Derbyshire Healthcare NHS Foundation Trust

Updated 2 November 2023

There have been significant improvements in the ethos, culture and services in the trust since the last inspection. Staff told us the trust was more clinically led and they were more empowered.

Leaders had the skills, knowledge and experience to perform their roles, had a good understanding of the services they managed, and were visible in the service and approachable for patients and staff. Leaders had embedded methods of communication and engagement with staff since the last inspection.

All staff we spoke with felt positive and proud about working for the trust. Throughout the inspection staff described how teams worked well together. Staff told us the trust had come a long way to improve culture and that they were listened to and given space to make changes.

Staff knew and understood the trust vision and values and how they were applied in the work of their team.

There was a good relationship between the trust board and council of governors. The council of governors held the non-executives to account.

Governance processes operated effectively at trust and operational, performance and risk were managed well.

Staff collected and analysed data about outcomes and performance and engaged actively in local and national quality improvement activities.

There was good systemic leadership within the local Sustainable Transformation Partnership, with board and service leaders engaged actively with other local health and social care providers to ensure that an integrated health and care system was commissioned and provided to meet the needs of the local population.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. The service managed patient safety incidents well. When things went wrong, staff apologised and gave patients and their families honest information and suitable support.

Staff provided a range of care and treatment interventions suitable for patient groups and consistent with national guidance on best practice. Staff ensured that patients had good access to physical healthcare and supported patients to live healthier lives. We saw significant change in the acute admission wards.

Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Health Act Code of Practice and discharged these well. Staff supported patients to make decisions on their care for themselves. They understood the provider’s policy on the Mental Capacity Act 2005 and assessed and recorded capacity clearly for patients who might have impaired mental capacity.

Staff treated patients with compassion and kindness. They understood the individual needs of patients and supported patients to understand and manage their care, treatment or condition. There was good engagement with patients and carers in the transformational plans for clinical services.

Service were easy to access. Referral criteria did not exclude patients who would have benefitted from care. Where waiting times were still a concern, people could access the service when they needed it and received the right care in a timely way. Staff followed up patients who missed appointments. Discharge was rarely delayed for other than clinical reasons.

Staff well being was a priority in the trust. Staff recognition for good work schemes were in place.

The trust was implementing a quality improvement approach, participated in audits, research and development. Lessons learnt from incidents, deaths, audits, service transformation were shared with staff.

However:

There was a long list of mandatory courses, of which 39 failed to score above 75%. Of concerns were the poor compliance figures for;- safeguarding adults and children level 3, adult basic life support, basic life support, first aid at work, suicide awareness and response, medicines management, dementia awareness, falls prevention.

Ward staff did not always store and dispose of illicit substances in line with policy. There was no accessible up to date British National Formulary for staff on any of the wards.

Health-based places of safety staff did not assess and record the outcome of risk assessments clear and consistently.

Not all teams had adequate leadership to provide staff with managerial supervision, clinical guidance and support with incidents.

Updated 6 March 2020

Our rating of this service improved. We rated it as outstanding because:

• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• When we reviewed the cleaning audit for the physiotherapy team, we found it difficult to assess whether the cleaning had been completed or whether the premises had not been used.
• Staff were unable to give examples of feedback including lessons learnt from incidents external to the service.
• The service had a text messaging service that children and young people could access for advice. This was manned between working hours and staff were unsure of the protocol should a young person contact it in crisis out of hours
• The service did not have standard agendas for team meetings and as such could not evidence where information such as learning from incidents and complaints had occurred.

Updated 29 September 2016

We rated CAMHS as outstanding because;

• The teams delivered a good range of evidence based care and treatment and there was high use of routine outcome measures.
• Urgent referrals and deterioration in mental health were responded to quickly and the development of the rapid intervention, support and empowerment team meant that staff were accessible seven days a week, 08.00 to 23.00.
• Routine referrals were seen within an average time of six weeks and urgent referrals were seen within 24 hours. The target for routine referrals was 18 weeks.
• Risk assessments were completed and updated regularly and care plans were up to date and patient focused.
• Feedback from young people and families was very positive and the team were described as going the extra mile.
• The inspection team observed staff showing warmth and being respectful to young people and their families.
• There was a high level of participation by young people and parents throughout all levels of the service.

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Updated 6 March 2020

Our rating of this service improved. We rated it as good because:

• The service provided safe care. Clinical premises where patients were seen were safe and clean. The number of patients on the caseload of the teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff managed waiting lists well to ensure that patients who required urgent care were seen promptly. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood the principles underpinning capacity, competence and consent and managed and recorded decisions relating to these well.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The service was easy to access, and staff and managers managed waiting lists and caseloads well. The criteria for referral to the service did not exclude patients who would have benefitted from care. Staff assessed and initiated care for patients who required urgent care promptly and those who did not require urgent care did not wait too long to receive help.
• The service was well led, and the governance processes ensured that procedures relating to the work of the service ran smoothly.

