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, and fair culture. At our last assessment we rated this key question Good. At this assessment, the rating has remained Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.The senior leadership team had action plans, strategies, policies, and procedures in place which maintained good governance, oversight, and overall management of the service. Leaders celebrated having a culturally diverse workforce as it better represented the patient group and the wider community. The service had clear vision and values around the patient experience and the quality of care and support they provided. The service provided various innovative initiatives for its staff to maximise their skill set and practice which enhanced the care, support, and treatment they were able to offer, provide patients and their families. The service had a culture of openness, honesty, and inclusion which encouraged and supported staff in all areas to provide feedback. Where appropriate lessons had been learnt, and this maintained the drive for improvement.

This service scored 79 (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 openness, honesty, equality, diversity, and inclusion. Staff aligned with and promoted the trust’s values in their day to day working roles. Leaders communicated the vision effectively to all staff, this ensured alignment with the service’s aims and ambitions.

Staff had opportunities to contribute to discussions regarding the service’s strategy, especially through changes and transformation, this made them feel valued and included. Staff knew how their roles and practice helped to maintain the delivery of high-quality care and treatment.

Leaders proactively addressed workforce inequalities and fostered a culture of inclusion, resulting in more equitable and person-centred care and treatment for all patients. They showed a strong understanding of, and consistently modelled behaviours that promoted equality, diversity, and human rights.

The provider’s strategy focused on delivering safe, effective, and compassionate high-quality care while promoting equality, and partnership working, always putting people at the centre of everything they did. The service ensured all staff received regular, and clear communication promoting the shared goals and direction of the organisation. Staff felt included and valued, which underpinned, and promoted a positive culture.

Leaders had the skills, experience, and knowledge to perform their roles effectively. They had defined roles, responsibilities, and accountability which ensured each leader was aware of any issues or concerns, and service priorities.

Leaders had an in-depth understanding of the services they managed and demonstrated how they consistently supported their teams to deliver high-quality and effective care and treatment. They were visible, available, and approachable to patients, their families and staff. This behaviour modelled inclusivity which promoted the organisation’s values.

Career development opportunities were available for all staff, with numerous examples of staff progression. Leaders valued their staff and proactively challenged and addressed any cultural issues that could impact care or have a negative impact on the wellbeing of staff.

A freedom to speak up (FTSU) policy and procedure was in place. Staff had access to the Freedom to Speak Up Guardian and service, the service also had 3 freedom to speak up champions who were based on the wards. They told us they knew how to raise concerns were supported to do so if the need arose.

Leaders promoted an open culture where concerns were listened to, acknowledged, investigated, and addressed with updates provided and outcomes shared. Staff received training on whistleblowing and were confident to raise concerns.

Freedom to speak up concerns were monitored and audited to identify common themes, if a theme was identified an action plan was formulated and put in place to address the findings. Staff felt confident that concerns were taken seriously and led to positive change.

There had been 4 freedom to speak up concerns raised in the 3 months prior to our on-site assessment. We found evidence that showed the concerns had been addressed promptly, a Datix incident report had been completed when required, appropriate actions had been taken, and updates had been given to the person raising the concern. We also found evidence that support had been provided, and learning shared from outcomes.

There was a strong commitment to EDI across the service. The organisations values were at the centre how care was delivered and how staff were supported. Leaders had good oversight of the service and its culture, they ensured staff were treated fairly, with kindness, and respect. Any unfair treatment or differences in experience were identified and addressed, particularly for staff with protected characteristics or from marginalised groups. The service facilitated reasonable adjustments and flexible working arrangements that supported the individual needs of staff whenever possible.

The service participated in a successful sponsorship programme for overseas staff. Overseas staff were supported by the by the sponsorship programmes liaison lead, who ensured that all role-relevant training was completed, and they were competent in their roles. They felt listened to, valued and were recognised by colleagues for their positive contributions, and roles within the service.

