Derbyshire Healthcare NHS Foundation Trust

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first inspection for this service. This key question has been rated good.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

In the last 12 months, there were 8 serious incidents reported within the service and 3 deaths (natural causes/expected end of life) across older adult wards. Staff investigated these incidents thoroughly, in line with trust policy and national guidance, and shared learning across teams to improve patient safety and prevent recurrence.

When incidents such as falls or episodes of aggression occurred, staff responded promptly, reported them accurately, and updated care plans and risk assessments based on the outcomes. Staff demonstrated a strong understanding of the duty of candour. When things went wrong, they spoke openly with patients and families, offered clear explanations, and apologised.

Managers and clinical leads provided staff with regular feedback following investigations. Teams discussed learning during handovers and team meetings to identify areas for improvement. Staff acted on feedback and learned lessons from adverse events. For example, one patient sustained a serious injury following a fall. The provider's investigation identified a delay in the referral to physiotherapy, which may have contributed to the incident. As a result, staff implemented measures to improve the timeliness of referrals and increased physiotherapy presence on the ward.

Patients felt well-supported during the referral and admission process. They had information about what to expect from care and treatment available to them in a variety of formats.

Staff and leaders explained that the service had robust systems in place to ensure safe admissions and discharge planning. They reviewed referral documents carefully, including clinical history, risk assessments, and care plans. Staff said this process helped ensure they could safely meet each patient’s needs. Leaders highlighted the importance of early planning and communication across teams. We attended a number of meetings, including multidisciplinary team meeting (MDT), staff team meeting and handovers, where staff discussed information about continuity of patient’s care and supporting their transition in a professional and collaborative way. Discharge planning involved close coordination between services to ensure safe and supported transitions. Where delays occurred, they were clearly justified and reflected the need to secure appropriate care and support. Staff made every effort to avoid unnecessary delays and remained focused on achieving timely discharges wherever possible.

Leader held admission meetings and handovers to prepare staff for each new patient, ensuring a smooth and safe transition into care. The service followed a structured process where staff completed the checklist on the day of admission, reviewed it at 72 hours, and followed up promptly on any missing information to support safe and timely care planning.

Patients felt safe and were supported to understand how to raise concerns if they felt unsafe or were worried about others.

Staff demonstrated a good understanding of safeguarding and knew how to identify and respond to concerns. They took appropriate and timely actions to protect patients from abuse, neglect, or discrimination and worked collaboratively with external agencies where needed. Staff discussed safeguarding incidents in MDT and staff meetings. Staff also understood and applied the Deprivation of Liberty Safeguards (DoLS) appropriately, ensuring they were only used when in the patient’s best interests. Staff explained patient’s rights, including their rights under the Mental Health Act, Mental Capacity Act 2005 and the Equality Act 2010. Leaders ensured staff had the knowledge, support and confidence to act swiftly and appropriately.

The service had effective safeguarding systems, policies and practices in place that upheld patients' human rights and promoted a culture of safety. We reviewed safeguarding incidents log for period of time December 2024 to February 2025 and found that concerns were escalated without delay.

We reviewed 12 risk management plans , 2 incidents of restraint and 1 incident of when RT was used. It was evident that staff understood patients’ individual risks and ensured that they intervened to support patients when their risk increased.

Risk assessments were person-centred and mostly reviewed in line with trust policy. The service took a balanced, proportionate approach to risk, adjusting wellbeing checks and observations based on patients' needs. While patients and staff confirmed that observations were in place, they were not always recorded. The trust was aware of this issue and explained that the IT system they used did not always allow staff to record observations in a timely manner due to internet access issues. The trust was working on resolving this. The lack of timely recording could affect the ability to monitor patient progress and respond to changes in behaviour, potentially compromising the effectiveness of care planning and overall service delivery.

Staff managed patients' needs, emotions, or distress positively, protecting their rights and dignity while understanding the causes of their distress.However, staff did not always use ABC charts — an evidence-based tool to monitor and track patient behaviour — consistently and effectively. This could have been a missed opportunity to better analyse the causes of behaviour. While we acknowledge that staff have been trained in positive and safe approaches, and other tools were used on the ward to manage distressed behaviour, the inconsistent use of ABC charts limited the ability to track patterns and inform responsive care

Staff involved patients and, where appropriate, their relatives in risk assessments, with evidence of participation in multidisciplinary team reviews Staff helped patients understand their risks and how to manage then by adapting communication methods for those with language or other difficulties.

Restraint was used only as a last resort, in line with best practice, and care plans reflected any restrictions. Staff considered equality and human rights legislation when imposing restrictions. When rapid tranquilisation was used, it was also conducted and recorded in line with best practice.

Patients and staff felt the environment was safe. The service maintained well-equipped and suitable environments that supported the delivery of safe care. Equipment was well-maintained, stored securely, and used appropriately for its intended purpose.

We observed that staff conducted regular risk assessments of the care environment, ensuring potential hazards were identified and mitigated. Any ligature risks were assessed, and appropriate risk assessments were in place to manage and reduce these risks effectively. During our site visit, we noted one hazardous item that was left accessible to patients of Cubley Court. Following our feedback, it was promptly removed and replaced with a safer alternative.

