Source · CQC inspection

Royal Derby Hospital

Provider University Hospitals of Derby and Burton NHS Foundation Trust Type NHS Healthcare Organisation Region East Midlands Last inspected 12 May 2026

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Good

Effective

Good

Caring

Good

Responsive

Good

Well-led

Good

Current CQC assessment

Single Assessment Framework

From 2024 CQC rates services through ongoing assessments rather than comprehensive inspections.

Good Assessed 12 May 2026

The service is performing well and meeting our expectations.

Date of inspection: 11 to 13 November 2025. Royal Derby Hospital is part of University Hospitals of Derby and Burton NHS Foundation Trust. Royal Derby Hospital has 1,159 beds and provides care to around one million patients from Derby and the surrounding areas every year.This was a scheduled inspection which looked at outpatient services. This was the first inspection of this service using the single assessment framework. The service was rated as good. Following our inspection the overall rating of Royal Derby Hospital has improved to good.

Ratings by service

Critical care

Good

Nov 2025

Maternity

Requires Improvement

Oct 2025

Diagnostic imaging

Good

Sep 2025

Outpatients

Good

Sep 2025

Diagnostic imaging

Good

Sep 2025

Outpatients

Good

Sep 2025

Regulatory breaches & enforcement

Current-framework "must do" equivalent

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, stated verbatim in the CQC assessment.

Urgent enforcement Overall

This was a scheduled assessment to review compliance with the urgent enforcement action we took in August 2023 University Hospitals of Derby and Burton NHS Foundation Trust provide maternity services for women in Derbyshire at Royal Derby and Queens Hospital.

· 7 Nov 2025 · CQC source

Earlier inspection findings

pre-2024 framework · 11 must-do 2 should-do

Must-do actions (11)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 11

Must do

Safe

Ensure staff have access to an evidence-based standardised risk assessment and prioritisation tool for maternity triage.

Regulation: Regulation 12(2)(a)(b)

⚠ Staff did not use an evidence-based, standardised risk assessment tool for maternity triage. Staff used a form to prioritise women accessing the pregnancy assessment unit that prompted staff to assess if immediate, medium and low risk but there was not a clear framework to support clinical decision-making. Due to the …

Must-do action 2 of 11

Must do

Safe

Ensure staff are up to date with midwifery mandatory training modules including level 3 safeguarding training and yearly obstetric emergency skills and drills training.

Regulation: Regulation 12(2)(c)

⚠ Not all staff were up to date with maternity mandatory training in key skills, including midwifery specific modules (infant feeding, perinatal mental health, substance misuse, diabetes), PrOMPT, fetal monitoring training, and safeguarding adults and children level 3 training. Compliance rates were below the trust target of 90% for various staff …

Must-do action 3 of 11

Must do

Safe

Ensure regular cleaning audits are completed.

Regulation: Regulation 12(2)(h)

⚠ Managers did not regularly complete cleaning audits. Managers did not always complete cleaning audits to ensure the cleanliness of bed frames, trollies, couches and mattresses. The May to July 2023 cleaning audit showed these audits were not completed at Royal Derby Hospital on the Birth Centre in May, June or …

Must-do action 4 of 11

Must do

Well-led

Ensure regular audits are completed to ensure patient safety. To include regular audit of escalation of modified early obstetric warningscore (MEOWS) charts, use of situation, background, assessment, recommendation (SBAR) to handover clinical information, escalation of fetal monitoring traces and timeliness of triage.

Regulation: Regulation 17(1)(2)(a)

⚠ Managers did not regularly audit completion and escalation of MEOWS charts, use of SBAR for handover, interpretation and management plans for fetal monitoring traces, and timeliness of triage phone calls. The local audit programme was not sufficient to monitor and improve performance.

Must-do action 5 of 11

Must do

Well-led

Ensure accurate data is available to monitor and review.

Regulation: Regulation 17(1)(2)(a)

⚠ Leaders didn't have access to reliable information systems to support monitoring of the service due to paper-based record keeping systems. The service had a recorded risk in relation to data and information being circulated that is incorrect on the maternity risk register since January 2022.

Must-do action 6 of 11

Must do

Well-led

Ensure effective governance and oversight of audits and action plans developed to improve performance, including analysis of key performance indicators by ethnicity and deprivation.

Regulation: Regulation 17(1)(2)(a)(b)

⚠ Leaders did not operate effective governance processes to ensure the safety of the service. Governance processes were inadequate to monitor and improve clinical outcomes. Action plans to improve clinical practice were not effective, and many processes required further embedding and quality control through audit, despite analysis of outcomes by ethnicity.

Must-do action 7 of 11

Must do

Well-led

Ensure there enough suitably qualified midwifery staff to ensure safety.

Regulation: Regulation 18(1)

⚠ The service did not always have enough maternity staff with the right qualifications, skills, training and experience to keep women and birthing people safe from avoidable harm and to provide the right care and treatment. The maternity vacancy level was 41.71 WTE.

Must-do action 8 of 11

Must do

Well-led

Ensure the midwifery on-call rota is staffed by midwives who are suitably qualified, competent, skilled and experienced.

Regulation: Regulation 18(1)

⚠ At the time of inspection, the senior midwife on-call rota was not adequately staffed to ensure the safety of the unit. Band 7 senior midwives frequently stayed on the unit working additional hours to support colleagues due to low staffing levels, raising concerns about the safety, sustainability and effectiveness of …

Must-do action 9 of 11

Must do

Well-led

Ensure staff working hours are monitored and staff have the appropriate amount of compensatory rest.

Regulation: Regulation 18(1)

⚠ At the time of inspection, the service did not have a process to monitor the number of hours worked by band 7 senior midwives on-call.

Must-do action 10 of 11

Must do

Well-led

Ensure there enough suitably qualified medical staff to ensure safety and ensure obstetric consultant staffing is in line with national recommendations for maternity units with 4000 to 5000 births a year.

Regulation: Regulation 18(1)

⚠ The service did not always have enough medical staff with the right qualifications, skills, training and experience to keep women, birthing people and babies safe from avoidable harm and to provide the right care and treatment. The labour ward had 83-hours of consultant cover, which was not in line with …

Must-do action 11 of 11

Must do

Well-led

Ensure midwifery staff receive a yearly appraisal.

Regulation: Regulation 18(2)(a)

⚠ Staff did not always receive a yearly appraisal to ensure they were competent for their roles. Data showed 52% of midwives working at Royal Derby Hospital had received a yearly appraisal as of August 2023, with compliance for midwifery staff working on the labour ward being only 36.5%.