Employment procedures ensured prompt, fair and equal treatment of all applicants in accordance with Equality Act 2010, and the trust’s EDI Policy. The organisation actively promoted Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ+) employment opportunities, and had an LGBTQ+ staff network, along with recruitment inclusion guardians that fostered representation and inclusion in the organisation. This also ensured the workforce was diverse and reflective of the people using and visiting the service.

Leaders fostered a culture of inclusion and promoted a zero-tolerance stance regarding bullying and harassment. They also endeavoured to make sure that all staff, including those who may be less heard, had input in shaping services. EDI were clearly embedded in the organisation’s values, policies and strategic priorities.

The service had clear governance and management processes that worked well and supported safe, high-quality, and sustainable care. Staff understood their roles and responsibilities within the service and were held accountable by leaders where appropriate.

Team meetings consistently covered key topics such as incidents and risk, complaints, safeguarding, patient admissions, discharges and care quality. Staff learned from audits and reviews and acted on outcomes, and any recommendations made, this demonstrated a culture of ongoing learning, improvement, and service development.

Staff collaborated and communicated well with colleagues and external partners to meet the needs of the patients they cared for. The services risk register was current, accessible, and regularly reviewed with staff escalating concerns promptly, and appropriately. Emergency response plans were in place, for example, in the event of infection outbreaks or other service disruptions.

IT systems were reliable and supported staff to complete their clinical work, while information governance processes ensured that patient information was managed securely and confidentially.

Leaders accessed timely and accurate performance data, which maintained effective oversight of the service. Leaders submitted required notifications promptly to external bodies, for example, Care Quality Commision CQC in accordance with their legal obligation.

Leaders implemented recognised quality frameworks and supported innovation through effective and proportionate risk management practises. This ensured that governance structures remained resilient, flexible, and sustainable.

Staff and leaders were consistently open, transparent, and proactively engaged with external stakeholders, and partners in care. They worked collaboratively with commissioners, and other relevant organisations to support and maintain service delivery and integrated care.

Leaders shared learning across local, and national networks and used partnerships to support, and drive continuous improvement. For example, the service worked collaboratively with IMPACT the provider collaborative across the Midlands region. IMPACT actively promoted the positive transformation of services, through co-production between services, patients, families and carers. This approach was designed to ensure people’s needs were met more effectively, and service variation minimised to ensure better and more consistent outcomes for patients. Leaders valued feedback from partners and communities and used this information to shape services and identify innovative ideas, and practice to improve and promote better outcomes for people.

The organisation fostered a culture of continuous learning and improvement. Staff and leaders understood how to drive and implement change and effectively applied quality improvement methods and projects to enhance care, support and service delivery. For example, Expert by Experience and Carer Engagement which had created a new and robust approach that involved and valued the input of experts by experience, carers, and families in service development and governance.

The organisation learned from patients and their families which led to meaningful service changes. For example, the trust had implemented changes to actively seek out and include the views of families and carers views in the care and safety planning processes. The trust had been awarded with the 'Digital Organisation of the Year ’award. This celebrated the trust’s implementation of an organisation-wide digital strategy and included the rollout of an integrated and future-proofed electronic patient record (EPR) system that enabled effective, and enhanced information sharing across services and with GPs. This empowered both clinicians and patients to make informed decisions without delay. The EPR system enabled the organisation to better capture valuable information from a carer's perspective, this ensured these views informed effective risk management.

The service participated in relevant national audits and clinical benchmarking schemes. For example, participation in the Quality Network for Forensic Mental Health Services (QNFMHS). The Quality Network for Forensic Mental Health Services utilised a multi-disciplinary approach to quality improvement in medium and low secure mental health services. This promoted the sharing of best practice, innovation, and ideas by listening to and being led by frontline staff and patients at different services across the region. Areas for improvement were identified through a culture of openness and enquiry. The approach was one of engagement rather than inspection and aimed to deliver quality improvement through a supportive network and peer-review process.

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 and clear communication with staff and promoted a culture of trust, and involvement where ideas for change were encouraged, welcomed and acted upon.