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. At our last assessment we rated this key question Good. At this assessment, the rating has remained Good. This meant people were safe and protected from avoidable harm. The service provided care and treatment in a way which made patients feel safe, supported, involved and listened to. Patients felt they were treated with kindness, compassion, dignity, and respect. They were treated as individuals and encouraged to be involved in their care and treatment planning. Staffing, processes, and equipment were in place to maintain the safety of the patient and to meet their needs. Staff engaged with patients in a kind, compassionate, and caring way. The environment, and equipment was clean, tidy, and well maintained. Information regarding the patient's care, treatment, and external resources available were displayed throughout the service.

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.

When incidents such as episodes of agitation or aggression occurred, staff responded promptly, reported them appropriately, and updated care plans and risk assessments accurately. Following any incidents patients and staff had debrief meetings, staff also had individual or group reflective practice sessions with the Psychology team. Staff demonstrated a strong understanding of the duty of candour. If things went wrong, they spoke openly and honestly with patients and families, offered clear explanations, and apologised whenever needed.

Managers and clinical leads provided staff with regular feedback following investigations. Teams discussed learning during patient safety meetings, handovers, fortnightly team meetings, and monthly operational meetings to identify areas for improvement. Staff used feedback, both positive and negative as learning opportunities to improve upon practice, and service delivery.

Patients felt well-supported, and reassured during the referral, admission, transfer, and discharge process, which helped reduce anxiety during times of transition. They had information about what to expect from their care and treatment available to them in a variety of formats to suit individual needs.

Staff and leaders explained that the service had robust systems in place to ensure safe admissions, care transfer, 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 promoted the importance of early planning and communication across teams. Discharge planning involved coordination between services, for example, The Assertive Transitions Service (ATS) to ensure safe and supported transitions, and ongoing care and support. Staff made every effort to avoid unnecessary delays and remained focused on achieving timely discharges or transfers of care wherever possible.

The service had admission meetings and handovers to prepare staff for each new patient, ensuring an effective and safe transition. The service followed a structured process where staff completed an admission checklist when a patient was admitted, the process involved the patient as much as possible and was reviewed regularly, any follow up information was used to support safe and timely care planning, and assessment of risk.

Patients consistently felt safe and were empowered to raise concerns, knowing staff would respond appropriately, if they felt unsafe or had any concerns about others.

Staff demonstrated a thorough understanding of safeguarding, confidently identifying and responding to concerns to protect patients from harm. They took appropriate and timely action to protect patients from abuse, neglect, or discrimination and worked collaboratively with external agencies when required. Staff discussed safeguarding incidents in safeguarding meetings, multidisciplinary team meetings (MDM), and staff meetings. Staff were also supported by unit based safeguarding leads. Staff demonstrated a clear understanding of Deprivation of Liberty Safeguards (DoLS). Staff explained patients’ rights to them, including their rights under the Mental Health Act 1983, Mental Capacity Act 2005 and the Equality Act 2010. Leaders ensured staff had the knowledge, support and confidence to act accordingly and promptly to safeguard the patients they cared for and supported.

The service had effective safeguarding systems, policies and procedures in place that upheld patients' human rights and promoted a culture of safety. We reviewed the safeguarding incidents log for the period from May 2025 to July 2025 and found that concerns were investigated, escalated in a timely manner, and outcomes and learning shared.

Staff knew and understood patients’ individual risks which ensured that they intervened quickly to support patients to minimise any distress and to decrease risk.

We reviewed 9 risk management plans and found they were person-centred with obvious patient and family involvement and were reviewed in line with trust policy. One patient told us “I feel really involved, my family are also involved, and this is so important to me.” The service took a proportionate, and balanced approach to risk, completing welfare checks and observations based on care plans, and individual patient need. The patient records we reviewed showed observations were completed as prescribed.

