You are here

Provider: Derbyshire Healthcare NHS Foundation Trust Requires improvement

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 28 September 2018

Our rating of the trust stayed the same. We rated it as requires improvement because:

  • We rated  safe, effective, responsive and well-led  overall as requires improvement and caring as good.This includes the previous ratings of three services that we did not inspect on this occasion. We rated four of the trust's 10 core services as good and four as requires improvement, one as inadequate and one as outstanding.

  • Although the trust leadership team had a comprehensive knowledge of current priorities and challenges and acted to address them, the pace of change was slow, which we highlighted in previous inspection. This meant that we did not see enough improvement in clinical services, and a deterioration in the acute admission wards. We found a lack of leadership in some core services such as the acute admission wards and crisis service.

  • The quality committee did not have robust oversight and assurances of drug and therapeutics and medicines management in the trust. There were no clear measures for performance management of the pharmacy service or evaluation of the impact of staff shortages.

  • Staff in four clinical settings did not check the fridge temperatures for stored medication regularly. This meant that there was a risk that medicines would deteriorate and be unfit to use. We flagged up this problem at our last inspection.

  • Four core services did not have enough staff. For example there was a shortage of, speech and language therapists, psychologists. This meant that longer waiting times occurred for dysphagia assessments and psychologist assessments. There was also a shortage of nurses and psychiatrists. Besides  the care coordinators ,we found this in the previous inspection.

  • There was a lack of trained staff for the health based place of safety. Staff mandatory training, supervision and appraisals still did not meet the trust targets.

  • We found there were small groups of staff who did not feel valued and involved in strategic decision making, for example, allied health professionals and psychologists. We found this in our previous inspection.

  • Not all staff had heard of the Speak Up Guardian role. There was a perceived conflict of interest between the post holder carrying out the Speak Up Guardian role and being a human resources manager at the same time.

  • Staff in three clinical services did not check emergency bags regularly in accordance with trust policy, to make sure they were ready to use.

  • Staff in three clinical services had not completed incident forms when making safeguarding referrals in accordance with trust policy. This meant they would not have accurate data.

  • Some staff did not implement the smoking policy as they did not wholly agree with the non smoking policy directives, this meant smoking occurred within buildings and within hospital grounds posing a fire risk.

  • The quality of care plans, physical health assessments and physical health care plans undertaken by staff was still not consistent across clinical services. This meant staff would not have all the information required about a patient to provide care.

  • We continued to find that not all patients were involved in their care plans or given copies of their care plans. Not all patients had crisis plans in place. There was variability in the use of advance decisions across core services. Patients make advance decisions to indicate their preferred treatment in particular situations.

  • The ward environments did not support safe care. Acute admission wards had blind spots along their bedroom corridors and lacked parabolic mirrors, and staff were not always present in these areas.  The cleaning trolleys used on the wards at Hartington Unit held hazardous cleaning materials but had broken doors that did not lock. The health based place of safety had ligature points ( these are places were a ligature could be tied to self harm).

  • Slow IT systems impacted on the quality of care, for example staff found the log in and log out process for recording 15-minute observations hindered the recording of real time observations.
  • The trust did not have up to date service level agreements with one local acute trust to support Mental Health Act functions and psychiatric liaison services.

However:

  • The trust board had the range of skills, knowledge and experience to perform its role. Significant improvement had occurred in the stability of the trust board and board development since our earlier inspection. The trust chief executive continued to give good systemic leadership in the Sustainable Transformation Partnership and the mental health workstream.

  • There was improvement in the extent most staff felt respected, supported, and valued in the trust since our previous inspection. The trust recognised staffing challenges and had a robust recruitment strategy using a range of initiatives.

  • Since our previous inspection the trust had made improvements in the human resources department, in relationships with trade unions and in its approach to equality and diversity.

  • Since the previous inspection the trust had improved its governance structures to support the delivery of its strategy. Non-executive and executive directors were now clear about their areas of responsibility.

  • There was improvement in the relationship between the trust board and council of governors'. Improvements in the composition, accountability, functioning and training of the governors’ council had occurred since our previous inspection. The governors held the non executives to account.

  • The wards and clinical bases that we visited were clean.

  • There were good systems in place to support staff, patients, and carers when serious incidents occurred.

  • There was good management of complaints and there was an increase in compliments.

  • Patients had safety plans and recovery hubs provided patients with a range of activities. Care and treatment followed the National Institute Health and Care Excellence (NICE) guidance. Information was available to patients on a range of issues. .

  • Patients and carers said staff were compassionate, caring and kind. Staff listened and treated patients with dignity and respect.  Staff knew their patients and patents gave positive feedback on the quality of care.
  • Staff had good knowledge of the Mental Health Act. Improvements had occurred in relation to the Mental Capacity Act and recording of capacity and consent.