Staff had easy access to alarms, and patients in relevant areas had access to nurse call systems to ensure they could request assistance when needed.

Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs, which staff checked regularly to ensure preparedness for any emergency situations.

Facilities, equipment, and technology were well-maintained and consistently supported staff to deliver safe and effective care. The service had effective arrangements in place to monitor the safety and upkeep of the premises. Equipment used to deliver care and treatment was suitable for its intended purpose, stored securely, and used properly.

On Bluebell Ward, the service had implemented Oxevision, a patient monitoring system that uses optical sensors to monitor vital signs and activity without physical contact. This technology enhanced patient safety by allowing staff to monitor breathing, movement, and sleep patterns in real time, supporting more effective observation, especially at night or during periods of increased risk.

Leaders and staff considered how environments could keep people safe from psychological harm as well as physical harm, including attention to sexual safety and sensory needs.

Patients felt well supported, with staff consistently present and available. Familiar staff delivered care, and patients were able to have regular one-to-one time with their named nurse and occupational therapist. This helped maintain therapeutic relationships and supported continuity of care.

Staff were present in communal areas at all times. There was adequate medical cover during the day and night, with doctors available to respond quickly in emergencies.

Leaders regularly reviewed staffing levels and adjusted them according to patient needs and case mix. We saw evidence of how staff levels were increased when patients’ needs escalated

We reviewed vacancies, staff turnover and sickness absence levels in the past 12 months and found no concerns. Sickness absence has significantly reduced on Tissington Ward. Staffing rotas confirmed the required numbers and skill mix were met on all shifts, with any gaps covered appropriately.

Agency and bank staff were only used as a last resort to maintain safe staffing levels, and their use was minimal. When used, agency staff received appropriate induction and were familiar with the ward environment.

Recruitment processes were robust and followed safe practices to ensure that all staff, including agency staff, were suitably qualified, experienced, and competent. Disciplinary and capability processes were fair, regularly reviewed, and free from bias related to protected characteristics

Staff felt supported through regular supervision and appraisal. They had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service. Staff demonstrated confidence and competence in delivering care. Opportunities for learning and development were available at all levels, and poor performance was managed appropriately.

Patients expressed confidence in the infection prevention and control measures in place and were assured that staff were taking necessary precautions to protect them from the risk of infection.

Staff adhered to infection prevention and control principles and consistently followed handwashing protocols, used personal protective equipment (PPE) appropriately, and cleaned equipment according to established procedures.

We observed that all ward areas were clean and well-maintained. Cleaning records were up to date and showed that areas were cleaned regularly, ensuring the environment was hygienic and safe. Staff were observed following appropriate handwashing and infection control procedures, with a clear understanding of their roles in maintaining a clean environment. We saw how contingency plan was used when there was a temporary issue with hot water supply in the toilets at one of the buildings and hand sanitizing stations were dotted around the ward to protect everyone from the risk of infection.

The service had clear processes in place for assessing and managing infection risks. The infection prevention and control procedures aligned with current national guidance. Cleaning and infection control audits were conducted regularly, and any concerns were promptly addressed. Information about infection risks was shared appropriately with external agencies, staff, patients, and visitors. There were clear roles and responsibilities for infection prevention and control, and staff received ongoing training to stay updated with best practices.

Patients were supported to be involved in decisions about their medicines where possible. For those who had capacity, staff ensured they understood what their medicines were for and included them in any changes to their treatment. When patients were unable to fully understand or participate—due to dementia or other cognitive conditions—staff followed best-interest decision-making processes in line with the Mental Capacity Act 2005 and Mental Health Act. Care plans reflected each person's level of understanding and documented whether and how they were involved in managing their medicines.

Staff followed safe and effective practices in all areas of medicines management, including transport, storage, dispensing, administration, reconciliation, recording, and disposal. They worked within national guidance and professional standards and described how they involved patients in discussions about treatment where possible. When covert medication was necessary, the correct legal processes were followed, including capacity assessments, best-interest meetings, and regular reviews. Staff reviewed the effects of medicines on patients’ physical health, particularly in those prescribed high-dose antipsychotics, in line with NICE guidance.

We observed staff administering medicines safely, explaining their use clearly when appropriate, and supporting patients respectfully. Medicines were stored securely, including controlled drugs, which were managed under the required legal safeguards. Fridge and room temperatures were checked daily, and all medications were within date. Expired or unused medicines were disposed of safely. Staff ensured medicines were not used to control behaviour inappropriately.

The service had robust systems in place for medicines management that reflected current best practice. Prescribing followed national guidance, and the service ensured continuity of care during transitions between settings through effective medicines reconciliation and clear documentation. Controlled drugs were managed safely with appropriate oversight. The service conducted regular audits, acted on any findings, and maintained a learning culture through incident reporting and review. Staff had received training and competency assessments to support the safe, effective, and person-centred use of medicines.