Staff ensured patients' physical and emotional needs were managed positively, protecting their rights and their dignity. Staff were calm when supporting patients with any episodes of distress which promoted safety and mitigated any further potential risk.

Staff involved patients and, where appropriate, their families and people who knew them well in risk assessments. Patients and their families participated in multidisciplinary team meeting reviews in the patients care records we reviewed. Staff from various teams within the service supported patients to understand their risks and how to manage them positively. Numerous communication methods were used for patients with identified language barriers or other complexed needs, for example, easy read print. Restraint was used as a last resort. It was accurately documented, and in line with best practice, care plans reflected any restrictions, and these were individualised to avoid blanket restrictions. Staff considered equality and human rights legislation when imposing any restrictions. If rapid tranquilisation was used, it was also proportionate, documented appropriately and recorded in line with best practice.

Patients and staff felt the environment was safe. The service maintained clean, and well-equipped environments that were conducive to the physical, and mental wellbeing of the patient and supported the safe delivery of care. Equipment was well-maintained, stored safely, and used appropriately for its intended purpose.

A security Nurse completed safety audits of the environment on every shift, the security Nurse was a member off staff delegated with the task of checking the environment on a shift-to-shift basis to ensure there were no unidentified risks. The ward staff teams also completed regular risk assessments of the environment throughout the day and night. This ensured any potential hazards were identified and mitigations were put in place to reduce the risks. Ligature risks were assessed, and the appropriate assessments were in place to manage and reduce any potential risks of harm. The service had 360-degree motion sensor CCTV throughout, this supported and safeguarded both patients and staff against the potential risk of blind spots.

The service had installed Oxevision, a patient monitoring system that used infared cameras and optical sensors to monitor the wellbeing and activity of the patient without actual physical contact. The technology enhanced patient safety, and enabled staff to monitor breathing, movement, and sleep patterns in real time, this supported more effective observations and promoted unnecessary disruption for the patient, especially through the night or during periods of increased risk and unrest.

Staff carried personal alarms and radio communication systems. Patients had access to nurse call systems in their bedrooms, bathrooms and throughout the environment. this ensured they could request assistance or support whenever needed.

The clinic room was fully equipped with accessible resuscitation equipment and emergency medicines, staff checked and audited these regularly to ensure they were prepared for any potential emergency situations, the pharmacy team also completed audits which further promoted accuracy, and safe practice.

Equipment, and technology was well-maintained and enabled staff to deliver safe and effective care. The service had effective processes to monitor the safety and upkeep of the environment, and premises.

Leaders and staff were aware of what was required to provide and maintain environments that kept people safe from harm both psychological, and physical, including attention to sexual safety and sensory needs.

Patients were well supported, staff were always present, visible and available. One family member told us “I know my son is safe here, whenever I visit the staff are always there, and I feel safe too.” Patients were supported to have regular one-to-one time with their named nurse which we found evidence of in the care records we reviewed. This maintained therapeutic relationships and promoted continuity of care.

Staff were always present in communal areas, and throughout the environment. The appropriate medical cover was in place throughout the day and night, with doctors and pharmacists being readily available to respond quickly in emergencies, and to also offer support to ward staff whenever required.

Leaders regularly reviewed staffing levels and aligned them to the needs of the patients. We saw evidence of how staffing levels were increased when patients’ needs changed. Staffing rotas confirmed the required numbers, and the appropriate skill mix was met on the vast majority of shifts.

The service utilised bank staff to complement the existing workforce when required. Bank staff had completed an induction and mandatory training prior to employment and were regular to the service, they were familiar with the patients and environment. Any gaps identified in staffing had been covered in a timely and efficient way to maintain the service provision.

We reviewed vacancies, staff turnover and sickness absence levels in the past 12 months and found no concerns. The service did have staff vacancies, and they were recruiting into these roles at the time of our visit.