  • Good multi agency working occurred and staff said there was good team working. This resulted in good discharge planning.

Inspection areas

Safe

Requires improvement

Updated 28 September 2018

Our rating of safe stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as requires improvement because:

  • Four clinical services did not have enough staff. These were older peoples’ wards, crisis services, acute admissions, and community learning disability service. This led to increased waiting times for speech and language therapists and psychologists. In acute admission wards it was difficult to keep safe staffing levels all of the time, resulting in delays in activities, leave and medication administration.
  • Staff in three clinical services did not check emergency bags regularly in accordance with trust policy to make sure the bags were ready for use.
  • Staff in four clinical settings did not check the stored medication fridge temperatures regularly. This meant that there was a risk that medicines would deteriorate and be unfit to use.
  • In three core services, staff did not complete incident forms when making safeguarding referrals in accordance with trust policy which effected the quality of information.
  • Staff mandatory training, supervision and appraisals did not consistently meet the trusts targets
  • Some staff did not implement the no smoking policy and did not wholly agree with the non smoking policy directives and smoking occurred within buildings and on grounds.
  • The ward environments did not support safe care. Acute admission wards had blind spots along their bedroom corridors and lacked parabolic mirrors, and staff were not always present in these areas. Rooms in the acute admission wards did not have nurse call alarm systems. The cleaning trolleys used on the wards at Hartington Unit held hazardous cleaning materials but had broken doors that did not lock. The health based place of safety had ligature points (these are places a ligature could be tied to self harm).

  • A number of wards had dormitory-style bedrooms. This meant that some patients had to share a bedroom; which compromised their privacy and dignity.

  • Community teams did not always have sufficient space to see patients or work.

However:

  • The wards and clinical bases that we visited were clean.

  • Patients had safety plans in place to support the management of risks.

  • There were good systems in place to support staff, patients, and carers when serious incidents occurred.

Effective

Requires improvement

Updated 28 September 2018

Our rating of effective stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as requires improvement because:

  • Staff poorly recorded the results of; screening tools for people on anti-psychotic medication, physical health questionnaires and observations. This meant that physical care plans were not consistently done or of good quality.
  • The quality of care plans and assessments written by staff were not consistent
  • Patients lacked access to speech and language therapists resulting in long dysphagia waiting lists.
  • Patients lacked access to psychologists and psychological assessments resulting in longer waiting lists.
  • Staff lacked training to support them in working in the health based place of safety.
  • Staff reported computers were slow and hindered the recording of observations in real time.

However:

  • Staff had good knowledge of the Mental Health Act. Improvements had occurred in relation to the Mental Capacity Act and recording of capacity and consent.
  • Good multi agency working occurred and staff said there was good team working. This helped patients during discharge planning.
  • Staff used National Institute Health and Care Excellence (NICE) guidance, for example in relation to violence and aggression and care of older people. This meant evidence base care was given.

Caring

Good

Updated 28 September 2018

Our rating of caring stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as good because:

  • Patients and carers said staff were compassionate, caring and kind. They listened and treated patients with dignity and respect.
  • There was good carers involvement and carers assessment in place.
  • Staff knew their patients and patents gave positive feedback on the quality of care.

However:

  • We continued to find that not all patients were involved in their care plans or given copies of their care plans. Not all patients had crisis plans.
  • There was variability in the use of advance decisions. These are plans that patients make to enable staff to carry out their wishes when situations arise.

Responsive

Requires improvement

Updated 28 September 2018

Our rating of responsive stayed the same. We took into account the previous ratings of services not inspected this time. We rated it as requires improvement because:

  • Patients had long waits for care coordinators, psychologists and speech and language therapists. We found this at the last inspection
  • Staff did not have enough space in all community bases to see patients.
  • A number of wards had dormitory style provision of bedrooms. This meant that some patients had to share a bedroom; which compromised their privacy and dignity.

However:

  • The trust had a good complaints management system. Patient compliments had increased.
  • We found good discharge planning occurred in clinical services, supported by good multidisciplinary and multi agency working.
  • Recovery hubs provided a range of activities for patients who were able to leave the ward.
  • Information was available to patients on a range of issues to support their understanding of medication, support available, rights and conditions.

Well-led

Requires improvement

Updated 28 September 2018

Our rating of well-led improved. We took into account the previous ratings of services not inspected this time. We rated it as requires improvement because:

  • Although the trust leadership team had a comprehensive knowledge of current priorities and challenges and acted to address them, the pace of change was slow, which we highlighted in previous inspection. This meant that we did not see enough improvement in clinical services, and a deterioration in the acute admission wards. We found a lack of leadership in some core services such as the acute admission wards and crisis service.