Updated 28 September 2018

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

• The service had enough staff to provide care and treatment. Staff had access to a range of training opportunities that included courses about caring for patients with dementia. Managers ensured staff had regular access to supervision practices and appraisals.
• Teams were multi-disciplinary and met regularly to review patient care and treatment. Staff reported effective working relationships with other teams within the trust and external to the trust. Staff worked with external organisations and supported carers to assist patients to remain in their own homes
• Staff provided patients with advice, help and support. These were delivered professionally with warmth and respect. Staff used an electronic patient record to document the care and treatment provided to patients. Staff involved patients in their care and, where appropriate, involved and supported families and carers.
• The trust provided a range of community services to meet the mental health needs of older adults. Services were accessible for disabled people and those with communication needs. The trust had processes in place that enabled everyone who had contact with services to provide feedback on their experience.
• The trust had a vision for what it wanted to achieve. The trust demonstrated how it was working to meet the recommendations of previous inspections and address areas of service delivery where challenges had been identified.

However:

• Staff did not always follow policies and procedures to ensure that medicines and emergency equipment remained safe for use. This included failing to transport medicine in the community safely.
• Staff practices around assessing patients’ physical health and care planning were not consistent across the teams visited.
• All teams continued to have waiting times to access psychology services.

Updated 6 March 2020

Our rating of this service improved. We rated it as good because:

• Clinical premises where patients were seen were safe and the physical environment of the health-based places of safety met the requirements of the Mental Health Act Code of Practice. The number of patients on the caseload of the mental health crisis teams, and of individual members of staff, was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk and followed good practice with respect to safeguarding.
• Staff working for the mental health crisis teams developed holistic care plans informed by a comprehensive assessment and in collaboration with families and carers. They provided a range of treatments that were informed by best-practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The mental health crisis teams included or had access to the full range of specialists required to meet the needs of the patients. Managers ensured that these staff received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• The mental health crisis service and the health-based places of safety were easy to access. Staff assessed patients promptly. Those who required urgent care were taken onto the caseload of the crisis teams immediately. Staff and managers managed the caseloads of the mental health crisis teams well. The services did not exclude patients who would have benefitted from care.
• The service was well led and the governance processes ensured that the service’s procedures ran smoothly.

However:

• Within health-based places of safety, staff practices to risk assess and record the outcomes of risk assessments were not clear and staff did not always check emergency equipment to the frequency directed by trust guidance.
• Records were not always available to guide staff about what to clean, when to clean it and where to record when cleaning had been completed.
• Of the mandatory training courses listed by the trust, 39 failed to achieve the trust’s target completion rate.
• Crisis resolution and home treatment staff practices to assess and record the severity of symptoms and outcomes with people was not consistent across all the services.
• Records did not demonstrate that staff routinely shared copies of care plans with people using the service.
• Staff did not routinely offer people using the service with verbal or written information about raising a concern or making a complaint.
• Audit tools did not prompt staff to measure all areas of the service previously identified as requiring improvement.

Updated 28 September 2018

Our rating of this service improved. We rated safe, effective, caring, responsive and well led as good because:

• The ward manager had taken action to make sure that requirement notices made at our previous inspection had been met to improve the service. These requirement notices were about the safety of the environment, staff understanding of the Mental Capacity Act 2005, staff training and staff assessment of patient risk.
• Staff consistently assessed patients for their risk of violence through completion of risk assessments.
• The trust made sure that staff had the training they needed to ensure patients’ safety and wellbeing.
• The trust had completed the refurbishment of the unit which included the seclusion suite and reduced environmental and ligature risks to patients.
• The trust had bought new furniture for the unit which was clean and in good condition.
• Patients were involved in their care plans and this included ongoing monitoring of their physical health needs.
• Staff managed patient's medicines well and where appropriate staff supported patients to manage their own medicines.
• Staff had formally assessed and recorded patients’ capacity to consent to care and treatment.
• Staff offered patients the opportunity to record their preferences in an advance directive (a statement written with the patient about their decision to refuse treatment at a time they may not have the mental capacity to make this decision).
• Staff offered patients scheduled activities in the evenings and at weekends.
• Staff displayed information relating to the complaints procedure, patient advice and liaison service and the Care Quality Commission on the wards.

Updated 29 September 2016

We rated long stay/rehabilitation wards for working age adults as good because:

• Staff completed risk assessments on admission and updated them regularly. Potential risks to patients were discussed ward handovers. Staff had received safeguarding training and understood when to make a referral. Medicines management was of a high standard and used a system that considered patient safety while also promoting independence

• Patients said that they staff were open and honest with them. Staff treated them with dignity and respect and there were high levels of staff engaging with patients. Carers felt fully involved and appreciated being able to attend carers groups.

• Patients had access to lounges, outside space and were encouraged to shop for their own food and prepare this. Staff offered support and guidance around healthy eating if required. The wards and the rehabilitation occupational therapy team provided access to a wide range of community based activities, which promoted recovery and independence.