Recruitment processes were robust and ensured that all staff, including bank staff had current Disclosure and Barring Service (DBS) documentation in place, were suitably qualified, experienced, and competent. Disciplinary and capability processes were adhered to, reviewed regularly, and free from bias related to protected characteristics

Staff felt supported by leaders, however, we identified supervision and appraisal compliance was 73%, this was below the trusts target compliance rate of 90%. This had also been identified by the trust, and an action plan was already in place. The trust had already submitted an action plan update to us which evidenced moderate improvement. Staff had completed and were up to date with role specific mandatory training. One staff member told us “The training is excellent, and we have opportunities to complete various training packages in other areas of interest, we are not limited.” The training undertaken was appropriate for the patient group being supported. Staff demonstrated confidence and competence in care delivery. Opportunities for learning and development were available to staff at all levels. Any poor performance was managed effectively, and the appropriate support provided.

Patients were confident in the infection prevention and control (IPC) processes in place and felt assured that staff were taking necessary precautions to protect them from the risk of infection and potential harm. One patient told us “The wards are always clean; the cleaners are always about. If anything happens its usually cleaned very quickly.” Staff adhered to infection prevention and control procedures and followed handwashing guidance, they used personal protective equipment (PPE) appropriately, and cleaned equipment in line with guidance, and best practice.

We observed staff adhering to hand hygiene principles and guidance between patient interventions, for example, administering medicines. All ward areas were clean and well-maintained. Cleaning records were up to date and showed that areas were cleaned, and audited regularly, this ensured the environment was hygienic and safe. Staff demonstrated a good understanding of their roles in maintaining the cleanliness of the environment. Hand sanitising stations were situated around both wards to protect and mitigate the risk of infection and potential harm.

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 prevention and control audits were completed regularly, with all concerns addressed promptly. Information about infection risks was shared appropriately with staff, patients, visitors to the service and external partners. There were clear roles and responsibilities for infection prevention and control, and staff received ongoing training in line with trust policy, and best practice guidance.

Staff supported patients to be involved in decisions about their medicines. For those who had capacity, staff ensured they understood what their medicines were for and involved them in any discussions regarding changes to their treatment. Where a patient had reduced capacity, and were not able to fully understand or participate, due to diagnosis related impairment, staff adhered to processes in line with the Mental Capacity Act 2005 and the Mental Health Act 1983. Care plans we reviewed reflected each person's level of understanding and evidenced the level of involvement they had in making decisions about their medicines and treatment.

Staff followed safe and effective practices in all areas of medicines management, including storage, dispensing, administration, reconciliation, recording, and disposal. The service adhered to national guidance and best practice, and evidenced how they involved patients, their families, and people who knew them well in discussions and decisions about their care and treatment wherever possible. A large proportion of the patients were supported to self-administer their medicines (SAM), the trusts self-administration of medicines policy was adhered to and audited regularly to maintain the safety of the patient. Staff regularly reviewed the effects of medicines on patients’ physical health, particularly in those prescribed a high dose of antipsychotic medication, in line with NICE guidance.

We observed staff administering medicines safely, explaining their use clearly, and supporting patients with kindness, compassion, dignity and respect. The service stored medicines securely, including controlled drugs. All medicines were managed under the required legal frameworks. Fridge and room temperatures were checked daily, and all medications were within date. Expired or unused medicines were disposed of safely. Staff ensured that medicines were used appropriately, were Pro Re Nata (PRN) or when required medicines were used, we found they had been appropriately and not purely to control behaviour.

The service had robust and effective systems in place for the management of medicines and adhered to current best practice, prescribing followed national guidance. When staff identified medicines errors, they were addressed and the appropriate actions taken to mitigate the risk of harm, or reoccurrence. Continuity of care was maintained during transitions between care settings through effective medicines reconciliation and clear concise documentation. Controlled drugs were managed safely and audited regularly, and any outcomes from audits were acted on, this promoted a learning culture through incident reporting and review. Staff had received training and competency assessments to support the safe, effective, and appropriate use of medicines.