  • The quality committee did not have robust oversight and assurances of drug and therapeutics and medicines management in the trust. There were no clear measures for performance management of the pharmacy service or evaluation of the impact of staff shortages.

  • We found there were small groups of staff who did not feel valued and involved in strategic decision making, for example, allied health professionals and psychologists.
  • Staff perceived a conflict of interest between the post holder carrying out the Speak Up Guardian role and being a human resources manager at the same time.
  • Staff mandatory training, supervision and appraisals did not meet the trust targets.
  • Staff team meetings did not have a standardised approach to make sure all governance issues were covered..
  • Access to electronic patient records was slow and inconsistent storage of information in the same place within the record, made it difficult to find. Recording of observations in real time was onerous.
  • The trust did not have up to date service level agreements with local acute trusts to support mental health act functions and psychiatric liaison team services.

However:

  • Staff understood the trust vision and values
  • The culture and staff morale had improved since our last inspection.
  • There was visibility of senior leadership
  • Staff felt able to raise concerns and knew about the whistleblowing, bullying and harassment policies.
  • Staff received awards from the trust for good work undertaken.
Checks on specific services

Long stay or rehabilitation mental health wards for working age adults

Good

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.

Acute wards for adults of working age and psychiatric intensive care units

Inadequate

Updated 4 June 2019

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

  • Overall, the service had not made enough improvement in the nine months since the last full inspection. There were some issues that the trust had resolved. However, there were ongoing issues and issues where the trust had started to make improvements but needed to improve further. There were lapses of governance on wards and a number of these related to the safety of staff and patients.

  • Staff did not always manage risks well. This included ligature risks and patients’ access to razors. Patients smoked in and around the hospitals. This presented a fire risk. Observation practices had improved but staff did not always carry these out in line with good practice; staff did not carry out intermittent observations at varied times which could increase risk for patients who self-harmed.
  • The trust had increased staff numbers since our last inspections, but there were still staffing issues and overall the vacancy rate was 14%. The trust had over recruited unqualified staff as they had a shortage of qualified nursing staff. Having less qualified staff sometimes affected the frequency of patients’ one to one sessions and meant there was not always a qualified nurse out in communal areas of the wards.
  • Staff did not always create detailed care plans that described all of the patients’ needs and these were not always recovery focused and personalised. We saw that staff did not always record when they had offered patients a care plan. We reviewed 31 records and saw that on seven occasions staff had not recorded that they had offered patients a copy of their plan.
  • Training compliance for mandatory physical intervention training, life support training and level three safeguarding training was low. This meant that not all staff that should have been were skilled to restrain patients and use life support skills.
  • There were dormitories on all the wards. However, the trust had discussed dormitory plans with commissioners and there were plans to take a staged approach to this to replace these in time in line with national guidance.
  • There were blanket restrictions in place across the wards that were not individually risk assessed. These varied throughout the wards but reduced the liberty of patients who did not always present with specific risks that the restrictions were in place to reduce.
  • Staff did not always ensure the privacy and dignity of patients. We observed staff unlocking doors to patient bathrooms, without knocking when they were in use. The ward environment was not always suitably designed to protect patients’ privacy and dignity.
  • There were some omissions where staff had not always signed to say patients had received their medication.
  • The main treatment model of care on the wards was psychiatry, occupational therapy and nursing. The trust had made some improvements to develop access to psychology. However, only a limited number of patients were able to access psychological interventions.
  • Staff did not always respond to physical health needs or make records where needed. We saw two occasions when staff had not acted when a patient’s blood pressure was outside of the normal range. Staff had failed to complete an insulin care plan and record their observations and reviews of one episode of seclusion.

However:

  • The trust had started on a journey of improvement. There was evidence of some improvements following our recommendations from earlier inspections.There was improved oversight and assurance by senior managers and increased stability in ward leadership. 
  • Staff had reduced the use of restrictive interventions since our inspection in May 2018. The trust had a programme in place to review and reduce restrictive interventions.
  • Staff reviewed the effects of medication on patient’s physical health as recommended by the National Institute for Health and Care Excellence. Staff completed blood tests for patients prescribed medication that needed additional monitoring and monitored patients after they had administered rapid tranquilisation.
  • Ward managers were skilled and experienced. There was increased ward leadership stability throughout the service. Ward managers demonstrated how they supported their teams and staff felt well supported by their immediate managers.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff reported incidents and they shared learning after incidents took place. Staff supported patients to make complaints and responded to them appropriately.