• Staff showed a high level of commitment to the patients. They felt well supported by managers and were engaged in making improvements to the services by giving feedback. This support allowed them to feel confident in being open and transparent with patients when incidents.

However:

• Staff were not always clear about the use of the Mental Capacity Act and Deprivation of Liberty Safeguards, or when to use this legislation.

• Patients at Cherry Tree Close felt the five-week rotation of multidisciplinary team meetings meant they had to wait to discuss their treatment. They felt they would like to have appointments that are more regular.

Updated 28 September 2018

Our rating of this service improved. We rated it as good because:

• Lessons learned were shared and staff were supported following serious incidents. Staff felt able to report incidents.
• Staff were observed to be caring and respectful of patients’ privacy and dignity.
• A number of measures had been implemented to try and reduce short staffing on the wards, although they remained regularly short staffed.
• Staff undertook risk assessments to identify patients who might be at risk of falling. They also ensured that patients had access to good physical healthcare.
• Staff provided appropriate support to patients to ensure that they ate sufficient food and drank enough to keep properly hydrated.
• Ward staff worked closely with the community teams that would provide care for the patients after they were discharged. They also planned discharge well to ensure that services met patients' care needs when they left the ward.

However:

• We found several omissions from patient observations and a need for increased observations were not always recognised and responded to.
• Staff reported difficulties using the electronic record system for recording patient observations.

Updated 6 March 2020

Our rating of this service improved. We rated it as requires improvement because:

• There were still ongoing staffing challenges and a high number of vacancies, but we did see evidence the trust had improved the way they managed these. 
• Ward staff did not always store and dispose of illicit substances in line with policy. We found staff did not store illicit drugs and paraphernalia in tamper proof bags in medicines cupboards and in one example these had been there for several months. This was not in line with policy. 
• We saw that there were several blanket restrictions for patients in seclusion. Staff did not follow the Mental Health Act Code of Practice in their seclusion record keeping. Staff did not always attach consent to treatment forms to medicine cards. This meant that staff did not have information indicating what patients' agreed treatments were.  
• Not all staff were compliant with their mandatory training. 
• Staff did not always provide appropriate physical healthcare to patients. We saw one record where staff had not followed a patient’s diabetes care plan and had not completed physical health observations and blood glucose tests. 
• There were still dormitories on the wards. However, the trust had a plan in place to improve and change these into individual rooms for patients. There were blind spots in the seclusion room, which meant it was not possible for staff to see patients all the time.
• The trust did not have a psychiatric intensive care unit for patients and there was not one in the local area. This meant some patients had to travel out of area for care and treatment. 

However: 

• The trust had made improvements since our last inspection and these were completed in a timely way. There were improved governance processes including increased meetings, clearer lines of communication, increased audits and visible leadership.  
• The ward environments were safe and clean. Staff assessed and managed risk well. They managed medicines safely and followed good practice with respect to safeguarding. 
• Staff developed holistic, recovery-oriented care plans informed by a comprehensive assessment. They provided a range of treatments suitable to the needs of the patients and in line with national guidance about best practice. Staff engaged in clinical audit to evaluate the quality of care they provided. 
• The ward teams had access to the full range of specialists required to meet the needs of patients on the wards. Managers ensured that these staff received training, supervision and appraisal. The ward staff worked well together as a multidisciplinary team and with those outside the ward who would have a role in providing aftercare. Discharge was rarely delayed other than for clinical reasons.  
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. 
• Staff treated patients with compassion and kindness. They actively involved patients and families and carers in care decisions.

Updated 6 March 2020

• Staff in one team did not feel respected, valued and well supported by leaders. They did not feel able to raise concerns without fear of retribution and did not always receive managerial supervision, debriefs or support. Morale in the team was low and there were high rates of staff sickness.
• The service had a large number of mandatory training courses which did not meet the compliance target of 75%.
• The service did not have a clear protocol for the use of alarms in community bases.
• The service included patients who were not ready to receive treatment on their waiting lists. This meant it was not clear how long most patients waited to receive the service.
• Managers did not always complete actions in response to incidents in a timely manner.

However:

• The service provided safe care. The number of patients on staff caseloads was not too high to prevent staff from giving each patient the time they needed. Staff assessed and managed risk well and followed good practice with respect to safeguarding.
• Staff developed detailed care plans informed by a comprehensive assessment and in collaboration with patients and carers. They provided a range of treatments that were informed by best practice guidance and suitable to the needs of the patients. Staff engaged in clinical audit to evaluate the quality of care they provided.
• The teams included or had access to the full range of specialists required to meet the needs of the patients. Most teams received training, supervision and appraisal. Staff worked well together as a multidisciplinary team and with relevant services outside the organisation.
• Staff understood and discharged their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, and understood the individual needs of patients. They actively involved patients and families and carers in care decisions.
• Staff assessed and treated patients who required urgent care promptly and those who did not require urgent care received information on when they could expect to receive it. The criteria for referral to the service did not exclude patients who would have benefitted from care.