Derby

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first inspection for this service. At this inspection the rating is good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People had their needs assessed in a detailed and person‑centred way. Assessments captured people’s health conditions, disabilities, communication needs, routines and risks. They reflected the daily realities of people’s lives. Staff considered people’s wishes, preferences and cultural needs as part of the assessment process. Where people required community‑based support, assessments explained clearly how the environment, sensory needs and predictability affected their engagement.

The provider planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Care plans set out clear strategies to support complex conditions such as diabetes, dementia, pressure‑care needs, fluctuating mobility, mental health conditions and learning disabilities. Staff used approaches aligned with positive behaviour support, least‑restrictive practice and trauma‑informed care. Care plans linked conditions to their day‑to‑day impact, explaining why certain strategies were required, such as supervision in the community or structured routines to reduce distress. Health risks, including nutrition, skin integrity, continence and medication‑related risks, were monitored appropriately with clear escalation pathways. The involvement of community nurses, safeguarding teams and mental health professionals demonstrated that care was evidence‑based and tailored to individual need.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Care plans showed regular involvement from community nurses, social workers, mental health practitioners, advocates and local authority teams. Staff understood their roles and responsibilities, and people benefited from consistent communication between services. For those with complex health needs, staff worked closely with external professionals to monitor symptoms, manage treatment plans and respond to deterioration. Professionals provided updates, and decisions were shared appropriately to ensure consistency. Staff feedback highlighted good teamwork and a supportive culture where colleagues “work together as a team” and solve problems collectively. This contributed to coordinated, joined‑up care.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

Care plans included detailed monitoring of nutrition, hydration, mobility, continence and skin integrity. Staff encouraged people to eat regular meals, stay hydrated and follow routines that supported emotional stability. People were supported to remain active in the community when safe to do so, including going to the library, accessing day services, and maintaining meaningful routines. Staff used gentle encouragement without pressure, respecting people’s choices while monitoring for signs of decline. People with diabetes had diet and fluid charts in place, and staff monitored for symptoms that required escalation. These approaches helped people maintain healthier lifestyles in ways that were achievable and person‑centred.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of people themselves.

Staff monitored people’s progress and outcomes through day‑to‑day records, community nursing input, and regular updates from external professionals. Care plans clearly documented changes in presentation, declines in health, or improvements in skills and confidence. Examples included people gaining independence in daily tasks, becoming more confident in communication, reducing reliance on translation support, or maintaining stable nutrition and skin health through monitoring. Relatives provided positive feedback about people’s progress, and staff described pride in supporting individuals to achieve their goals. Although governance systems required improvement overall, monitoring at individual level was strong, and outcomes were consistently tracked and reflected in care planning.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

While staff showed good understanding of people’s rights, and care plans often described how information was simplified or repeated to support decision‑making, decision‑specific capacity assessments were not always completed or clearly recorded. Some care plans did not explain whether decisions had been assessed individually or how capacity was determined for situations such as refusals of care, managing medicines or safeguarding concerns. Although staff worked respectfully and involved people in daily decisions, the lack of clear MCA documentation meant it was not always evident how decisions had been reached or whether best‑interest processes were followed where required. We raised this with the provider, who acknowledged this needed strengthening and took immediate action to address this.