and the toilets and shower rooms in each bay.

Most people told us there were enough staff available to meet their needs. They said “there’s always staff around when I need them” and “they’re always coming to check I’m ok”. Two people on one ward said that they sometimes had to wait for assistance as there were not always enough staff around.

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 were inspected between 13-14 July 2016. Unannounced visits were carried out on 20 July 2016. This inspection is a focused follow up inspection following a comprehensive inspection in April 2015. The purpose of this focused follow up inspection was to inspect domains that had previously been deemed to require improvement.We did not rate the trust overall. We looked at domains that had previously been rated as less than good. We made judgements about seven services across the trust as well as making judgements about the five key questions that we ask.

Our key findings were as follows:

• There was an effective incident reporting system. However, there were incidents that had not been closed on the reporting system. There was an open and honest culture, and people who used the service were told when something went wrong.
• The environment where care was delivered was visibly clean. There were systems, processes and procedures in place for infection prevention and control which were adhered to by the majority of staff.
• The day time ward staffing levels were planned in line with the National Quality Board guidance published in 2013 and 2016.
• There was ongoing, and on occasions, significant numbers of bank and agency staff being used.
• Generally systems were in place to assess and respond to risks where patients were identified as deteriorating.
• There was no critical care outreach team within the hospital, although one was being established.
• Medications were stored appropriately and administered safely.
• An assessment tool was used to assess patient’s pain. Where patients experienced pain this was managed well.
• Most equipment, including resuscitation equipment was checked, serviced and safe for use, however some resuscitation equipment was not checked in line with trust policy.
• The trust had recently introduced a new system for staff to access and record their training activities. At the time of the inspection the trust was experiencing difficulties accessing current accurate data of the number of staff who had attended their mandatory training, therefore the trust was not certain on how many staff were currently trained.
• Patient care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation.
• There were a significant number of patients being moved between wards in the hospital and moves routinely happened after 10pm. These were predominantly from the initial assessment wards to inpatient wards.
• Since our last inspection in April 2015 the trust had achieved the appropriate level of suitably qualified nursing staff per shift with the European paediatric life support (EPLS) qualification.
• There was effective multidisciplinary working to deliver patient care.
• Patients were supported, treated with dignity and respect. Relatives and friends were involved in patients care. We saw staff carrying out care with a kind, caring and compassionate attitude.
• Systems were in place to acknowledge complaints within three days. A triage system was in place to establish response times to complaints depending on the complexity. Response times to complaints had improved since our last visit after an action plan was put in place.
• Concerns resolved at ward level were not reported on the incident reporting system; therefore opportunities for learning could be missed however a pilot was taking place to start capturing this information.
• High bed occupancy levels above the trust target was identified as an operational risk with the potential to impact on staffing levels and the quality of patient care. This was being managed on the trust’s risk register and a weekly report was being prepared for the commissioners.
• Staff we spoke with were aware of, and understood, the vision and values of the trust. Staff identified the “proud to care” initiative to look after patients.

We saw several areas of outstanding practice including:

• The neonatal gentamicin prescription sheet that had been produced because of lessons learnt from gentamicin medication errors was outstanding. This has reduced the number of incidents to zero within the department and ensured that all patients received the correct management.
• “Toolbox talks”- had been developed and trialled amongst porters with the aim of increasing knowledge of end of life care. “Toolbox talks” were short talks developed and delivered to the porter service manager who then delivered this to their teams. There was a plan in place to roll this out to other non-clinical staff within the trust.
• Members of staff on Markham Ward had written a poem to provide support to relatives of end of life patients. “The palliative approach” poem was sensitively written and described how the ward would care for relatives and their loved ones on the ward.
• Markham Ward had created a “comfort tin” for relatives of patients in the last days or hours of life which included biscuits and tissues had been developed.
• A “comfort tin” for relatives of patients in the last days or hours of life, which included biscuits and tissues, had been developed. We also saw the use of “comfort packs” , which included essential toiletries, such as toothbrushes and cleansing wipes.

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

• The trust must ensure the resuscitation equipment provides a full range of equipment to meet all sizes of children, young people and adults.
• The trust must ensure that in areas where children are treated, appropriate safeguarding measures and staff training are in place.
• The trust must ensure nursing staff who deliver end of life care are familiar with and receive training in the Mental Capacity Act (2005).

In addition the trust should:

• The trust should ensure all DNACPR order forms are completed accurately and in line with trust policy.
• The trust should improve infection control training within the medical division.
• The trust should ensure there are consistent processes in place to assure cleanliness of equipment including the birthing pools within maternity and gynaecology services.
• The trust should ensure cleaning records are maintained for the milk fridges within maternity and gynaecology services.
• The trust should ensure all staff are compliant with trust targets and intercollegiate standards in regards to safeguarding level three training.
• The trust should ensure there is a consistent process for assuring the safety of electrical items and they are clearly marked with details of when safety checks are next required. It should be ensured staff are aware to the process for ensuring equipment is checked and safe to use.
• The trust should ensure there is a formalised risk assessment produced for the paediatric resuscitation trolley on Nightingale Ward remaining unlocked.
• The trust should ensure all investigations involving a child or young person should have representation from the Women and Children’s division.
• The trust should ensure the sepsis management of children and young people is fully embedded within the service.
• The trust should ensure they work closely with the local hospice in finalising the service level agreement.
• The trust should ensure they continue with the plan to monitor how rapidly patients are discharged from hospitals once identified for “fast track”.
• The trust should ensure they audit the achievement of patient's preferred place of death.
• The trust should ensure the legal process of the Mental Capacity Act 2005 is followed where a patient lacks the capacity to make decisions, particularly in relation to ‘Do Not Attempt Cardio Pulmonary Resuscitation’ (DNACPR) orders.
• The trust should consider reviewing the process for transferring obese deceased patients to the mortuary.
• Consider the environment in Hollywell Day Case Unit to ensure the environment where trolleys are located and equipment is washed is suitable to ensure effective infection prevention and control measures can be adhered to.
• Ensure that all ward and department staff receive information on the policy for the monitoring and recording drug fridge temperatures including details of any actions they are accountable for.
• The trust should continue to prioritise reviewing the open incidents, ensure actions are taken to minimise risk ,and ensure actions are completed, learning is shared and records updated.
• Should ensure that the surgical department morbidity and mortality quarterly meetings are established and that there is a robust system is in place to secure attendance and enable learning to be shared.
• Ensure all staff receive annual appraisals.
• Ensure all staff attend mandatory training days.
• Ensure all staff complete safeguarding training suitable to their role and grade.
• The trust should ensure there is a consistent process for assuring the safety of electrical items and they are clearly marked with details of when safety checks are next required. It should be ensured staff are aware to the process for ensuring equipment is checked and safe to use.
• Ensure where resuscitation trolleys are shared between two wards both wards carry out and document the checks as per the trust policy.
• Ensure VIP scores are recorded in a consistent manner and that there is no duplication of information.
• Ensure data is captured when complaints/concerns are resolved at ward level, and ensure that learning is shared.
• Ensure patient transfers are effectively managed to minimise the number of patients transferred after 10pm.
• Ensure sufficient medical staffing is available to meet periods of increased demand and to cover staff absences.
• Ensure the safer steps to surgery check list is fully completed and audit monthly to achieve 100% compliance.
• Ensure the safer steps to surgery check list is used for invasive procedures.
• Ensure all of the divisions have shared governance structures which are consistent and collective.

Professor Sir Mike Richards

Chief Inspector of Hospitals