  • We observed staff were kind and caring in their interactions with patients and patients were happy with the way staff treated them.  Doctors discussed treatment options with patients at ward round meetings and staff encouraged patients to engage with advocacy services.
  • The trust had a low number of delayed discharges. The average over the 12 months prior to our inspection was 1%. The trust had a robust process to monitor and review discharge pathways with the support of professionals both internal and external to the trust to improve outcomes for patients.
  • Managers and staff involved patients and carers in service developments. The trust had developed a forum for staff, carers and patients to improve coproduction. The trust had a centre for research and development and there was evidence of quality improvement projects in place.

Forensic inpatient or secure wards

Good

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.

Community mental health services with learning disabilities or autism

Requires improvement

Updated 28 September 2018

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

  • Staff reported low morale due to shortage of staff and impact on workloads. Staffing shortages were significantly impacting the average waiting time for patients to access speech and language therapy.
  • Patient records were not always complete and actions from audits had not been completed. Patient assessments, risk assessments and care plans and prescription charts were all areas where we found out of date or incomplete documents. Staff could not always locate documentation in electronic records or had completed documents inconsistently across the service.
  • Care plans did not all reflect the views of patients and carers and staff had not always recorded whether they had been offered a copy.
  • There was no consistent application of use of outcome measures with patients. Staff did not routinely monitor the effectiveness of care and treatment. We requested evidence of specific outcome measures used with patients and the service was unable to provide a consistent response or demonstrate how outcome measures were recorded or used.

However:

  • Staff were skilled and knowledgeable in working with people with learning disabilities. Staff had completed mandatory training and were up to date with supervision and appraisal.
  • Staff recognised and responded to safeguarding concerns without delay. Staff reviewed and made changes to the service following lessons learnt through the Learning Disabilities Mortality Review.
  • Staff knew their patients well and understood individual needs. They treated patients with kindness and dignity and feedback from carers and patients was overwhelmingly positive. Observations of staff demonstrated they were respectful towards their patients and responsive to their needs.
  • Staff worked well with internal and external organisations to ensure good handover of patient care. Multi-team working between the assessment and treatment support service and the community learning disabilities team was good.
  • Information given to patients was presented in accessible and learning disability friendly formats to ensure patients understood their treatment. Patients could access advocacy and were supported to do so.
  • The trust had a vision for what it wanted to achieve for learning disability services and was going through consultation with involvement from staff, patients, and carers.

Wards for older people with mental health problems

Good

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.

Community-based mental health services for older people

Good

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.

Community-based mental health services for adults of working age

Requires improvement

Updated 28 September 2018

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

  • Waiting lists for care coordinators, clinical psychology, outpatients were long across the service and there was no plan in place to show how these would be reduced.
  • Waiting lists did not show what interventions each patient was waiting for, their level of risk and whether they were open to another part of the service.
  • Staff relied on patients and/or referrers to alert them if their mental health deteriorated while waiting.
  • Records showed not all teams checked fridge and room temperatures daily. The emergency bag in one team had not been checked for a year.
  • There was no psychiatry cover at Dale Bank View and the manager was unable to tell us what actions have been taken by the trust to improve recruitment or provide adequate cover.
  • Team managers did not use a caseload management tool, this meant managers did not have effective tools to monitor the high caseload numbers in order to support staff. 
  • Rating scales and outcome measures were not being routinely collected and analysed to improve service delivery and ensure interventions offered were effective.
  • There were not enough rooms across the teams to see patients in and some environments were cluttered and in need of repair.

Mental health crisis services and health-based places of safety

Requires improvement

Updated 28 September 2018

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

  • We rated safe and effective as requires improvement, and caring, responsive and well-led as good.
  • The environments of the health based places of safety did not ensure patients were safe at all times. Staff working in the health based places of safety did not robustly assess all patients’ risks.
  • There were not enough staff in the City and County South crisis resolution and home treatment teams to meet the needs of all patients. There was a lack of operational leadership in the City and County South crisis resolution and home treatment team.
  • The safety plan was new and there were some delays in how staff accessed this so they could clearly know patients’ risks.
  • Lone working practices were not robust enough to ensure the safety of all staff.
  • Staff did not always assess and monitor patients’ physical health needs. Staff did not assess all patients’ needs.
  • Staff did not record patients’ involvement in their care plans.

However:

  • Staff knew how to safeguard patients from abuse and harm.
  • Staff made sure patients had their prescribed medicines at the right time and stored these safely.
  • Managers supervised and appraised staff.
  • Staff had a better understanding of the Mental Capacity Act 2005 than at our previous inspection.
  • Staff were kind, caring, compassionate and respected patients and carers.
  • The crisis resolution and home treatment teams responded to individual patients’ needs and helped to prevent them being admitted to hospital.
  • All staff knew the vision and values of the trust and agreed with them. Senior managers in the trust were more visible.

Community health services for children, young people and families

Requires improvement

Updated 4 April 2017

Specialist community mental health services for children and young people

Outstanding

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.

.