Derbyshire Healthcare NHS Foundation Trust

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well led- This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture This is the first inspection for this service. This key question has been rated good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service demonstrated a clear shared vision and culture based on transparency, equity, equality, human rights, diversity, and inclusion. Staff understood and applied the provider’s values in their daily work. Leaders effectively communicated the vision to frontline staff, ensuring alignment with the service’s goals.

Staff had opportunities to contribute to discussions about the service strategy, especially during changes, which made them feel valued. They explained how their roles supported delivering high-quality care within available budgets.

Staff and leaders showed a strong understanding of equality, diversity, and human rights. They identified and addressed workforce inequalities and promoted inclusion, ensuring equitable care for all patients.

Leaders identified risks to the strategy and implemented action plans. They regularly reviewed progress and kept staff informed, which staff appreciated.

The provider’s strategy focused on delivering safe, effective, and compassionate care while promoting staff engagement, equality, partnership working, and financial sustainability. Staff reported that clear communication and shared goals helped them deliver better patient outcomes and foster a positive culture.

Leaders had the skills, knowledge, and experience to perform their roles effectively, with a clear hierarchy ensuring each leader understood their remit and was aware of key issues and priorities. They demonstrated a strong understanding of the services they managed, clearly explaining how teams delivered high-quality care. Leaders were visible and approachable to both patients and staff, serving as inclusive role models who embodied the organization’s values. Leadership development opportunities were available for all staff, with multiple examples of individuals progressing from lower NHS bands to the highest levels. Leaders also actively addressed any cultural issues that could impact care quality or staff wellbeing.

A Freedom to Speak Up policy and procedure was in place. Staff had access to a Freedom to Speak Up Guardian and told us they felt safe and supported to speak up when needed. Leaders promoted an open culture where concerns were listened to and acted on. Staff received training in whistleblowing and knew how to raise concerns.

Leaders reviewed Freedom to Speak Up concerns regularly. They identified common themes, tracked them by profession and department, and implemented action plans to address issues. Staff felt confident their concerns would be taken seriously and lead to change.

There was a strong and visible commitment to equality, diversity, inclusion, and human rights across the organisation. These values were central to how care was delivered and how staff were supported. Leaders took regular action to improve the culture, making sure all staff were treated fairly, with kindness, dignity, and respect. They identified and addressed any unfair treatment or differences in experience, particularly for staff with protected characteristics or from marginalised groups. Reasonable adjustments were made for disabled staff, and flexible working options were available to support staff with different needs.

Recruitment Inclusion Guardians were included in the shortlisting and interview panels for all Band 8 and above roles, helping to make recruitment fairer and more inclusive. The organisation had active LGBT+ network groups and carried out equality monitoring to make sure the workforce was diverse and reflective of the people using the service. Staff told us they felt heard, valued, and confident that raising issues would lead to real change. There was also ongoing review of policies and procedures to reduce bias and tackle structural discrimination.

Leaders promoted a culture of inclusion and took steps to prevent and address bullying and harassment. They also worked to make sure that all staff, including those who may be less heard, were involved in shaping services. Equality, diversity, and inclusion were clearly embedded in the organisation’s values and priorities

The inspected wards established clear governance and management systems that supported safe, high-quality, and sustainable care. Staff understood their roles and were held accountable by managers.

Team meetings consistently covered key topics such as incidents, complaints, and safeguarding. Staff acted on recommendations from reviews and audits, demonstrating ongoing learning.

Staff collaborated well internally and externally to meet patient needs. The risk register was current and accessible, with staff escalating concerns appropriately. Emergency plans were in place, for example for adverse weather and outbreaks.

IT systems were mostly reliable and supported clinical work, while information governance protected patient confidentiality. However, there were ongoing issues with the internet connection that made it more difficult for staff to record care in a timely manner. The trust were aware and were actively working to resolve the issue.

Managers accessed timely and accurate performance data, aiding effective oversight. The leaders submitted required notifications to external bodies, including CQC.

Leaders implemented recognised quality frameworks and supported innovation through proportionate risk management.

Staff and leaders remained open, transparent, and actively engaged with external stakeholders. They worked in partnership with commissioners, and external partners, and other key organisations to support service delivery and integrated care.

Leaders shared learning across local networks and used these partnerships to support continuous improvement. Leaders sought feedback from communities and partners and used this insight to shape services and identify innovative ideas to improve outcomes.

Staff fostered a culture of continuous learning and improvement. Staff and leaders understood how to drive change and consistently applied quality improvement methods to enhance care. For example, when staff identified an increase in patient’s falls, they promptly took actions to reduce them. This included, bed sensors and chair sensors being provided, reviewing level of patient’s observations, referral to physiotherapist, considering moving patient’s bedroom closer to nurses stations, reviewing patient care needs at falls meeting.

Staff explored new ideas, which led to meaningful service changes, for example staff trailed trauma- informed environmental changes on Blubell Ward such as soothing colour schemes, plenty of natural light and outdoor access and availability of semi- private spaces where patients could retreat for quite time. Leaders encouraged staff to share improvement ideas and created space for collective reflection and problem-solving.

Staff involved people using the service, as well as their families and carers, in shaping and evaluating improvement initiatives.

Wards participated in relevant national audits and accreditation schemes, and staff learned from the findings. The service also supported staff to engage in research and embedded evidence-based practice into care delivery.

Strong external links supported innovation. Leaders maintained open channels of communication with staff and built a culture of trust where ideas for change were welcomed and acted upon.